Obstetrics and Gynecology in Chinese Medicine Second Edition Giovanni Maciocia, CAc (Nanjing) Acupuncturist and Medical Herbalist, Visiting Professor, Nanjing University of Traditional Chinese Medicine, Nanjing, People’s Republic of China
Churchill Livingstone
Front matter Obstetrics and Gynecology in Chinese Medicine Commissioning Editor: Claire Wilson Development Editor: Veronika Watkins Project Manager: Nancy Arnott Designer/Design Direction: Charles Gray Illustration Manager: Merlyn Harvey Illustrator: Michael Courtney/Richard Morris/Jonathan Haste/E.P.S
Obstetrics and Gynecology in Chinese Medicine SECOND EDITION Giovanni Maciocia CAc (Nanjing), Acupuncturist and Medical Herbalist, Visiting Professor, Nanjing University of Traditional Chinese Medicine, Nanjing, People’s Republic of China Foreword by Dr Ted J Kapthcuk OMD, Associate Professor of Medicine, Harvard Medical School, Boston, USA
Copyright
© 2011 Giovanni Maciocia. Published by Elsevier Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our Web site: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). First edition 1998 Second edition 2011 ISBN 978-0-443-10422-0 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience
and knowledge in evaluating and using any information, methods, compounds or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein.
Printed in China
Foreword to the First Edition East Asian medicine must always negotiate a peculiar tension between revered point of departure and thousands of years of experience. If the ancients are overvalued, the clinical application could be interpreted as a decline. If the accumulated experience is praised too highly, the original sources can seem to have been a bit too flawed. Each practitioner must also embody this tension; to what extent does one follow strictly the established authority and to what extent do unique cultural and personal exigencies supersede ‘standard’ perspectives? Successfully navigating this polarity has been a key component of the vitality of the entire East Asian medical tradition and a hallmark of a sensitive and masterly practitioner. Excellence in the tradition of East Asian medicine has always been defined by the ability to be simultaneously immersed in the past while also responding meaningfully and practically to the present. To be a great teacher for any generation of the tradition requires the rare ability to summarize contemporary experience and then integrate these insights into the perennial dialogue of the archaic. Time and timelessness. New insights and revered knowledge. Change and reverence. Movement and stillness. These two poles must balance upon a single fulcrum, becoming a unified body of knowledge in an unbroken transmission. An almost impossible goal, this enterprise is also an absolutely necessary task for every generation. The history of East Asian medicine is a remarkable chain of transmission and modulation from one generation, dynasty, and even country, to the next. Our generation seems especially significant in this transmission and transformation of East Asian medicine. We are participants in a huge leap: health expectations, disease burdens, linguistic barriers and complex cultural obstacles must be bridged. The ancient traditions must not only co-habit and interact with modern biomedicine and a host of other complementary therapies, but also graft themselves upon a very different civilization. Clarity, sensitivity, knowledge and wisdom must all be brought to bear lest the
authenticity of age-old theory and techniques weaken into shallow semblance. Under what circumstances should modern clinical experience suggest modification in ancient approaches? How would such alteration fit comfortably into the tradition? How can such an adjustment become the very link to preserving the continuity with the past? These are serious questions needing thoughtful responses. Giovanni Maciocia is a respected guide in this transitional period of East Asian medicine to the Western arena. His accomplishments as a teacher and writer have made him a major force in this successful movement from one world to another. The Foundations of Chinese Medicine, The Practice of Chinese Medicine and Tongue Diagnosis in Chinese Medicine are all outstanding contributions of scholarship and clinical acumen, and this present volume, Obstetrics and Gynecology in Chinese Medicine, adds significantly to his accomplishments. Indeed, one begins to see the outlines of a Maciocia transmission or tradition existing within our very own generation. This volume is simultaneously an encounter with the classics of Chinese medicine, this morning’s patient and the insights of a seasoned practitioner. It is a wonderful example of balancing old and new in order to fulfil the mandate of ‘accurate’ transmission. The contemporary clinical insights in Obstetrics and Gynecology in Chinese Medicine are deep, while its references to classical sources are precise and relevant. Classical citations are balanced with contemporary case histories to provoke understanding and clinical guidance while eschewing mere pedantry. Giovanni Maciocia is wonderful in exhuming details of the archaic knowledge that has been neglected in Asia itself. This is apparent throughout the text and two important examples are his discussions of the Extraordinary Vessels and of post-natal melancholy. Giovanni Maciocia is comfortable acknowledging the divergence of his clinical experience with that of his mentors in China. This textbook is unafraid to present the details of patterns of disharmony that are relatively infrequent in China, and therefore not mentioned in typical books or lectures, but which actually appear frequently in Western societies. The text extensively addresses a simultaneous deficiency of Kidney-Yin and KidneyYang in women which is rarely mentioned in Chinese sources. Giovanni
Maciocia is also unafraid to quote contradictory authoritative sources. The ancients were physicians, not a ‘health cult’ with all the answers, and their multiple voices in this text help to give them depth and allow our modern voice to embrace diversity. Obstetrics and Gynecology in Chinese Medicine is a paradigmatic work. It is tempered with reverence and innovation, meticulous archival attention and detailed modern clinical insight. When future generations look back at this work and other books by Giovanni Maciocia, they will find not only knowledge and wisdom but also reasons for inspiration and awe. As a community of practitioners, we are fortunate to benefit from the efforts of giants such as Giovanni Maciocia. Because of his efforts and also our entire community’s dedication, our ‘generation’ will probably succeed in its critical destiny and responsibility for bringing East Asian medicine to the centre of a new cosmopolitan healthcare agenda. Ted J. Kaptchuk
1997
Preface to the Second Edition I finished writing the first edition of Obstetrics and Gynecology in Chinese Medicine in 1997. Now, 13 years later, I have had the chance to treat many more women and to appreciate even more how effective Chinese medicine is in treating gynecological problems. The main features of the second edition of this text compared to the first are as follows: 1. The text has been thoroughly revised throughout. 2. I have added more patterns and new prescriptions to many diseases. 3. I have added three chapters on important biomedically defined diseases, i.e. endometriosis, polycystic ovary syndrome and myomas. 4. The chapter on obstetrics (Ch. 44) has been completely revised and expanded by Sarah Budd, a midwife/acupuncturist at the forefront of the integration of acupuncture in a biomedical setting for labour and pre- and post-natal care. As for the first edition, I have chosen to name the gynecological conditions in the traditional Chinese way, for example ‘Painful Periods’ rather than ‘Dysmenorrhoea’, ‘Flooding and Trickling’ rather than ‘Metrorrhagia’, ‘Heavy Periods’ rather than ‘Menorrhagia’, ‘No Periods’ rather than ‘Amenorrhoea’, etc. Please note that these are disease entities (which I call ‘disease-symptoms’) in Chinese medicine although not in Western medicine. For example, in Western medicine, ‘painful periods’ is not a disease but a symptom; endometriosis is a ‘disease’ which could cause the symptom of painful periods. A Chinese gynecologist would always diagnose the disease before diagnosing the pattern. Diagnosing the disease (e.g. Flooding and Trickling) is
called bian bing while diagnosing the pattern is called bian zheng. It may be argued by some that diagnosis of the (Chinese) disease is not that important because we treat according to patterns. This is not so for two main reasons. The first is that one should be clear about the disease being treated. For example, a woman might complain of ‘heavy periods’ and we might diagnose ‘Flooding and Trickling’ when, on close observation, she suffers from ‘MidCycle Bleeding’. Second, simply treating according to pattern is not enough. For example, the Blood stasis occurring in ‘Flooding and Trickling’ is treated differently (and therefore with different formulae) than the Blood stasis in ‘Painful Periods’. Even more so, the Blood stasis in ‘Abdominal Masses’ is treated very differently than the Blood stasis in ‘Painful Periods’. As in all my other texts, the acupuncture points given under each pattern are not combinations of points (with a few exceptions) but a range of points from which the practitioner can choose. Whenever points do form a combination, it is called ‘Ancient Prescription’. The principles of combination of points is discussed at length in The Channels of Acupuncture. The reader should be alerted to the fact that some of the formulae contained in this book may contain substances that are illegal in certain countries, either because they are protected species of plants or animals or because the substance is deemed to be toxic (in some cases wrongly so). The reader is therefore urged to familiarize himself or herself with the laws governing the use of herbs (and minerals and animal products) of their particular country. The prescriptions containing potentially illegal substances have been retained in this book for two reasons. First, since the book is sold all over the world, laws governing the use of such substances vary from country to country; for example, the use of Fu Zi Radix Aconiti lateralis preparata is illegal in Europe but not in the USA. Second, the formulae have been given as they appear in old and modern Chinese books to highlight the thinking and treatment strategy behind a particular formula. Once we understand the rationale of a formula’s composition, we are in a position to modify it by making substitutions for some of its ingredients. If we did not know the original ingredients, we could not make a rational substitution. For example, if a formula contains Fu Zi Radix Aconiti lateralis
preparata we know that it is meant to heat the body strongly and expel Cold and so, should we decide to eliminate Fu Zi from the formula, we need to substitute another herb (or possibly more than one) in a dose that is high enough to mimic the action of Fu Zi. In this example, Rou Gui Cortex Cinnamomi would be a possible substitution. Another example is that of Quan Xie Buthus Martensi (scorpion): a formula that contains this animal product is meant to have a strong Wind-extinguishing action and, if we want to replace it, we know that we need to use a herb (or possibly more than one) that has a similar strong action. On the subject of toxicity and the law regulations, I would like particularly to draw attention to Mu Tong and Aristolochia. There are several species that are called ‘Mu Tong’ in Chinese (and some of them are not Aristolochia, e.g. Akebia) and the use of Aristolochia is not allowed in Europe due to its alleged renal toxicity. As there has been an exceptional level of attention dedicated to this herb following cases of renal toxicity, I strongly advise practitioners against using this herb (in any country). Indeed, authorities are so strict on this that they do not allow the use of any herb called ‘Mu Tong’ even if it not Aristolochia (e.g. Caulis Akebiae) due to the possibility of mistaken identification. Again, the reason this herb has been retained in the old formulae is to allow the practitioner to make a rational substitution. In particular, a frequent substitution for Mu Tong is Tong Cao Medulla Tetrapanacis. The material in this book is gathered from many old and modern Chinese texts, from the teaching of various Chinese teachers and from my own experience. Whenever I write something that reflects my experience, I make that clear by saying ‘according to my experience’. The two main texts used as sources are Gynaecology in Chinese Medicine by Cong Chun Yu (Zhong Yi Fu Ke Xue) 1989 Ancient Chinese Medicine Texts Publishing House, Beijing, and Luo Yuan Kai’s Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue) 1986 Shanghai Science and Technology Press, Shanghai. Please note that the dosages indicated in the herbal prescriptions are those from the original texts. In my practice, I generally use low dosages and
certainly lower than those used in modern China. For example, my dosages for a decoction range generally from 3 to 9 grams per herb daily whereas doctors in China tend to use 10 grams or usually more. Thus, whenever a source does not specify the dosages within a prescription, I have indicated the dosages that I would use. Compared to the first edition, I have removed all Chinese patent remedies due to the unverifiable quality controls of Chinese patent remedies. Finally, each chapter includes the differentiation of the disease-symptom discussed in Western medicine: e.g. the possible causes of painful periods in Western medicine. Of course, this is not intended to replace a good book on Western gynecology (some are mentioned in the bibliography): it is simply meant to provide the practitioner in a clinical setting with a quick check list of the possible Western causes of that particular symptom. This is important because we should know when to refer a patient to a Western gynecologist for a further diagnosis. For example, a patient may come to us presenting with postmenopausal uterine bleeding and we should know when to suspect uterine carcinoma. Another reason for familiarizing ourselves with the Western differentiation of symptoms is prognosis. Although Chinese medicine is excellent at providing not only a diagnosis but also a reasonable prognosis by carefully examining symptoms, signs, tongue and pulse, in many cases the prognosis depends also on the Western diagnosis; it makes a considerable difference to prognosis, for example, if excessive uterine bleeding is merely functional or is caused by a large myoma. The last 13 years of practice (since the publication of the first edition) have confirmed to me even more the importance of a Western diagnosis in many gynecological conditions, e.g. breast lumps (possible breast cancer), uterine bleeding (possible myoma), painful periods (possible endometriosis), amenorrhoea (possible polycystic ovary), etc. Giovanni Maciocia
2011
Acknowledgements I acknowledge with sincere thanks the many people who, in one way or another, have helped me to write this book. The most important period in my professional training was spent at the Nanjing University of Traditional Chinese Medicine and I am deeply indebted to its directors, teachers and other members of staff for the care and patience in sharing their profound knowledge with me. I am also grateful to the teaching staff of the Jiangsu Province Hospital for Traditional Chinese Medicine where my clinical training took place. The late Dr J H F Shen was an inspiration for me. I owe him a debt of gratitude for communicating his diagnostic skills to me. Dr Ted Kaptchuk provided my first introduction to Chinese herbs and for that I am very grateful. I am indebted to Fi Lyburn for editing and proofreading my manuscript with great care and for providing useful suggestions. I was fortunate to obtain the collaboration of Sarah Budd, a midwife/acupuncturist who has been practising midwifery at Derriford Hospital, Plymouth, England since 1988 using acupuncture for ante-natal, intra- and post-partum care within the National Health Service: her knowledge and long experience in the use of Chinese medicine in obstetrics is a great bonus to my book. I am also indebted to Debra Betts for her contribution and suggestions regarding the chapter on labour (Ch. 44). I am indebted to Dr Xia Gui Cheng, director of the Gynaecology Department of the Nanjing Province Hospital of Chinese Medicine (affiliated to the Nanjing University of Traditional Chinese Medicine) for communicating his experiences to me during my study period in Nanjing. Dr Serena Selva read the sections on the Western differentiation in each chapter and gave me her invaluable comments and criticism: for this I am very grateful.
I would like to thank the staff of Elsevier for their expertise, efficiency and courtesy: in particular, I am grateful to Veronika Watkins and Claire Wilson for their help and support with this project.
Note on the Translation of Chinese Medical Terms The terminology used in this book generally follows that used in The Foundations of Chinese Medicine (2nd edn) and The Practice of Chinese Medicine (2nd edn). In my books, I have opted for translating all Chinese medical terms with the exception of ‘Yin’, ‘Yang’, ‘Qi’ and ‘cun’ (unit of measurement). I have also continued to use initial capitals for the terms which are specific to Chinese medicine. For example, ‘Blood’ indicates one of the vital substances of Chinese medicine, whereas ‘blood’ denotes the liquid flowing in the blood vessels; e.g. ‘In Blood deficiency the menstrual blood may be pale’. I use initial capitals also for all pulse qualities and for pathological colours and shapes of the tongue body. This system has served readers of my books well. As most teachers (including myself) use Chinese terms when lecturing (e.g. Yuan Qi rather than ‘Original Qi’), I have given each term in Pinyin whenever it is introduced for the first time. One change I have introduced recently (as in the second edition of The Foundations of Chinese Medicine) is to use the Pinyin terms more often throughout the text and at least once in each chapter when the Chinese term is first introduced. I have done this to reduce the frequency with which the reader may need to consult the glossary. I made the choice of translating all Chinese terms (with the exceptions indicated above) mostly for reasons of style: I believe that a well-written English text reads better than one peppered with Chinese terms in Pinyin. Leaving Chinese terms in Pinyin is probably the easiest option but this is not ideal also because a single Pinyin word can often have more than one meaning; for example, jing can mean ‘channels’, ‘periods’, ‘Essence’ or ‘shock’, while shen can mean ‘Kidneys’, ‘Mind’ or ‘Spirit’. I am conscious of the fact that there is no such thing as a ‘right’
translation of a Chinese medicine term and my terminology is not proposed in this spirit; in fact, Chinese medicine terms are essentially impossible to translate. The greatest difficulty in translating Chinese terms is probably that a term has many facets and different meanings in different contexts: thus, it would be impossible for one translation to be ‘right’ in every situation and
every context. For example, the term jue ( ) has many different meanings; a translation can illustrate only one aspect of a multifaceted term. In fact, jue can mean a state of collapse with unconsciousness; coldness of hands and feet; or a critical situation of retention of urine. In other contexts it has other meanings: e.g. jue qi (
Qi;
jue
xin
), a condition of chaotic tong (
), a condition of violent chest pain with cold hands; and jue yin zheng (
), the Terminal-Yin pattern within the Six-Stage Identification of Patterns characterized by Heat above and Cold below. Many sinologists concur that Chinese philosophical terms are essentially impossible to translate and that, the moment we translate them, we distort them with a world view that is not Chinese. Ames is particularly clear about the intrinsic distortion of Chinese concepts when they are translated. He gives examples of Chinese terms that are distorted when translated, such as Tian
You-Wu
(‘Heaven’),
(‘Being’
Being’), Dao
(‘Way’), Xing
and
‘Non-
(‘human
nature’),
Ren
(‘benevolence’),
Li
(‘Principle’), Qi (‘primal substance’), etc.1 Ames is particularly forceful in rejecting a single, one-to-one translation of a Chinese term into a Western one in the introduction of his book Focusing the Familiar (a translation of the Confucian text Zhong Yong).2 Ames says: Our Western languages are substance-oriented and are therefore most relevant to the descriptions of a world defined by discreteness, objectivity and permanence. Such languages are ill disposed to describe and interpret a world, such as that of the Chinese, that is primarily characterized by continuity, process and becoming.3 Ames then gives some examples of what he considers to be serious mis-translations of Chinese philosophical terms. The important thing is that these are not ‘mis-translations’ because the terms are ‘wrong’ but because of the intrinsic difference between Chinese and Western thinking and therefore the inherent inability of Western terms to convey Chinese philosophical ideas. Ames says:
For
example,
‘You’
and
‘Wu’
have often been uncritically rendered as ‘Being’ and ‘Non-Being’. Influential translators, until quite recently, have rendered ‘wu xing’
as
‘Five
Elements’. ‘Xing’ is still most often translated as ‘nature’. All these translations promote the fixed and univocal characterizations of objects or essences emergent from a language rooted in a substantialist perspective [our Western languages].4
Ames stresses that the use of a ‘substances language’ (i.e. a Western language) to translate Chinese insights into a world of process and change has led to seriously inappropriate interpretations of the Chinese sensibility. Ames asserts that it is the very difference between Chinese and Western philosophy that makes translation of Chinese terms virtually impossible. He says: In the classical traditions of the West, being takes precedence over becoming and thus becoming is ultimately unreal. Whatever becomes is realized by achieving its end – that is, coming into being. In the Chinese world, becoming takes precedence over being. ‘Being’ is interpreted as a transitory state marked by further transition.5 Ames then says: The Chinese world is a phenomenal world of continuity, becoming and change. In such a world there is no final discreteness. Things cannot be understood as objects. Without this notion of objectivity, there can only be the flux of passing circumstances in which things dissolve into the flux and flow. A processive language precludes the assumption that objects serve as references of linguistic expressions. The precise referential language of denotation and description is to be replaced by a language of ‘deference’ in which meanings both allude to and defer to one another in a shifting field of significance. A referential language [Western language] characterizes an event, object, or state of affairs through an act of naming meant to indicate a particular thing. On the other hand, the language of deference [Chinese] does not employ proper names simply as indicators of particular individuals or things, but invokes hints, suggestions, or allusions to indicate foci in a field of meanings.6 As an example of this intrinsic impossibility of translating a Chinese
philosophical term into a Western language, Ames then cites Steve Owen’s
reluctance in translating shi
as ‘poem’. Owen says:
If we translate ‘shi’ as ‘poem’, it is merely for the sake of convenience. ‘Shi’ is not a ‘poem’: ‘shi’ is not a thing made in the same way one makes a bed, a painting or a shoe. A ‘shi’ can be worked on, polished and crafted; but that has nothing to do with what a ‘shi’ fundamentally ‘is’ … ‘Shi’ is not the ‘object’ of its writer: it is the writer, the outside of an inside.7 Ames gives various translations of Li (a Confucian concept) as an example of how a multiplicity of terms may apply to a single Chinese term and how none of them is ‘wrong’. He says that Li has been variously translated as ‘ritual’, ‘rites’, ‘customs’, ‘etiquette’, ‘propriety’, ‘morals’, ‘rules of proper behaviour’ and ‘worship’. Ames says: Properly contextualized, each of these English terms can render li on occasion. In classical Chinese, however, the character carries all of these meanings on every occasion of its use.8 This confirms clearly how, by the very translation, we limit a Chinese term that is rich with multiple meanings to a single meaning in Chinese. Ames says that in classical Chinese philosophical texts, allusive and connotatively rich language is more highly prized than clarity, precision and argumentative rigor. This rather dramatic contrast between Chinese and Western languages with respect to the issue of clarity presents the translator of Chinese philosophical texts with a peculiar burden. For the Chinese, the opposite of clarity is not confusion, but something like vagueness. Vague ideas are really determinable in the sense that a
variety of meanings are associated with them. Each Chinese term constitutes a field of meanings which may be focused by any of a number of its meanings. Ames says that in the translation of Chinese texts we must avoid what Whitehead called ‘the Fallacy of the Perfect Dictionary’. By this, he means the assumption that there exists a complete semantic repository of terms of which we may adequately characterize the variety and depth of our experience and that, ideally, one may seek a one-to-one correspondence between word and meaning. With this ‘fallacy’ in mind, Ames and Hall say: We challenge the wisdom and accuracy of proposing ‘one-to-one’ equivalencies in translating terms from one language to another. We introduce the notion of ‘linguistic clustering’ as an alternative strategy to ‘literal translation’ that allows us to put the semantic value of a term first by parsing [describe grammatically] its range of meaning according to context, with the assumption that a range of meaning with a different configuration of emphasis is present on each appearance of the term.9 These ideas could not be more apt to illustrate the problems in translating Chinese medicine terms. Of course we must strive for precision and consistency but to think that there is a one-to-one, ‘right’ correspondence between a Chinese medicine idea and a Western term is a misunderstanding of the very essence of Chinese medicine. For example, to say that the only ‘right’ translation of Chong Mai is ‘Thoroughfare Vessel’ makes us fall into the trap of what Whitehead calls the ‘Fallacy of the Perfect Dictionary’. Of course, Chong Mai can be translated as ‘Thoroughfare Vessel’ but that is only one of its meanings and it is absolutely impossible for a single Western term to convey the richness of ideas behind the word Chong Mai (which I translate as ‘Penetrating Vessel’): to think that we can reduce a rich Chinese medicine idea to a single, one-to-one term in a Western language reveals, in my opinion, a misunderstanding of the very essence of Chinese medicine.
Ames makes this point very forcefully. He says: The Fallacy of the Perfect Dictionary is largely a consequence of our analytical bias towards univocity. We would suggest that this bias does not serve us well when approaching Chinese texts. Not only is there the continued possibility of novel experiences requiring appeal to novel terminologies, but also there is seldom, if ever, a simple, one-to-one translation of Chinese terms into Western languages. The allusiveness of the classical Chinese language is hardly conducive to univocal translations. We would contend that, in translating Chinese texts into Western languages, it is most unproductive to seek a single equivalent for a Chinese character. In fact, rather than trying to avoid ambiguity by a dogged use of formally stipulated terms, the translator might have to concede that characters often require a cluster of words to do justice to their range of meanings – all of which are suggested in any given rendering of the character. In fact, any attempt to employ univocal translations of Chinese terms justified by appeal to the criteria of clarity or univocity often reduces philosophical insight to nonsense and poetry to doggerel. Such an approach to translation serves only to numb Western readers to the provocative significance harboured within the richly vague and allusive language of the Chinese texts.10 As an example of the multiplicity of meanings of a Chinese term and therefore of the fact that it is perfectly legitimate to translate a single Chinese idea into more than one term according to different contexts, Ames says that he translates the term zhong (‘centre’ or ‘central’) in the title of the Confucian text sometimes as ‘focus’, sometimes as ‘focusing’ and other times as ‘equilibrium’. Other times, he even translates it as ‘centre’ or ‘impartiality’. He says strongly: The Chinese language is not logocentric. Words do not name essences. Rather, they indicate always-transitory processes and
events. It is important therefore to stress the gerundative character of the language. The language of process is vague, allusive and suggestive.11 According to Ames, in the field of philosophy, two terms particularly stand out as being influenced by a Western thinking when translated, namely Tian (‘Heaven’) and Ren (‘benevolence’). Ames says: When we translate Tian as ‘Heaven’, like it or not, we invoke in the Western reader a notion of transcendent creator Deity, along with the language of soul, sin and afterlife … When we translate Ren as ‘benevolence’, we psychologize and make altruistic a term which originally had a radically different range of sociological connotations. Being altruistic, for example, implies being selfless in the service of others. But this ‘self-sacrifice’ implicitly entails a notion of ‘self” which exists independently of others and that can be surrendered – a notion of self which we believe is alien to the world of the Analects [of Confucius]: indeed, such a reading [of the term ‘ren’] transforms what is fundamentally a strategy for self-realization into one of selfabnegation.12
With regard to Chinese medicine, the term Xue (‘Blood’) is a good example of the above-mentioned problem reported by Ames. When we translate the word Xue as ‘Blood’ we immediately alter its essential character and give it a Western medical connotation; in fact, in Chinese medicine, Xue is itself actually a form of Qi and one that is closely bound with Nutritive Qi (Ying Qi). Indeed, the term mai
appearing in the Yellow Emperor’s Classic of Internal Medicine is often ambiguous as it sometimes clearly refers to the acupuncture channels and other times to the blood vessels. After highlighting the problems in translating Chinese terms, Ames confirms that a single Chinese term may have different meaning in different
contexts. For example, the term shen in some cases 13 means ‘human spirituality’, in others it means ‘divinity’. As he considers only the philosophical meanings of the word shen, we could actually add many others in the context of Chinese medicine, for example ‘mind’, ‘spirit’, ‘lustre’ (in the context of diagnosis). Graham says: Every Western sinologist knows that there is no exact equivalent
in his own language for such a word as ren
or de , and that as long as he thinks of it as synonymous with ‘benevolence’ or ‘virtue’ he will impose Western preconceptions on the thought he is studying.14 Ames then surveys the options that are presented to a translator and seems to favour simply transliterating the Chinese terms and leave them untranslated. He says: To some, this approach may appear to be simply the laziest way out of a difficult problem. But ‘ritual’ has a narrowly circumscribed set of meanings in English, and Li an importantly different and less circumscribed set. Just as no Indological scholar would look for English equivalent for ‘karma’, ‘dharma’ and so on, perhaps it is time to do the same for classical Chinese, the homonymity of the language notwithstanding.15 Hall confirms that a single Chinese term may have a plurality of meanings. He says: The Chinese have traditionally affirmed as the ground of their intellectual and institutional harmony the recognition of the copresence of a plurality of significances with which any given term might easily resonate.16 Finally, another sinologist, Yung Sik Kim, discusses the difficulty presented by the plurality of meanings of a single Chinese term. He says: I have adopted the policy of sticking to one English translation for a particular Chinese word whenever possible … Of course, exceptions cannot be avoided altogether. I have had to resort to
different
translations
for
such
characters
as
‘xin’
which means both ‘heart’ and ‘mind’; ‘tian’
, both ‘heaven’ and ‘sky’.17 In another passage, Yung Sik Kim affirms that transliteration of a Chinese term with a plurality of meanings is the only alternative:
The term ‘li’ is difficult to define. It is difficult even to translate because there is no single word in Western languages that covers all facets of what ‘li’ meant to the traditional Chinese mind. The existence of many translations for the term, which often leaves transliteration as the only viable option, bespeaks the difficulty.18 Although a diversity of translation of Chinese terms may present its problems, these are easily overcome if an author explains the translation in a glossary and, most importantly, explains the meaning of a given Chinese term in its context (in our case, Chinese medicine). In my books, I have chosen to translate all Chinese medicine terms
rather than using Pinyin purely for reasons of style as a sentence written half in English and half in Pinyin is often awkward. Moreover, if we use Pinyin terms in writing, it could be argued that we should be consistent and use Pinyin terms for all Chinese medicine terms and this would not make for very clear reading. Consider the following sentence: “To treat Pi-Yang Xu we adopt the zhi fa of bu pi and wen Yang” (“To treat Spleen-Yang deficiency we adopt the treatment principle of tonifying the Spleen and warming Yang”). Moreover, the problem arises only in the written form as, in my experience, most lecturers in colleges throughout the Western world normally prefer using Pinyin terms rather than their counterparts in English (or any other Western languages). Thus, a lecturer will refer to Kidney-Jing rather than ‘Kidney-Essence’. Indeed, when I myself lecture, I generally use the Pinyin terms rather than their English translation. Again, most lecturers use a pragmatic approach translating some terms into English (such as ‘treatment principle’ instead of ‘zhi fa’) and leaving others in Pinyin such as ‘Yuan Qi’ or ‘Chong Mai’. When I lecture I always try to give the participants an idea of the meaning of a particular Chinese character and its significance and application in Chinese medicine. Indeed, the use of Pinyin when lecturing renders Chinese medicine truly international as I can lecture in the Czech Republic and mention Jing, Yang Qiao Mai, Wei Qi, etc., knowing that I will be understood by everyone. A diversity of translation of Chinese terms may even have a positive aspect as each author may highlight a particular facet of a Chinese term so that diversity actually enriches our understanding of Chinese medicine. If someone translates Zong Qi (
) as ‘Initial Qi’, for example, we learn something about that author’s view and understanding of
Zong Qi; the translation cannot be branded as ‘wrong’ (I translate this term as ‘Gathering Qi’). Another example: if someone translates yang qiao mai as ‘Yang Motility Vessel’, the translation captures one aspect of this vessel’s nature; again, this could not be defined as wrong (I translate the name of this vessel as ‘Yang Stepping Vessel’). Trying to impose a standard, ‘right’ translation of Chinese medicine terms may lead to suppression of healthy debate; I therefore hope that readers will continue to benefit from the diversity of translation of Chinese medicine terms and draw inspiration from the rich heritage of Chinese medicine that it represents. I firmly believe that the future lies not in trying to establish a rigid, embalmed, fossilized, ‘right’ terminology based on single, one-to-one translations of Chinese ideas. Indeed, I believe this is a potentially dangerous trend as it would, in my opinion, lead students and practitioners away from the richness of Chinese language and richness of meanings of Chinese medicine ideas. The adoption of a standardized, ‘approved’ terminology of Chinese medicine terms may indeed, in time, divorce students and practitioners from the essence of Chinese medicine. If an ‘official’, standardized translation of Chinese terms took hold, then students would be less inclined to study the Chinese terms to explore their meaning. Ames and Hall make the same point: Such translations have been ‘legitimized’ by their gradual insinuation into the standard Chinese–English dictionaries and glosses. By encouraging the uncritical assumption in those who consult these reference works that this formula of translations provides the student with a ‘literal’ rendering of the terms, these lexicons have become complicit in an entrenched cultural equivocation that we strive to avoid.19 They then further make the point that using a one-to-one translation of Chinese terms ignores the cultural background where they came from: Our argument is that it is in fact these formulaic usages that are radical interpretations. To our mind, to consciously or
unconsciously transplant a text from its own historical and intellectual soil and replant it in one that has decidedly different philosophical landscape is to take liberties with the text and is radical in the sense it tampers with its very roots.20 As I said above, an ‘official’, standardized translation of Chinese terms may make students and practitioners less inclined to study the Chinese terms to explore their meaning with their own interpretation. Ames and Hall say: Our goal is not to replace one inadequate formula with another. Our translations are intended as no more than suggestive ‘placeholders’ that refer readers back to this glossary to negotiate their own meaning, and, we hope, to appropriate the Chinese terms for themselves.21 Moreover, imposing an ‘approved’ terminology in English betrays an Anglo-centric world view: to be consistent, we should then have an ‘approved’ terminology in every major language of the world. It seems to me much better to try and understand the spirit and the essence of Chinese medicine by studying its characters and their clinical significance and using Pinyin transliteration whenever appropriate. Trying to fossilize Chinese medicine terms into an imposed terminology goes against the very essence of the Chinese language which, as Ames says, is not logocentric and in which words do not name essences: rather, they indicate always-transitory processes and events. The language of process is vague, allusive and suggestive. Because Chinese language is a language of process, the question arises also whether practising Chinese medicine actually helps the understanding of Chinese medicine terminology: in my opinion, in many cases it does. For example, I feel that clinical experience helps us to understand the nature of the Chong Mai (Penetrating Vessel) and therefore helps us to understand the term Chong in a ‘knowing practice’ way (as Farquhar defines it)22 rather than a theoretical way. Of course, a translator of Chinese books should strive for precision and
consistency, but we must accept that there is a rich multiplicity of meanings for any give idea of Chinese medicine. The Chong Mai is a good example of this multiplicity as the term chong could be translated as ‘thoroughfare’, ‘strategic cross-roads’, ‘to penetrate’, ‘to rush’, ‘to rush upwards’, ‘to charge’, ‘activity’, ‘movement’ and ‘free passage’. Which of these translations is ‘correct’? They are all correct as they all convey an idea of the nature and function of the Chong Mai. I therefore think that the future of teaching Chinese medicine lies not in trying to impose the straight-jacket of a rigid terminology of the rich ideas of Chinese medicine, but in teaching students more and more Chinese characters explaining the richness of meanings associated with them in the context of Chinese medicine. I myself would not like my own terminology to be ‘adopted’ as the ‘correct’ or ‘official’ one: I would rather see colleges teaching more and more Chinese to their students by illustrating the rich meanings of Chinese medicine terms. As mentioned above, my main motive for translating all terms is purely for reasons of style in an English-language textbook; when I lecture I generally use Pinyin terms but, most of all, I show the students the Chinese characters and try to convey their meaning in the context of Chinese medicine. Finally, I would like to explain my continued translation of Wu Xing as ‘Five Elements’. The term ‘Five Elements’ has been used by most Western practitioners of Chinese Medicine for a long time (also in French and other European languages). Some authors consider this to be a misunderstanding of the meaning of the Chinese term ‘Wu Xing’, perpetuated over the years. ‘Wu’ means ‘five’ and ‘Xing’ means ‘movement’, ‘process’, ‘to go’, ‘conduct’ or ‘behaviour’. Most authors therefore think that the word ‘Xing’ cannot indicate ‘element’ as a basic constituent of Nature, as was supposedly intended in ancient Greek philosophy. This is, in my opinion, only partly true as the elements, as they were conceived by various Greek philosophers over the centuries, were not always considered ‘basic constituents’ of Nature or ‘passive motionless fundamental substances’.23 Some Greek philosophers conceived the elements as dynamic qualities of Nature, in a way similar to Chinese
philosophy. For example, Aristotle gave a definite dynamic interpretation to the four elements and called them ‘primary form’ (prota somata). He said: Earth and Fire are opposites also due to the opposition of the respective qualities with which they are revealed to our senses: Fire is hot, Earth is cold. Besides the fundamental opposition of hot and cold, there is another one, i.e. that of dry and wet: hence the four possible combinations of hot–dry [Fire], hot–wet [Air], cold–dry [Earth] and cold–wet [Water] … the elements can mix with each other and can even transform into one another … thus Earth, which is cold and dry, can generate Water if wetness replaces dryness.24 To Aristotle, therefore, the four elements became the four basic qualities of natural phenomena, classified as combinations of four qualities: hot, cold, dry and wet. As is apparent from the above statement, the Aristotelian elements could even transform into one another and generate each other. This interpretation is very similar to the Chinese one, in which the elements are qualities of Nature. Furthermore, it is interesting to note the similarity with the Chinese theory of Yin–Yang: the four Aristotelian elements derive from the interaction of the basic Yin–Yang qualities of cold–hot and dry–wet. Thus, it is not entirely true to say that the Greek elements were conceived only as the basic constituents of matter, the ‘building blocks’ of Nature which would make the use of the word ‘element’ wrong to indicate xing. Furthermore, the word ‘element’ does not necessarily imply that: it does so only in its modern chemical interpretation. In conclusion, for the above reasons I have kept the word ‘element’ as a translation of the Chinese word ‘xing’. According to Wang, the term ‘Five Elements’ could be translated in a number of ways, e.g. ‘agents’, ‘entities’, ‘goings’, ‘conduct’, ‘doings’, ‘forces’, ‘activities’ and ‘stages of change’.25 Recently, the term ‘Five Phases’ is gaining acceptance but some sinologists disagree with this translation and propose returning to ‘Five
Elements’. Friedrich and Lackner, for example, suggest restoring the term ‘elements’.26 Graham uses the term ‘Five Processes’.27 I would probably agree that ‘processes’ is the best translation of Wu Xing. In fact, the book Shang Shu written during the Western Zhou dynasty (1000–771 BC) said: The Five Elements are Water, Fire, Wood, Metal and Earth. Water moistens downwards; Fire flares upwards; Wood can be bent and straightened; Metal can be moulded and can harden; Earth allows sowing, growing and reaping.28 Some sinologists (e.g. Needham and Fung Yu Lan) still use the term ‘element’. Fung Yu Lan suggests that a possible translation of wu xing could be ‘Five Activities’ or ‘Five Agents’.29 Although the term ‘five phases’ has gained some acceptance as a translation of ‘wu xing’, I find this term restrictive as it clearly refers to only one aspect of the Five Elements, i.e. phases of a (seasonal) cycle.
1.
Ames R T, Rosemont H 1998 The Analects of Confucius – A Philosophical Translation, Ballantine Publishing Group, New York, p. 311.
2.
Ames R T, Hall D L 2001 Focusing the Familiar – A Translation and Philosophical Interpretation of the Zhong Yong, University of Hawaii Press, Honolulu, pp 6–16.
3.
Ibid., p. 6.
4.
Ibid., p. 6.
5.
Ibid., p. 10.
6.
Ibid., p. 10.
7.
Ibid., p. 13.
8.
Ibid., p. 69.
9.
Ames R T, Hall D L 2003 Daodejing – Making This Life Significant, A Philosophical Translation, Ballantine Books, New York, p. 56.
10.
Ibid., p. 16.
11.
Ibid., p. 16.
12.
The Analects of Confucius, p. 312.
13.
Ibid., p. 313.
14.
Hall D L, Ames R T 1998 Thinking from the Han – Self, Truth and Transcendence in Chinese and Western Culture, State University of New York Press, New York, p. 238.
15.
The Analects of Confucius, p. 314.
16.
Thinking from the Han, p. 4.
17.
Yung Sik Kim 2000 The Natural Philosophy of Chu Hsi, American Philosophical Society, Philadelphia, p. 11.
18.
Ibid., p. 19.
19.
Daodejing, p. 55.
20
Ibid., pp 55–56.
21.
Ibid., p. 56.
22.
Farquhar J 1994 Knowing Practice – The Clinical Encounter of Chinese Medicine, Westview Press, Boulder, USA.
23.
Needham J 1977 Science and Civilization in China, Vol. 2, Cambridge University Press, Cambridge, p. 244.
24
Lamanna E P 1967 Storia della Filosofia (History of Philosophy), Vol. 1, Le Monnier, Florence, pp 220–221.
25.
Wang Ai He 1999 Cosmology and Political Culture in Early China,
Cambridge University Press, Cambridge, p. 3. 26.
Friedrich M, Lackner M 1986 Once Again: the Concept of Wu Xing, Early China 9–10: 218–219.
27
Graham A C 1986 Yin–Yang and the Nature of Correlative Thinking, Institute of East Asian Philosophies, Singapore, pp 42–66 and 70–92.
28.
Shang Shu (c. 659 BC) cited in Practical Chinese Medicine (Shi Yong Zhong Yi Xue
) 1975 Beijing Publishing House, Beijing, p. 32. The book Shang Shu is placed by some in the early Zhou dynasty (hence c. 1000 BC), but the prevalent opinion is that it was written sometime between 659 BC and 627 BC. 29.
Fung Yu Lan 1966 A Short History of Chinese Philosophy, Free Press, New York, p. 131.
Table of Contents
Front matter Copyright Foreword to the First Edition Preface to the Second Edition Acknowledgements Note on the Translation of Chinese Medical Terms SECTION 1: Physiology and Pathology Chapter 1: History of Gynecology in Chinese Medicine Chapter 2: Women’s Physiology Chapter 3: Women’s Pathology SECTION 2: Aetiology and Diagnosis Chapter 4: Aetiology Chapter 5: Diagnosis SECTION 3: Methods of Treatment Chapter 6: Principles and Methods of Treatment Chapter 7: Treatment of the Extraordinary Vessels
SECTION 4: Menstrual Irregularities Introduction Chapter 8: Early Periods Chapter 9: Late Periods Chapter 10: Irregular Periods Chapter 11: Heavy Periods Chapter 12: Scanty Periods Chapter 13: Long Periods Chapter 14: Painful Periods Chapter 15: Bleeding between Periods Chapter 16: No Periods Chapter 17: Flooding and Trickling Chapter 18: Pre-Menstrual Syndrome SECTION 5: Problems at Period Time Introduction Chapter 19: Pre-Menstrual Breast Distension Chapter 20: Headaches During Periods Chapter 21: Oedema During Periods Chapter 22: Diarrhoea at Period Time Chapter 23: Body Aches at Period Time
Chapter 24: Fever at Period Time Chapter 25: Epistaxis or Haemoptysis at Period Time Chapter 26: Mouth Ulcers at Period Time Chapter 27: Skin Eruptions at Period Time Chapter 28: Dizziness at Period Time SECTION 6: Diseases of Pregnancy Introduction Chapter 29: Morning Sickness Chapter 30: Abdominal Pain During Pregnancy Chapter 31: Threatened Miscarriage Chapter 32: Fetus not Growing Chapter 33: Oedema During Pregnancy Chapter 34: Anxiety During Pregnancy Chapter 35: Dizziness During Pregnancy Chapter 36: Convulsions During Pregnancy Chapter 37: Feeling of Suffocation During Pregnancy Chapter 38: Aphonia During Pregnancy Chapter 39: Cough During Pregnancy Chapter 40: Urinary Syndrome During Pregnancy Chapter 41: Retention of Urine During Pregnancy
Chapter 42: Constipation During Pregnancy Chapter 43: Habitual Miscarriage Chapter 44: Acupuncture and Herbal Treatment in Midwifery SECTION 7: Diseases after Childbirth Introduction Chapter 45: Post-Natal Depression Chapter 46: Abdominal Pain after Childbirth Chapter 47: Persistent Lochial Discharge (and Retention of Lochia) Chapter 48: Urinary Difficulty after Childbirth Chapter 49: Sweating after Childbirth Chapter 50: Constipation and Haemorrhoids after Childbirth Chapter 51: Fever after Childbirth Chapter 52: Joint Pain after Childbirth Chapter 53: Breast Milk not Flowing (and Acute Mastitis) Chapter 54: Spontaneous Flow of Milk Chapter 55: Collapse after Childbirth Chapter 56: Convulsions after Childbirth SECTION 8: Miscellaneous Diseases Introduction Chapter 57: Infertility
Chapter 58: Menopausal Syndrome Chapter 59: Breast Lumps Chapter 60: Abdominal Masses Chapter 61: Excessive Vaginal Discharge Chapter 62: Vaginal Itching (and Trichomonas and Candida Infections and Genital Eczema) Chapter 63: Prolapse of the Uterus Chapter 64: Vulvar Sores Chapter 65: Endometriosis Chapter 66: Polycystic Ovary Syndrome Chapter 67: Myoma APPENDIX 1: Herbal Prescriptions APPENDIX 2: Suggested Substitutions of Chinese Herbs Pinyin-English Glossary Of Chinese Terms English-Pinyin Glossary of Chinese Terms Cross-Reference of Chinese Disease-Symptoms with Western Diseases Cross-Reference of Western Diseases with Chinese Disease-Symptoms Chronology of Chinese Dynasties Bibliography Index
Colour Plates
SECTION 1 Physiology and Pathology
CHAPTER 1 History of Gynecology in Chinese Medicine Like all branches of Chinese medicine, traditional gynecology has a long history. The earliest records of gynecological medical writings date from the Shang dynasty (1500–1000 BC): bones and tortoise shells have been found with inscriptions dealing with childbirth problems. The text Book of Mountains and Seas from the Warring States period (476–221 BC) describes medicinal plants to treat infertility. The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen) has many references to women’s physiology, anatomy, diagnosis and treatment of gynecological problems. It describes the function of the Uterus and states its connection to the Heart and Kidneys via the Bao Mai (Uterus Vessel) and Bao Luo (Uterus Channel) respectively. For example, the Simple Questions in Chapter 33 says: In amenorrhoea, the Uterus Vessel is shut. The Uterus Vessel pertains to the Heart and communicates with the Uterus; when Qi rebels upwards to press towards the Lungs, Heart-Qi cannot flow downwards and amenorrhoea results.1 In Chapter 47 it says: “The Uterus Channel connects with the Kidneys; the Kidney channel reaches the root of the tongue.”2 The very first chapter of the Simple Questions describes the hormonal changes occurring in women at 7-year intervals and attributes these to the waning and waxing of the Directing and Penetrating Vessels. The Simple Questions also describes the aetiology and treatment of amenorrhoea and menorrhagia. The first chapter of the Simple Questions mentions for the first time the important substance Tian Gui. Tian Gui is a transformation of Kidney-
Essence that occurs at puberty. In men, it is sperm; in women, it is menstrual blood and ova. Chapter 1 of the Simple Questions says: “When a girl is 14, the Tian Gui arrives, the Directing Vessel is open and the Penetrating Vessel flourishing, the period arrives and she can conceive.”3 That gynecology already existed as a speciality during the Warring States period is recorded in the Historical Annals (Shi Ji) which refers to the famous doctor Bian Que as one who ‘treats diseases under the skirt belt’ (Dai Xia Yi), i.e. a gynecologist. During the Han dynasty (206 BC–AD 220), a gynecologist was called a ‘breast doctor’ (Ru Yi) or ‘women’s doctor’ (Nu Yi). The earliest recorded gynecologists under that name were two doctors called Yi Xu and Chun Yu Yan who treated one of the empresses during the Western Han dynasty (206 BC–AD 24). The famous doctor Zhang Zhong Jing refers in his work Discussion on Cold-induced Diseases (Shang Han Lun) to a previous book entitled Series of Herbs for Obstetrics (Tai Lu Yao Lu) which proves that even before the Han dynasty there were books dealing exclusively with gynecology, but all of these have been lost. The Discussion of Prescriptions of the Golden Cabinet (Jin Gui Yao Lue Fang Lun) by the same author has three chapters on gynecology, i.e. ‘On pregnancy’, ‘Post-partum diseases’ and ‘Women’s miscellaneous diseases’. These chapters discuss disorders of menstruation, leucorrhoea, pregnancy, miscellaneous diseases and post-partum problems. Over thirty gynecological formulae are discussed, e.g. Wen Jing Tang Warming the Menses Decoction, Jiao Ai Tang Donkey’s Hide Glue-Artemisia Decoction, Dang Gui San Angelica Powder, Gan Jiang Ren Shen Ban Xia Wan Zingiber-Ginseng-Pinellia Pill, Gui Zhi Fu Ling Wan Ramulus Cinnamomi-Poria Pill, etc. All these formulae are still widely used nowadays. These three chapters on gynecology represent one of the earliest gynecological treatises and they formed the model upon which subsequent books were based. The Pulse Classic (Mai Jing, AD 280) by Wang Shu He, a famous doctor of the Jin dynasty (265–420), describes pulse pictures and differentiation of women’s diseases in Volume 9. This book constitutes an assimilation and systematization of the gynecological material from earlier
texts, notably the Yellow Emperor’s Classic of Internal Medicine, the Classic of Difficulties and the Synopsis of Prescriptions from the Golden Cabinet. Wang Shu He also added a wealth of comment from his personal experience in the gynecological field. For example, he says that “The Kidneys govern the Uterus, and its condition is reflected at the Rear position of the pulse. If the pulse at this region does not fade on pressure, it indicates pregnancy.”4 In another passage he says that “A superficial pulse accompanied by abdominal pain referred to the midline of the lower back, indicates impending labour.”5 The book also describes the qualities of the pulse before an imminent miscarriage, normal and abnormal pulses during the post-partum stage and pulses in women with abdominal masses in relation to prognosis. During the Sui dynasty (581–618), Chao Yuan Fang wrote the General Treatise on the Symptomatology and Aetiology of Diseases (Zhu Bing Yuan Hou Zong Lun, AD 610) which deals with gynecology and obstetrics in Volumes 37 to 44. The book describes 283 syndromes covering diseases of menstruation, leucorrhoea, pregnancy and post-partum diseases. The Thousand Golden Ducat Prescriptions (Qian Jin Yao Fang, AD 652) written by Sun Si Miao during the Tang dynasty (618–907) has three volumes dealing with gynecology, including the differentiation and treatment of infertility, diseases of pregnancy, menstruation, leucorrhoea, etc., with hundreds of formulae for these diseases. Sun Si Miao made the interesting observation that a metal knife should never be used to cut the umbilical cord: from a modern perspective, this was an important recommendation as, if dirty, a metal instrument could easily provoke a tetanus infection. The Treasure of Obstetrics (Jing Xiao Chan Bao), written during the Tang dynasty, is the earliest obstetrics book. The book contains 12 chapters on diseases of pregnancy, 4 chapters on difficult labour and 25 chapters on post-partum diseases. Diseases of pregnancy discussed include morning sickness, bleeding, threatened miscarriage, miscarriage, urinary problems and oedema. The discussion on labour problems includes formulae for promoting labour, and on dealing with a dead fetus, prolonged labour or retention of placenta. The discussion on post-partum diseases includes tetanus, puerperal
infections, abdominal pain, persistent bleeding, retention of urine, insufficient lactation and mastitis. During the Song dynasty (960–1279), the imperial medical college was staffed by 300 people; there were nine departments, one of which was obstetrics and gynecology. This was probably the earliest medical school department dedicated entirely to gynecology and obstetrics. The specialization fostered by the division of the imperial medical college into different departments stimulated the development of the various specialties, among which was gynecology. This led to the publication of many books specializing in obstetrics and gynecology, an important one being the Great Treatise of Useful Prescriptions for Women (Fu Ren Liang Fang Da Quan, 1237) written by Chen Zi Ming during the Southern Song dynasty. The book comprises 24 volumes including 20 chapters on menstrual diseases, 91 on miscellaneous diseases, 10 on infertility, 8 on ‘fetal education’, 9 on pregnancy problems, 70 on post-partum diseases and 10 on boils and ulcers. More than 260 diseases are discussed in all with various formulae for each. This book exerted a profound influence on the development of obstetrics and gynecology in subsequent dynasties. During the Jin and Yuan dynasties (1115–1368) many different medical schools of thought flourished, among which the main ones were those headed by Liu Wan Su, Li Dong Yuan, Zhu Dan Xi and Zhang Zi He. Liu Wan Su (1120–1200) maintained that Fire is the primary cause of disease and he therefore advocated the use of cold herbs in gynecological problems. For example, he attributed amenorrhoea to Heart-Fire. He also advocated treating the Kidney channel in girls before puberty, the Liver channel in young women and the Spleen channel in post-menopausal women. He also paid attention to modifying gynecological formulae according to the seasons. Recognizing the influence of the seasons on medical conditions, he advocated doubling the dosage of Chuan Xiong Radix Chuanxiong within the formula Si Wu Tang Four Substances Decoction during springtime, doubling Bai Shao Radix Paeoniae alba in summertime, doubling Shu Di Huang Radix Rehmanniae preparata during the autumn and doubling Dang Gui Radix Angelicae sinensis in wintertime. He also suggested adding Fang Feng
Radix Saposhnikoviae in springtime, Huang Qin Radix Scutellariae in summertime, Mai Men Dong Radix Ophiopogonis in the autumn and Gui Zhi Ramulus Cinnamomi in winter. Li Dong Yuan (1180–1251) was the founder of the ‘School of Stomach and Spleen’ which emphasized a disharmony of these two organs as the main aetiology and pathology of diseases. He therefore advocated tonifying the Stomach and Spleen as the main method of treatment in gynecology too. In his book Secret Record of the Orchid Chamber (Lan Shi Mi Cang), he says that prolonged deficiency of the Stomach and Spleen leads to amenorrhoea, and that to treat this, one needs to clear Stomach-Heat, generate Stomach fluids and tonify Qi and Blood. He says that uterine bleeding is due to deficiency of the Stomach and Spleen, arousing Minister Fire of the Kidneys and causing Damp-Heat to infuse downwards: to treat this he advocates tonifying the Stomach and Spleen and raising Qi. Zhu Dan Xi (1281–1358) maintained that “Yang is often in excess and Yin is often deficient” and therefore advocated nourishing Yin as one of the most important treatment principles. For example, for problems before childbirth he advised clearing Heat and nourishing Blood. He also indicated Huang Qin Radix Scutellariae and Bai Zhu Rhizoma Atractylodis macrocephalae as two important herbs to prevent miscarriage. Zhang Zi He (1156–1228) treated diseases by the three methods of sweating, vomiting and moving downwards. He used tonics only after first using herbs that eliminate pathogenic factors, since one cannot tonify when these are present. He applied this method to gynecological diseases as well, often advocating that the patient be made to vomit and using downwardmoving methods of treatment to eliminate Phlegm and Water in menstrual problems. The doctors of the Ming dynasty (1368–1644) consolidated and integrated the theories of these four great schools of medical thought. Many important gynecological books were written during the Ming dynasty, e.g. Standards of Diagnosis and Treatment of Women’s Diseases (Zheng Zhi Zhun Sheng – Nu Ke, 1602) by Wang Ken Tang, Summary of Gynecology and Obstetrics (Nu Ke She Yao, 1548) by Xue Ji, Summary
of Fertility (Guang Si Ji Yao) and Women’s Secrets (Fu Ren Mi Ke) by Wan Quan. He said that, in order to conceive, the man should clear his Heart and control his sexual desire to nourish the Essence, while a woman should calm her Mind and settle Qi to nourish Blood. The above-mentioned Standards of Diagnosis and Treatment by Wang Ken Tang summarized the experience of doctors of previous generations in the treatment of gynecological diseases. His book dealt with menstrual problems, miscellaneous diseases, pregnancy problems and post-partum diseases. Wu Zhi Wang adopted this book as a chief source to write his Compendium of Therapy of Women’s Diseases (Ji Yin Gang Mu, 1620) which became an authoritative text for subsequent generations of gynecologists. The Complete Works of Jing Yue (Jing Yue Quan Shu, 1624), by Zhang Jing Yue, has an extensive section on gynecology and obstetrics discussing the treatment of problems of pregnancy and labour, leucorrhoea, breast diseases, fertility, abdominal masses and menstruation. Zhang Jing Yue recommended paying particular attention to regulating menstruation in gynecological diseases. He said that the key to regulate menstruation is to nourish Blood by tonifying the Stomach and Spleen and calming the chamber of Blood by tonifying the Kidneys. On the question of whether the Spleen or the Kidneys was the more important organ, he decided in favour of the latter. During the Qing dynasty (1644–1911) many gynecological treatises were written. The three most important ones were Fu Qing Zhu’s Gynecology (Fu Qing Zhu Nu Ke) by Fu Qing Zhu (1607–1684), the Golden Mirror of Medicine (Yi Zong Jin Jian, Vol. 3, 1742) by Wu Qian and the Treatise on Obstetrics (Da Sheng Bian, 1715) by Ji Zhai Ju Shi (a pseudonym meaning ‘the Buddhist of Ji House’). Fu Qing Zhu’s Gynecology is unlike any other gynecology book insofar as the author proposes his own personal, and often unorthodox, ideas on the pathogenesis and treatment of gynecological diseases and his formulae are unlike any of those from previous gynecological books. One of the central theses of Fu Qing Zhu’s book is that the Kidneys are the most important organ for the menstrual function as they are the origin of menstrual blood. According to him, menstrual blood is unlike normal ‘Blood’: it is a
precious fluid derived from the Kidney-Essence. His book discusses the differentiation and treatment of menstrual problems, pregnancy, post-partum diseases, infertility, leucorrhoea and labour, with the different patterns and formulae for each. The gynecology volume of the Golden Mirror of Medicine by Wu Qian discusses the pathology and treatment of menstrual problems, leucorrhoea, pregnancy, labour, post-partum diseases, abdominal masses and miscellaneous diseases. One particular feature of this book is that it is written in a style that is easy to read. The Treatise on Obstetrics focuses on diseases of pregnancy, management of normal and difficult labour, and post-partum diseases. During the late Qing dynasty, Western medicine was introduced to China and integrated with Chinese medicine. The two principal doctors who advocated the integration of Chinese and Western medicine were Tang Zong Hai (1862–1918) and Zhang Xi Chun (1860–1933). These doctors did not write specialized books on gynecology but they did discuss gynecological and obstetric problems in their works. For example, in his book Discussion on Blood Syndromes (Xue Zheng Lun, 1885), Tang Zong Hai discusses the treatment of menstrual problems, uterine bleeding, stasis of Blood, accumulation of Blood, amenorrhoea, etc. Zhang Xi Chun paid special attention to regulating Spleen and Kidneys and invigorating Blood in treating gynecological diseases. He formulated several important prescriptions such as Li Chong Tang Regulating the Penetrating Vessel Decoction, An Chong Tang Calming the Penetrating Vessel Decoction, Gu Chong Tang Consolidating the Penetrating Vessel Decoction and Shou Tai Wan Fetus Longevity Pill in his book Records of Combined Chinese and Western Medicine (Yi Xue Zhong Zhong Can Xi Lu, 1918). Since 1949, the combination of Western and Chinese medicine has been emphasized and many innovative treatments have been devised. For example, ectopic pregnancy is often treated with acupuncture and Chinese herbs without recourse to surgery; acupuncture is used in breech presentation of the fetus; Chinese herbs are used in the treatment of myomas and cervical carcinoma, etc. Since the major colleges of traditional Chinese medicine
were established in 1956, many modern gynecology textbooks have been published and the ancient ones reprinted. End notes 1. 1979 The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Ti Nei Jing Su Wen
), People’s Health Publishing House, Beijing, p. 197. First published c. 100 BC..
2. Ibid., p. 259..
3. Ibid., p. 4..
4. Wang Shu He 1988 A Revised Explanation of the Pulse Classic (Mai Jing Jiao Shi
), with commentary by the Fuzhou City People’s Hospital, People’s Health Publishing House, Beijing, p. 585. First published in AD 280..
5. Ibid., p. 588..
CHAPTER 2 Women’s Physiology
THE UTERUS 8 PHYSIOLOGY OF MENSTRUATION AND THE FOUR PHASES 10 The origin, nature and function of Tian Gui 10 The four phases of the menstrual cycle 12 Menstruation in Western medicine 14 Hypothalamus–pituitary–ovarian axis 17 Chinese medicine view of the four phases in detail 19 The four phases and treatment principles 23 MENSTRUATION AND THE INTERNAL ORGANS 24 Kidneys 24 Liver 28 Spleen 30 Heart 31 Lungs 32 Stomach 32 MENSTRUATION AND THE EXTRAORDINARY VESSELS 33 Penetrating Vessel (Chong Mai) 33 Directing Vessel (Ren Mai) 36 Governing Vessel (Du Mai) 38 Girdle Vessel (Dai Mai) 40 Yin Stepping Vessel (Yin Qiao Mai) 42 CONCEPTION 43
PREGNANCY 44 MENOPAUSE 45 Women’s physiology and gynecological systems are influenced particularly by one organ, one vital substance and one structure: • The Kidneys. • Blood. • The Uterus. The Kidneys play a huge role in gynecology as they are the origin of Tian Gui, i.e. menstrual blood, and the ova from the ovaries. Without Tian Gui, there would be no menstrual cycle and no fertility. The origin, nature and function of Tian Gui are discussed at length below. In women, Blood plays a role in menstruation, fertility, conception, pregnancy and childbirth. Although Tian Gui is not equivalent to Blood, the Blood stored by the Liver and the Uterus does play a role in women’s physiology. Moreover, although menstrual blood is Tian Gui (and therefore ‘Water’), the Post-Natal Qi and Blood produced by Stomach and Spleen do play a (secondary) role in producing menstrual blood. Clinical Note Although menstrual blood is Tian Gui (and therefore ‘Water’), the PostNatal Blood of Stomach and Spleen does play a secondary role in producing menstrual blood. For this reason, in order to tonify Blood in women, we can reinforce BL-20 Pishu and BL-23 Shenshu to nourish the Post-Natal Blood and the Tian Gui respectively. Women’s physiology is, of course, also dominated by the fact that their lower Dan Tian houses the Uterus which, in turn, stores Blood. This is of huge clinical significance: because women’s lower abdomen contains the
Uterus which stores Blood, women are much more prone to Blood stasis than men are. Clinical Note Women are very prone to Blood stasis. In complicated, chronic gynecological problems, always suspect Blood stasis. In order to understand women’s physiology, it may be helpful to compare and contrast it with men’s physiology. Women pertain to Yin but some aspects of their physiology are Yang; men pertain to Yang but some aspects of their physiology are Yin. Women’s physiology is rooted in Blood, men’s in Qi; men store Essence, women store the Uterus, Blood and fetus. The book Elementary Medicine (1575) says: Men store Essence, women the Uterus and the fetus. Men take Qi as their foundation, they are Yang constitutionally but Yin functionally; the sperm is white but can be red if there is Fire. Women take Blood as their foundation; they are Yin constitutionally but Yang functionally; menstrual blood is red but it can be white if there is Phlegm.1 The Secret Records of Master Feng’s Brocade Bag says: Man pertains to Yang but there is Yin within Yang. The Yin number is 8 so man’s Yang essence rises at the age of 8 and is abundant at the age of 16. Woman pertains to Yin but there is Yang within Yin. The Yang number is 7 so woman’s essence rises at the age of 7 and is abundant at the age of 14.2 This passage of course makes reference to the life cycles of men (8 years) and women (7 years) first introduced by Chapter 1 of the Simple Questions. The discussion of women’s physiology will consist of the following parts: • The Uterus
• Physiology of menstruation and the Four Phases • Menstruation and the internal organs • Menstruation and Extraordinary Vessels • Conception • Pregnancy • Menopause
The uterus The Uterus received many different names during the development of Chinese medicine: Zi Bao, Bao Gong, Zi Zang, Zi Chu, Xue Zang (Baby’s Bao, Bao Palace, Baby’s Zang, Baby’s Abode, Blood Zang). The Chinese word Bao conveys the idea of a ‘container’ and for this reason the Uterus is called Zi Bao, i.e. the contained or the baby (in pregnancy). However, please note that Bao by itself is a structure that is common to both women and men; it is only the Zi Bao (‘baby’s container’) that is exclusive to women. As indicated below, in men, Bao is the Jing Shi which can be translated either as ‘Room of Sperm’ or ‘Room of Essence’. In women, the Uterus corresponds to the Lower Field of Elixir (Dan Tian) which in men houses the ‘Room of Sperm’. The Golden Mirror of Medicine (Yi Zong Jin Jian, 1742) says: The Governing Vessel [Du Mai] arises within the lower abdomen, externally in the abdomen, internally in the Bao … also called Dan Tian in both men and women: in women it is the Uterus, in men it is the Room of Sperm.3 This passage clearly shows that Bao is a structure common to both men and women, being the Uterus in women and the ‘Room of Sperm’ in men. As we shall see, the Extraordinary Vessels arise from this area (Fig. 2.1).
Figure 2.1 The Bao in men and women. The Uterus is one of the six ‘extra Yang organs’. These organs have the shape of a Yang organ (i.e. hollow) and the function of a Yin organ (i.e. storage). The Uterus’s shape is hollow and menstruation and labour are an expression of its function of discharging (as a Yang organ). On the other hand, the Uterus stores Blood and nourishes the fetus during pregnancy (an expression of its function as a Yin organ; see Fig. 2.2).
Figure 2.2 The Uterus as one of the six Extraordinary Yang organs. The Uterus is related to the Kidneys via a channel called the Uterus Channel (Bao Luo). Chapter 47 of the Simple Questions says: “The Uterus Channel extends to the Kidneys.”4 The Uterus is also physiologically related to the Heart via a channel called the Uterus Vessel (Bao Mai). Chapter 33 of the Simple Questions says: “The Uterus Vessel pertains to the Heart and extends to the Uterus” and “When the period does not come it means that the Uterus Vessel is obstructed”5 (Fig. 2.3).
Figure 2.3 The Uterus connection with Kidneys and Heart.
Clinical Note The Uterus is functionally related to the Kidneys via the Uterus Channel (Bao Luo) and to the Heart via the Uterus Vessel (Bao Mai). The latter
connection with the Heart explains the strong influence of emotional stress on menstruation. In order to influence the Uterus through the Heart channel I use mostly HE-5 Tongli. Hence normal menstruation and fertility depend on the state of the Kidney-Essence and of Heart-Qi and Heart-Blood. The Kidney-Essence and Tian Gui are the primary factors in menstruation and fertility: if the Kidney-Essence is deficient, there may be amenorrhoea and/or infertility. However, the Heart also plays a role. If Heart-Qi does not descend to the Uterus, this may also cause amenorrhoea. Figure 2.4 shows the connection between the Uterus and the internal organs.
Figure 2.4 The Uterus and internal organs. ‘Uterus’ has a broad definition in Chinese medicine, encompassing structures beyond the uterus itself, including the fallopian tubes and the ovaries. Thus, the ‘Uterus’ and, in particular, the Kidneys are responsible for all the functions that in Western medicine are related to uterus, tubes and ovaries, and indeed including the hypothalamus–pituitary–ovarian axis. For this reason, too, Tian Gui has a broader meaning than simply menstrual blood as it must include the ova from the ovaries.
!The ‘Uterus’ of Chinese medicine includes the ovaries and Tian Gui includes the ova. Interestingly, in Western medicine too there is a connection between the uterus and ovaries. There is evidence that hysterectomy with conservation of the ovaries is associated with earlier ovarian failure and this may be due to a reduction in the blood supply to the ovaries following surgical clamping of the uterine arteries. Animal studies have shown that uterine tissue is necessary to ensure the development of ovarian follicles.6 Summary
Uterus
• The Uterus was variously called Baby’s Bao, Bao Palace, Baby’s Zang, Baby’s Abode, Blood Zang • Bao by itself is a structure that is common to both women and men: in men, Bao is the Jing Shi which can be translated either as ‘Room of Sperm’ or ‘Room of Essence’ • The Uterus is one of the six ‘extra Yang organs’ with the shape of a Yang organ (i.e. hollow) and the function of a Yin organ (i.e. storage) • Menstruation and labour are an expression of its function of discharging (as a Yang organ). On the other hand, the Uterus stores Blood and nourishes the fetus during pregnancy (an expression of its function as a Yin organ) • The Uterus is related to the Kidneys via a channel called the Uterus Channel (Bao Luo) and to the Heart via a channel called the Uterus Vessel (Bao Mai) • Normal menstruation and fertility depend on the state of the Kidney-Essence and of Heart-Qi and Heart-Blood • ‘Uterus’ has a broad definition in Chinese medicine, encompassing structures beyond the uterus itself, including the fallopian tubes and the ovaries
Physiology of menstruation and the four phases Menarche (the onset of the first menstrual period) statistically starts at 12.8 years of age in industrialized countries, with a range of 10 to 16 years. In the United Kingdom, menarche occurs between the ages of 11 and 15 in 95% of girls and the median age is 13.7 In the USA, 90% of girls experience menarche between the ages of 11 and 13.75 and the median age is 12.43.8 In China, menarche occurs within the 13 to 15 age range in the overwhelming majority of girls.9 Menarche occurring before the age of 10 is considered premature, and menarche is delayed if it has not occurred by the age of 16. The mean age of menopause is 50: if it occurs before the age of 35 it is termed premature, and if it has not occurred by the age of 55, delayed. From a Western medical perspective, the menstrual cycle occurs every 21 to 36 days and lasts 3 to 7 days, with the woman losing an average amount of 30– 80 ml. The colour is usually dark red, lighter at the beginning, deep in the middle and pinkish at the end of the period. The normal flow does not coagulate and there are no clots; the blood is neither dilute nor thick. A study of 321 women showed that the commonest bleeding lengths were 5 and 6 days, found in 49% of women.10 The range of the above ‘normal’ values from a Western medical perspective is somewhat broader than what Chinese medicine would consider ‘normal’. For example, Chinese medicine would consider a range of 26 to 32 days more normal for the length of the menstrual cycle than a range of 21 to 36 days. It should be stressed here that regularity of the cycle is allimportant: if the cycle length varies from month to month, this would be considered abnormal even if it fell within the 26 to 32 days range. On the other hand, were the period to occur regularly every 33 days, this would be considered normal. Similarly, Chinese medicine would consider a duration of 4 to 6 days for menstruation as more ‘normal’ than that of 3 to 7 days.
The origin, nature and function of Tian Gui Tian Gui is mentioned in the first chapter of the Simple Questions in connection with the life cycles of men and women. Chapter 1 of the Simple Questions says: “At 14 the Tian Gui arrives, the Directing Vessel [Ren Mai] is open and the Penetrating Vessel [Chong Mai] flourishing, the period arrives and the girl can conceive.”11 Tian Gui is the ancient Chinese equivalent of hormonal development in modern medicine. In men, Tian Gui is sperm, while in women, it is menstrual blood and the ova. The root of Tian Gui is in the Kidney-Essence and the Minister Fire which are present from conception. They need 14 years in girls and 16 years in boys to mature into ova and sperm respectively. The Post-Natal Qi and Blood of the Stomach and Spleen play a role (albeit a secondary one) in the formation of menstrual blood and the maturation of eggs at puberty. The term Tian Gui is impossible to translate because Tian means ‘heaven’ or ‘heavenly’ but Gui refers to the 10th Heavenly stem of the Chinese calendar: thus the word ‘Gui’ must remain untranslated. The fact that the term for Tian Gui refers to ‘Heaven’ is significant: it refers to the fact that women’s menstrual cycle is influenced by cosmic cycles. Indeed, the term Tian Gui refers to ‘Heaven’ twice: once in the term ‘heavenly’ itself and once because Gui is a Heavenly stem, i.e. representing the heavenly influence of a particular year. Each year is denoted by one of the 10 Heavenly stems and one of the 12 Earthly Branches. Moreover, it is significant that the Heavenly stem Gui pertains to Water: in fact there are 10 stems divided into 5 couples, each couple pertaining to one of the Five Elements. The fact that the stem Gui pertains to Water indicates that Tian Gui is a form of Water, a transformation of Kidney-Water. What exactly is Tian Gui? All Chinese books say that Tian Gui is menstrual blood and that, for this reason, menstrual blood is not the same as Liver-Blood, i.e. the ‘Blood’ that nourishes the sinews, eyes, hair and skin. Menstrual Blood is a precious fluid that originates from Kidney-Water and Kidney-Essence.
Thus menstrual Blood is called ‘Heavenly Gui’ because it represents the descending of Heavenly Gui materializing into Water (the 10th stem Gui pertains to Water). The Great Treatise of Beneficial Formulae for Women (1237) explains: When the girl is 14 the Heavenly Gui arrives, the Directing Vessel is open, the Penetrating Vessel is flourishing and the period arrives. “Heavenly” indicates the descending of the True Qi of Heaven; “Gui” indicates Water [as this stem pertains to Water]: [menstrual blood is therefore] like heavenly clouds generating water.12 The famous Qing dynasty gynecologist Fu Qing Zhu (1607–1684) stressed forcefully that menstrual blood is not ‘Blood’ but ‘Water’. Fu Qing Zhu holds that menstrual blood is not Blood but Tian Gui which originates from the Kidneys. He says it is formed from Kidney-Yin but with the participation of Heart-Yang (another way in which the Heart influences menstruation) and that despite being blood-red in colour it is not Blood; hence its name of Tian Gui.13 He also says that the generation of Tian Gui has nothing to do with Heart, Liver or Spleen; these organs only help its transformation into Blood. His original passage says: Menstrual blood is not Blood but Heavenly Water, originating within the Kidneys, it is the essence of extreme Yin and Qi of extreme Yang. It is red like blood but it is not blood. That is why it is called Heavenly Gui. People nowadays regard menstrual blood as Blood, a mistake perpetuated for 1000 years … in fact it is not called bloodwater [Xue Shui] but menstrual water [Jing Shui] … the generation of Kidney Water [and therefore menstrual blood] has nothing to do with Heart, Liver and Spleen, but the transformation of Kidney Water is helped by Heart, Liver or Spleen.14 It should be emphasized that while menstrual blood is a form of Tian Gui, this is not only menstrual blood as it is also the origin of sperm in men (Fig. 2.5).
Figure 2.5 Generation and transformation of Tian Gui according to Fu Qing Zhu.
However, in women, in my opinion Tian Gui is not simply menstrual blood but it must include the ova. The first chapter of the Simple Questions obviously refers to the ova when it says that “Tian Gui arrives and the girl can conceive”. It is the maturation of the ova occurring at puberty, not menstrual blood, that allows conception. Summary The origin, nature and function of Tian Gui
• Tian Gui is mentioned in the first chapter of the Simple Questions in connection with the life cycles of men and women • When a girl is 14, the Tian Gui arrives, the Directing Vessel (Ren Mai) is open and the Penetrating Vessel (Chong Mai) flourishing, the period arrives and the girl can conceive • In men, Tian Gui is sperm, while in women it is menstrual blood and the ova • The root of Tian Gui is in the Kidney-Essence and the Minister Fire which are present from conception
• The Post-Natal Qi and Blood of the Stomach and Spleen play a role (albeit a secondary one) in the formation of menstrual blood and the maturation of eggs at puberty • Tian Gui is menstrual blood and, for this reason, menstrual blood is not the same as Liver-Blood, i.e. the ‘Blood’ that nourishes the sinews, eyes, hair and skin. Menstrual blood is a precious fluid that originates from Kidney-Water and Kidney-Essence • The famous Qing dynasty gynecologist Fu Qing Zhu (1607–1684) stressed forcefully that menstrual blood is not ‘Blood’ but ‘Water’ • Fu Qing Zhu holds that menstrual blood is not Blood but Tian Gui which originates from the Kidneys. He says it is formed from Kidney-Yin with the participation of Heart-Yang • He also says that the generation of Tian Gui is from the Kidneys while the Heart, Liver and Spleen help its transformation into menstrual blood • In women, in my opinion, Tian Gui is not simply menstrual blood but it must include the ova
The four phases of the menstrual cycle The theory of the four phases of the menstrual cycle is not an ancient, traditional theory but a modern one. However, it is a modern theory that is based on the integration of the ancient concepts of Yin-Yang and Kidney-Yin and Kidney-Yang with modern hormonal knowledge. This theory was developed largely by Professor Xia Gui Cheng of the Nanjing University of Traditional Chinese Medicine. According to this theory, the menstrual cycle is determined by the ebb and flow of two tides: one of Kidney-Yin, the other of Kidney-Yang. The amount of Yin and Yang (and specifically Kidney-Yin and Kidney-Yang) fluctuates like a tide during the month in a determined pattern. The pattern is that Yang decreases when the period starts and reaches a minimum at mid-cycle; Yin increases when the period starts and reaches a maximum at mid-cycle. Thus, Yang reaches its maximum level just before the period starts and then begins to decrease rapidly as soon as the period starts (this rapid decline of Yang explains the disappearance of pre-menstrual symptoms when the period starts). Yang reaches its minimum level at mid-cycle after which it starts to rise again. It rises rapidly in the few days before the period. As for Yin, it is at its minimum level at the beginning of the period after which it starts to rise, reaching its maximum at mid-cycle. After that, it starts to decline until the next period starts. Thus, at mid-cycle, there is a maximum of Yin and minimum of Yang; when the period starts, there is a maximum of Yang and minimum of Yin. Note that there are two crucial times of transformation from Yin to Yang and Yang to Yin. In fact, when the period starts, Yang decreases from its maximum level and Yin increases from its minimum level: thus, there is a switch, a transformation from Yang to Yin. The opposite happens at midcycle (around ovulation time). At this time, Yin has reached its maximum and starts to decline while Yang has reached its minimum level and starts to increase: thus, there is a switch, a transformation from Yin to Yang, the opposite of what happened at the beginning of the period. This transformation of Yang to Yin and vice versa is under the control of the Heart: it relies on the descending of Heart-Qi and Heart-Blood. If for any
reason Heart-Qi does not descend to the Uterus (via the Bao Mai, Uterus Vessel), then the period or ovulation might be delayed: conversely, should Heart-Qi descend too soon, the period or ovulation might come early. The times of transformation of Yang to Yin and vice versa are marked by discharge and downward movement. In fact, when the period starts (transformation from Yang to Yin), there is a discharge and downward movement of blood. During mid-cycle (transformation from Yin to Yang), there is a discharge and downward movement of the ovum (or ova). Figure 2.6 illustrates the ebb and tide of Yin and Yang in the four phases of the menstrual cycle. Please note that the diagram of the four phases is rather theoretical, i.e. it shows the ebb and flow of Yin and Yang as perfectly symmetrical during the month. In practice, it is not so. In practice, the diagram representing the ebb and flow of Yin and Yang would be rather different. One difference is, for example, that the Yin is at its minimum level not at the beginning of the period but towards the end of it. In fact, at the end of the period, Blood and Yin are in a state of ebb. Another difference is that the rise of Yang in the second half of the cycle is steeper at first and then levels off after ovulation (reflecting the rise in temperature that occurs after ovulation). Taking these two differences into account, the diagram might look like the diagram in Figure 2.7.
Figure 2.6 The four phases of the menstrual cycle. FSH, follicle-stimulating hormone; LH, luteinizing hormone.
Figure 2.7 Actual representation of flow of Yin and Yang in the four phases.
Summary The four phases of the menstrual cycle
• The menstrual cycle is determined by the ebb and flow of two tides: one of Kidney-Yin, the other of Kidney-Yang • The amount of Yin and Yang (and specifically Kidney-Yin and Kidney-Yang) fluctuates like a tide during the month in a determined pattern • The pattern is that Yang decreases when the period starts and reaches a minimum at mid-cycle; Yin increases when the period starts and reaches a maximum at mid-cycle • Thus, at mid-cycle, there is a maximum of Yin and minimum of Yang; when the period starts, there is a maximum of Yang and minimum of Yin • There are two crucial times of transformation from Yin to Yang and Yang to Yin. When the period starts, Yang decreases from its maximum level and Yin
increases from its minimum level: thus, there is a switch, a transformation from Yang to Yin. The opposite happens at mid-cycle • This transformation of Yang to Yin and vice versa is under the control of the Heart: it relies on the descending of Heart-Qi and Heart-Blood • The times of transformation of Yang to Yin and vice versa are marked by discharge and downward movement of menstrual blood in the former and of ova in the latter
Menstruation in Western medicine The menstrual cycle in Western medicine is largely composed of two main phases: the follicular phase (dominated by oestrogen) in the first half and the luteal phase (dominated by progesterone) in the second half. The release of oestrogen by the ovaries is triggered by follicle-stimulating hormone (FSH) from the pituitary gland, and the release of progesterone by luteinizing hormone (LH). In the follicular phase, stimulated by gradually increasing amounts of oestrogen, the lining of the uterus thickens. Follicles in the ovary begin developing under the influence of a complex interplay of hormones and, after several days, one or occasionally two become dominant (non-dominant follicles atrophy and die). The dominant follicle releases an ovum, inducing ovulation. After ovulation, in the luteal phase, the remains of the dominant follicle in the ovary become a corpus luteum which produces large amounts of progesterone. Under the influence of progesterone, the endometrium changes to prepare for potential implantation of an embryo to establish a pregnancy. If implantation does not occur within approximately 2 weeks, the corpus luteum will involute, causing sharp drops in levels of both progesterone and oestrogen. These hormone drops cause the uterus to shed its lining inducing menstruation. The following is a description of the individual menstrual phases from the Western medical viewpoint. Menstruation (bleeding time) The flow of menses normally serves as a sign that a woman has not become pregnant. Eumenorrhoea denotes normal, regular menstruation that lasts for a few days, usually 3 to 5 days, but anywhere from 2 to 7 days is considered normal (not in Chinese medicine). The menstrual fluid is largely a mixture of blood and tissue from the endometrium. The average blood loss during
menstruation is 35 ml with 10–80 ml considered normal. The enzyme plasmin inhibits clotting in the menstrual fluid. Slight cramping in the abdomen, back or upper thighs is common during the first few days of menstruation. When menstruation begins, symptoms of pre-menstrual syndrome (PMS) such as breast tenderness and irritability generally decrease. From the Chinese perspective, the menstruation (bleeding phase) is under the control of Liver-Blood and the Penetrating Vessel (Chong Mai). Summary Menstruation in Western medicine
• Eumenorrhoea denotes normal, regular menstruation that lasts for a few days, usually 3 to 5 days • The menstrual fluid is largely a mixture of blood and tissue from the endometrium • The average blood loss during menstruation is 35 ml with 10–80 ml considered normal • From the Chinese perspective, the menstruation (bleeding phase) is under the control of Liver-Blood and the Penetrating Vessel (Chong Mai)
Follicular phase The follicular phase is also called the proliferative phase because oestrogen causes the lining of the uterus to grow during this time. Through the influence of a rise in FSH during the first days of the cycle, a few ovarian follicles are stimulated. These follicles, which were present at birth and have been developing in a process known as folliculogenesis, compete with each other for dominance. Under the influence of several hormones, all but one of these
follicles will stop growing, while one dominant follicle in the ovary will continue to maturity. The follicle that reaches maturity is called a tertiary, or Graafian, follicle, and it forms the ovum. As they mature, the follicles secrete increasing amounts of oestradiol. The oestrogens initiate the formation of a new layer of endometrium in the uterus, histologically identified as the proliferative endometrium. The oestrogen also stimulates crypts in the cervix to produce fertile cervical mucus. From a Chinese perspective, the follicular phase is under the influence of Liver-Blood, the Kidneys and the Directing Vessel (Ren Mai). Summary Follicular phase
• The follicular or proliferative phase is characterized by the growth of follicles under the influence of FSH • Under the influence of several hormones, all but one of these follicles will stop growing, while one dominant follicle in the ovary will continue to maturity when it is called the Graafian follicle: this forms the ovum • As they mature, the follicles secrete increasing amounts of oestradiol • The oestrogens initiate the formation of a new layer of endometrium in the uterus • The oestrogen also stimulates crypts in the cervix to produce fertile cervical mucus • From a Chinese perspective, the follicular phase is under the influence of Liver-Blood, the Kidneys and the Directing Vessel (Ren Mai)
Ovulation
When the egg has nearly matured, the level of oestradiol in the body has increased enough to trigger a sudden release of LH from the anterior pituitary gland. In the average cycle, this LH surge starts around cycle day 12 and may last 48 hours. The release of LH matures the egg and weakens the wall of the follicle in the ovary, causing the fully developed follicle to release its secondary oocyte. The secondary oocyte promptly matures into an otid and then becomes a mature ovum. The mature ovum has a diameter of about 0.2 mm. After being released from the ovary, the egg is swept into the fallopian tube by the fimbria, a fringe of tissue at the end of each fallopian tube. After about a day, an unfertilized egg will disintegrate or dissolve in the fallopian tube. Fertilization by a spermatozoon, when it occurs, usually takes place in the ampulla, the widest section of the fallopian tubes. A fertilized egg immediately begins the process of embryogenesis. From the Chinese perspective, the ovulation phase is under the influence of the Kidneys (Yin and Yang) and of the Directing and Penetrating Vessels (Ren and Chong Mai). Summary Ovulation
• When the egg has nearly matured, the level of oestradiol in the body has increased enough to trigger a sudden release of luteinizing hormone (LH) from the anterior pituitary gland • In the average cycle, this LH surge starts around cycle day 12 and may last 48 hours • The release of LH matures the egg and starts a process that leads eventually to the release of an ovum
• If the ovum is not fertilized, it dissolves in the fallopian tube • From the Chinese perspective, the ovulation phase is under the influence of the Kidneys (Yin and Yang) and of the Directing and Penetrating Vessels (Ren and Chong Mai)
Luteal phase The luteal phase is the part of the cycle that starts at ovulation and ends the day before the next period. It usually lasts about 14 days. The corpus luteum produces progesterone in preparing the body for pregnancy. The luteal phase must be at least 10 days long to support pregnancy. Once the follicle expels the egg, the follicle is called a ‘corpus luteum’ (‘yellow body’ from its colour). The corpus luteum is responsible for producing progesterone: this induces a thickening of the uterine lining and the development of blood vessels, which gives the embryo a place to attach to. During the luteal phase, the corpus luteum will produce progesterone for approximately 12 to 15 days. From a Chinese perspective, the luteal phase should be subdivided into two parts. The first half is under the influence of the Minister Fire which is reflected in the increase in temperature occurring after ovulation. This half is also under the control of Kidney-Yang and of the Governing Vessel (Du Mai). The second half of the luteal phase is under the control of Liver-Qi and Liver-Blood (whose movement is essential to move Blood in preparation for the period) and of the Penetrating Vessel (Chong Mai). Figure 2.8 illustrates the changes occurring in the hormones and uterus lining during the menstrual cycle. Table 2.1 shows a comparison between the phases of
Figure 2.8 Hormonal and endometrial changes during the menstrual cycle.
Table 2.1 Comparison of menstrual phases in Western medicine with the Chinese view of the four phases of the menstrual cycle
Summary Luteal phase
• The luteal phase is the part of the cycle that starts at ovulation and ends the day before the next period. It usually lasts about 14 days • The corpus luteum produces progesterone in preparing the body for pregnancy • From a Chinese perspective, the first half of the luteal phase is under the influence of the Minister Fire, Kidney-Yang and of the Governing Vessel (Du Mai) • The second half of the luteal phase is under the control of Liver-Qi and LiverBlood and of the Penetrating Vessel (Chong Mai)
the menstrual cycle in Western medicine and those in Chinese medicine. The beginning of the luteal phase corresponds to the Chinese phase 3 while the
latter part corresponds to Chinese phase 4. Thus, there is a fairly close correspondence between phases 1 and 2 between Chinese and Western medicine (phase 1 being the bleeding time and phase 2 the follicular phase, which last about 8 days, but is variable). By contrast, the luteal phase, which may last 12 to 15 days and is fairly constant (except in pathology), is split between Chinese phases 3 and 4. Note that, although increased levels of FSH result in the formation of a mature egg-containing follicle, it is the surge of LH that prompts the follicle to burst and release the egg into the fallopian tube. LH also causes the fluid inside the follicles to change into the corpus luteum which is responsible for producing progesterone in the second half of the cycle. Therefore, the luteal phase spans two Chinese phases, i.e. 3 and 4. Phase 3 is characterized by ovulation itself under the influence of LH, the rise in temperature occurring after ovulation and by the initial development of the corpus luteum. In phase 4, the temperature dips slightly and levels off, LH drops and the sharp increase in Yang seen during and after ovulation levels off. In addition, the uterus lining thickens and new blood vessels develop: from the Chinese perspective, this reflects the influence of Liver-Blood and the Penetrating Vessel (Chong Mai). Progesterone is responsible for the rise in basal body temperature during the luteal phase. A level of progesterone less than 14 ng/ml indicates that progesterone production in the luteal phase is inadequate. Should progesterone levels prove to be low, the temptation in Western medicine is often to ‘treat the symptom’ by giving the patient progesterone supplementation during the luteal phase. In the case of inadequate corpus luteum performance, progesterone support may indeed be the appropriate solution. However, inadequate follicle development (in the follicular phase) may also be causing the low progesterone levels. Thus, it is important to measure mid-cycle follicle size (via ultrasound) and oestradiol levels (via a blood test). If follicle development is normal, then progesterone supplementation during the luteal phase is normally the correct treatment (from the Western point of view). If follicle development is inadequate, an ovulatory stimulant such as Clomid is often used; these drugs help the follicle
to mature more appropriately, which has the double benefit of producing a higher quality egg and a better functioning corpus luteum. However, from the Chinese perspective this is achieved at a cost: Dr Xia Gui Cheng thinks that follicle-stimulating drugs such as Clomid damage the ovaries. Women whose linings fail to respond to normal progesterone levels often have normal follicle development and adequate progesterone levels at 7 days post ovulation. An ultrasound image of the lining at 7 days after ovulation, however, will show a lining that has failed to convert from the triple layer lining typical of the time of ovulation. In this case, women are often given additional progesterone supplementation in the luteal phase in the hope that a higher level will be the push that the lining needs to convert appropriately. Some doctors use injections of human chorionic gonadotropin to further stimulate the corpus luteum. However, these injections can cause false positive pregnancy results. Thus, although oestradiol increases in the follicular phase stimulating development of the follicle, it is the surge in LH that induces ovulation. This confirms the Chinese view of the menstrual cycle in which Kidney-Yin (oestradiol and FSH) and Kidney-Yang (progesterone and LH) are inextricably linked. One depends on the other and ovulation cannot occur without both of them. The fact that the luteal phase depends partly on a good follicular phase also confirms what Dr Xia Gui Cheng says about phase 2, i.e. that it is a very important phase to set the menstrual cycle on the right footing (see below).
Hypothalamus–pituitary–ovarian axis The menstrual cycle is the result of a complex and delicate interplay among the hypothalamus, pituitary and ovaries. The hypothalamus secretes gonadotropin releasing hormone (GnRH) which, in turn, stimulates the secretion of FSH and LH by the pituitary. FSH stimulates follicle development in the ovaries during the follicular phase while LH stimulates the corpus luteum during the luteal phase. With the rise in oestrogen during the follicular phase, LH receptors are also expressed on the maturing follicle that produces an increasing amount of oestradiol. Eventually, at the time of the maturation of the follicle, the oestrogen rise leads via the hypothalamic interface to the ‘positive feedback’ effect, a release of LH over a 24 to 48 hour period. This LH surge triggers ovulation and the conversion of the residual follicle into a corpus luteum that, in turn, produces progesterone to prepare the endometrium for a possible implantation. GnRH is a neurohormone produced in the pre-optic area of the hypothalamus. In the pituitary, GnRH stimulates the synthesis and secretion of the gonadotropins, FSH and LH. These processes are controlled by the size and frequency of GnRH pulses, as well as by feedback from androgens and oestrogens. Low-frequency GnRH pulses lead to FSH release, whereas high-frequency GnRH pulses stimulate LH release (Fig. 2.9). In females, the frequency of the pulses varies during the menstrual cycle and there is a large surge of GnRH just before ovulation. GnRH secreted by the hypothalamus also stimulates the production of prolactin by the pituitary gland (Fig. 2.10).
Figure 2.9 Hypothalamus–pituitary–ovarian axis.
Figure 2.10 Stimulation of prolactin secretion by GnRH. The hypothalamus–pituitary–ovarian axis has its correspondent in the Du/Ren axis in Chinese medicine. Both the Governing and Directing Vessels originate in the ‘Kidneys’ (which includes the ovaries). The Governing Vessel, controlling the Yang aspect of the menstrual cycle, flows through the brain (where the hypothalamus is); both the Directing and Governing Vessels, controlling the Yin and Yang aspect of the menstrual cycle, flow through the ovaries (Fig. 2.11).
Figure 2.11 Correspondence between hypothalamus–pituitary–ovarian axis and Governing/Directing Vessels.
Although one has to exercise caution when making direct comparisons between Western and Chinese medicine, we can postulate that oestrogen is Yin (produced by Kidney-Yin) and progesterone Yang (produced by Kidney-Yang). Indeed, oestrogen is related to mucus production in the cervical glands and the fallopian tubes and a lower temperature: hence, mucus = fluids = Yin. Progesterone is linked to the drying up of the cervical mucus and the rise in temperature occurring after ovulation: hence, dryness = rise in temperature = Yang. It is interesting that exactly the same hypothalamus–pituitary–gonads axis exists in men. In men, the LH which is secreted by the pituitary gland in
response to a GnRH signal acts on the Leydig cells in the testes. Once stimulated with LH, the Leydig cells in the testes produce testosterone. FSH is also secreted by the pituitary gland in men. Together with testosterone, FSH stimulates Sertoli cells (located in the seminiferous tubules of the testes) to support the developing sperm (Fig. 2.12).
Figure 2.12 Hypothalamus–pituitary–testis axis in men. T, testosterone.
Summary Hypothalamus–pituitary–ovarian axis
• The menstrual cycle is the result of a complex and delicate interplay among the hypothalamus, pituitary and ovaries • The hypothalamus secretes gonadotropin releasing hormone (GnRH) which in turn stimulates the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) by the pituitary • FSH stimulates follicle development in the ovaries during the follicular phase while LH stimulates the corpus luteum during the luteal phase • The hypothalamus–pituitary–ovarian axis has its correspondent in the Du/Ren axis in Chinese medicine • Both the Governing and Directing Vessels originate in the ‘Kidneys’ (which includes the ovaries). The Governing Vessel, controlling the Yang aspect of the menstrual cycle, flows through the brain (where the hypothalamus is); both the Directing and Governing Vessels, controlling the Yin and Yang aspect of the menstrual cycle, flow through the ovaries • Oestrogen is Yin (produced by Kidney-Yin) and progesterone Yang (produced by Kidney-Yang)
Chinese medicine view of the four phases in detail In Chinese medicine, the four phases of the menstrual cycle are the result of the ebb and flow of Kidney-Yin and Kidney-Yang and also of the feedback mechanism between the Kidneys and the Heart. The Heart plays a role in the feedback mechanism. As we have seen, Heart-Qi descends to the Kidneys to promote ovulation and menstruation, and the switch from Yang to Yin occurs when the period starts and that from Yin to Yang when ovulation occurs. Thus, at the peak of Yin and Yang, there is a feedback to the Heart to induce that downward movement; at the ebb of Yin and Yang there is a feedback to the Kidneys (Fig. 2.13).
Figure 2.13 Feedback between Heart and Kidneys in the menstrual cycle. The communication between Heart and Kidneys in the physiology of menstruation is one aspect of the ‘vertical’ connection between Heart and Kidneys, Fire and Water. Fire and Water (and Heart and Kidneys) communicate with, respond to and nourish each other: this relationship is a direct one that is independent of the Five Element scheme in which the Kidneys nourish the Liver and this the Heart. Shen Zhai Wei Shu states:
The harmony of Heart and Kidneys depends on the ascending of the Kidney-Qi and descending of the Heart-Qi. The Kidneys pertain to Water, how can it ascend? Because there is genuine Yang in Water (i.e. Heart-Qi). The Heart pertains to Fire, how can it descend? Because there is genuine Yin in Fire (i.e. Kidney-Qi). The Governing and Directing Vessels control the ebb and flow of YinYang in the menstrual cycle. The two Stepping Vessels (Yin and Yang Qiao Mai) help the balance of Yin-Yang while the two Linking Vessels (Yin and Yang Wei Mai) control the connection of Yin-Yang. They have a secondary role in the regulation of the menstrual cycle as they do not flow through the uterus. Phase 1: Menstrual During phase 1, bleeding occurs. This phase is characterized by a downward movement of Qi and Blood which helps a good discharge of blood during the period. The activity during this phase is centred around the Xiao Fu area of the abdomen, i.e. the central area of the lower abdomen below the umbilicus (Fig. 2.14). This phase is under the influence of the Penetrating Vessel (Chong Mai) primarily.
Figure 2.14 Xiao Fu and Shao Fu areas in the lower abdomen. From the point of view of Yin-Yang, the beginning of phase 1 is characterized by a sharp drop of Yang which usually induces the disappearance of pre-menstrual symptoms. The beginning of the period marks a point of transformation (or switch) from Yang to Yin, i.e. Yang decreases rapidly and Yin begins to grow. The downward movement of Qi and Blood and the transformation from Yang to Yin occur under the influence of the descending of Heart-Qi. Phase 1 is under the influence of Liver-Blood and the Penetrating Vessel (although the main activity is in the centre of the abdomen in the Ren Mai area). So both Penetrating and Directing Vessels influence this phase. In phase 1, Yang decreases rapidly: if Yang does not decrease, the period may not start or may start late. If Yang decreases too much or too rapidly (due to a pre-existing Yang deficiency) then menstruation may be early and heavy. Herbs that conduct Blood downwards during the menses are: Chuan Niu Xi Radix Cyathulae, Ze Lan Herba Lycopi and Dan Shen Radix
Salviae miltiorrhizae. Clinical Note Herbs that conduct Blood downwards during the menses are: Chuan Niu Xi, Ze Lan and Dan Shen. It follows that the use of these herbs is not recommended if the period is heavy. Dr Xia Gui Cheng attaches great importance to a woman having a good discharge of menstrual blood during the period: he calls this a ‘discharge of the old’, i.e. discharge of old blood. If the blood discharge is insufficient, he says this may lead to ‘retention of menses’ and possibly endometriosis. Summary Phase 1: Menstrual
• Phase 1 is characterized by a downward movement of Qi and Blood which helps a good discharge of blood during the period • The activity during this phase is centred around the Xiao Fu area of the abdomen • The beginning of phase 1 is characterized by a sharp drop of Yang and the beginning of the period marks a point of transformation (or switch) from Yang to Yin, i.e. Yang decreases rapidly and Yin begins to grow • The downward movement of Qi and Blood and the transformation from Yang to Yin occur under the influence of the descending of Heart-Qi • Phase 1 is under the influence of Liver-Blood and of the Penetrating Vessel • Dr Xia Gui Cheng attaches great importance to a woman having a good discharge of menstrual blood during the period: he calls this a ‘discharge of the old’, i.e. discharge of old blood
Phase 2: Post-menstrual During phase 2, Yang is decreasing and Yin is increasing fairly rapidly, reflecting the development of the follicle under the influence of FSH. If Yin does not grow sufficiently, ovulation may be delayed. If Yang does not decrease sufficiently, ovulation may occur early. In phase 2, Blood and Yin are relatively Empty (as they have been consumed by the loss of blood during the period). Please note that the stress is on the word ‘relatively’. Therefore, this does not mean that every woman at the end of the period and in phase 2 suffers from Blood and/or Yin deficiency. What it does mean is that, in phase 2, Blood and Yin are relatively lower compared to other phases. According to Dr Xia Gui Cheng, phase 2 is a very important phase to establish a good basis for a normal menstrual cycle. This is confirmed by Western medicine as a good follicular phase also influences the luteal phase. There are three main characteristics in phase 2: 1. Yin starts to grow from its minimum level. This is an increase of KidneyYin, corresponding to oestrogen and the follicular phase. This phase is very important to lay the foundation for the whole menstrual cycle. During this phase, the Essence (Jing) matures, thus nourishing the Uterus and the follicles and promoting the growth of the endometrium. 2. The decrease of Yang in this phase ensures the growth of Yin (mutual consuming of Yin and Yang). If Yin or Yang fails to grow/decrease at the right time, it means that Yin and Yang at that time are too ‘equal’ and the cycle cannot progress normally. 3. The growth of Yin also implies growth of fluids in the vagina and the beginning of the formation of the cervical secretion in mid-cycle. Summary
Phase 2: Post-menstrual
• During phase 2, Yang is decreasing and Yin is increasing fairly rapidly • In phase 2, Blood and Yin are relatively Empty (as they have been consumed by the loss of blood during the period) • According to Dr Xia Gui Cheng, phase 2 is a very important phase to establish a good basis for a normal menstrual cycle • During this phase, the Essence (Jing) matures, thus nourishing the Uterus and the follicles and promoting the growth of the endometrium • The decrease of Yang in this phase ensures the growth of Yin (mutual consuming of Yin and Yang) • The growth of Yin also implies growth of fluids in the vagina and the beginning of the formation of the cervical secretion in mid-cycle
Phase 3: Mid-cycle (ovulation) Ovulation occurs at the beginning of phase 3. During this phase, the Governing, Directing and Penetrating Vessels are in full activity to produce ovulation. Ovulation depends on Kidney-Yin (the ova and oestrogen) but it needs the Heat of the Minister Fire (progesterone). At the beginning of phase 3, Yang rises steeply under the influence of LH and progesterone: this is reflected in the rise in temperature occurring soon after ovulation. In phase 3, Yin has reached its maximum. During phase 3, the activity is centred around the Shao Fu area, i.e. the lateral sides of the lower abdomen which are under the influence of the Penetrating Vessel (Fig. 2.14). The cervix produces a viscous, transparent secretion that indicates the imminent ovulation. This secretion reflects the
maximum of Yin at the beginning of this phase. Soon after the period, there is a sticky or ‘tacky’ cervical secretion. Immediately prior to ovulation, there is an increased cervical secretion that is wet and slippery (similar to the consistency of raw egg white). When placed between two fingers and the fingers are prized apart, the secretion stretches between the two fingers (Fig. 2.15). Generally, the body produces the greatest amount of this type of cervical secretion on the day of ovulation. Immediately following the day of ovulation, the cervical secretion gradually becomes thicker in consistency, and less is secreted.
Figure 2.15 Stretchy cervical secretion. The os of the cervix will remain closed until the oestrogen levels in the body begin to rise and trigger its gradual opening and the production of fertile mucus. As ovulation approaches, the os begins to open and the quality and consistency of mucus changes: fertile mucus can be seen clinging to the surface of the cervix in strands (Fig. 2.16). During the peak of fertility, the os
of the cervix is open, with clear, stretchy mucus present. The mucus looks wet: it is clear in colour rather than the cloudy or whitish colour when peak fertility was still approaching.
Figure 2.16 Cervical secretion on os of cervix. The fertile secretion appearing in phase 3 is a direct and reliable manifestation of the Kidney-Yin and Essence. When treating a woman for infertility, we should always ask about this secretion (see below). If this secretion is absent or very short lasting (e.g. only 1 day), it indicates a Kidney deficiency even in the absence of any Kidney symptom. Phase 3 can be compared and contrasted to phase 1. In both phases there is a transformation: in phase 1 from Yang to Yin and in phase 3 from Yin to Yang. Also, in both phases there is a movement of Qi: in phase 1 a downward flow in the Xiao Fu area and in phase 3 an upward flow in the Shao Fu area. Phase 1 is under the influence of the Penetrating Vessel (Chong Mai), phase 3 under the influence of the Governing, Directing and Penetrating Vessels (Du, Ren and Chong Mai). The descending of Heart-Qi induces the transformation of Yin to Yang and the discharge of the ovum from the ovaries. There are two characteristics of phase 3: 1. The flourishing of Directing and Penetrating Vessels ensures ovulation. There is a lot of activity of Qi and Blood which may cause distension in the Shao Fu abdomen, mood changes and breast distension. 2. During phase 3, Yin reaches its maximum and a transformation from Yin to Yang occurs. Oestrogen reaches its highest level. At this time, there is a physiological cervical secretion that is transparent; stringy, like egg white. Strictly speaking, one can distinguish two sub-phases in phase 3: before/during ovulation and after ovulation. In the first phase, the influence of Directing and Governing Vessels (Ren and Du) is obvious and Yang rises rapidly (hence the rise in temperature). The time after ovulation is under the influence of the Penetrating Vessel (Chong Mai) and the increase in Yang flattens out. However, for the purpose of treatment, it is not essential to distinguish these two sub-phases. The cervical secretion occurring before ovulation occurs in phase 3: it is
under the influence of the Directing Vessel (Ren Mai) and is a direct expression of Kidney-Essence. If it is absent or too short, it automatically indicates a deficiency of the Kidneys. During phase 3, Yin is decreasing and Yang increasing: if Yin does not decrease and/or Yang does not increase, Dampness and Phlegm are easily formed in the Uterus. Thus, excess of Yin in phase 3 means Dampness or Phlegm obstructing the Uterus: this may delay ovulation. The same would happen in deficiency of Yang. Vice versa, if there was excess of Yang, ovulation may come early: the same in case of deficiency of Yin. Summary Phase 3: Mid-cycle (ovulation)
• Ovulation occurs at the beginning of phase 3. During this phase, the Governing, Directing and Penetrating Vessels are in full activity to produce ovulation • Ovulation depends on Kidney-Yin (the ova and oestrogen) but it needs the Heat of the Minister Fire (progesterone) • At the beginning of phase 3, Yang rises steeply under the influence of LH and progesterone: this is reflected in the rise in temperature occurring soon after ovulation • In phase 3, Yin has reached its maximum • During phase 3, the activity is centred around the Shao Fu area • During phase 3, the cervix produces a viscous, transparent secretion that indicates the imminent ovulation • The fertile secretion appearing in phase 3 is a direct and reliable manifestation of the Kidney-Yin and Essence • The descending of Heart-Qi induces the transformation of Yin to Yang and the
discharge of the ovum from the ovaries • During phase 3, Yin is decreasing and Yang increasing: if Yin does not decrease and/or Yang does not increase, Dampness and Phlegm are easily formed in the Uterus
Phase 4: Pre-menstrual phase During phase 4, Qi and Blood are moving in preparation for the period. It is primarily Liver-Qi and Liver-Blood that influence this movement. From the point of view of Extraordinary Vessels, the Penetrating Vessel exerts the strongest influence at this time. From the point of view of Yin and Yang, Yang is rising rapidly during this phase and Yin is decreasing. The increase in Yang is important to expel potential Yin pathogenic factors in the Uterus such as Blood stasis, Damp-Phlegm or Cold. Pre-menstrual symptoms may appear in this phase. Please note that not all pre-menstrual symptoms are due to Liver-Qi stagnation. Since Yang is increasing in this phase, an excess of Yang (e.g. Liver-Fire or Heart-Fire) may cause pre-menstrual symptoms. A deficiency of Yang too (e.g. Spleenand Kidney-Yang deficiency) may cause pre-menstrual symptoms. Clinical Note Not all pre-menstrual symptoms are due to Liver-Qi stagnation. An excess of Yang (e.g. Liver-Fire or Heart-Fire) may cause pre-menstrual symptoms. A deficiency of Yang too (e.g. Spleen- and Kidney-Yang deficiency) may cause pre-menstrual symptoms. There are two characteristics to phase 4: 1. During this phase, Yang grows rapidly and Yin decreases. The growth of Yang provides warmth to the Uterus which makes the endometrium receptive to implantation. The growth of Yang in this phase ensures the
expulsion of Yin pathogenic factors from the Uterus such as Cold, Phlegm, Dampness and Blood stasis. For example, in endometriosis and polycystic ovary syndrome there is Blood stasis and Damp-Phlegm respectively, which are Yin pathogenic factors: growth of Yang in phase 4 is therefore important to prevent Blood stasis and Dampness/Phlegm/Cold. 2. The decrease of Yin in this phase ensures the growth of Yang: this is comparable to the decrease of Yang in phase 2 but it is clinically more significant. Summary Phase 4: Pre-menstrual phase
• During phase 4, Qi and Blood are moving in preparation for the period. It is primarily Liver-Qi and Liver-Blood that influence this movement • The Penetrating Vessel exerts the strongest influence at this time • Yang is rising rapidly during this phase and Yin is decreasing. The increase in Yang is important to expel potential Yin pathogenic factors in the Uterus such as Blood stasis, Damp-Phlegm or Cold • Pre-menstrual symptoms may appear in this phase. Please note that not all pre-menstrual symptoms are due to Liver-Qi stagnation.
The four phases and treatment principles An important clinical significance of the four phases lies in adapting the treatment principles according to them. I cannot emphasize how important and how useful this application of the four phases is in practice. We really cannot treat menstrual irregularities, infertility, endometriosis and polycystic ovary without adapting the treatment principle to the four phases. This means that often we may use two, three or even four different herbal formulae during the menstrual cycle. Indeed, this method applies also to acupuncture: with acupuncture too, we can concentrate on treating a woman according to the four phases. From the point of view of Extraordinary Vessels, in a nutshell: • Phase 1 = Penetrating Vessel (Chong Mai) • Phase 2 = Directing Vessel (Ren Mai) and Kidney-Yin • Phase 3 = Directing and Governing Vessels (Ren and Du Mai) and Kidney-Yin and Kidney-Yang • Phase 4 = Penetrating Vessel (Chong Mai) The treatment principles applied in each phase are as follows. Phase 1 Invigorate (‘move’) Blood. Phase 1 is the best time to invigorate Blood as Qi and Blood are already descending at this time. However, we cannot invigorate Blood if the period is heavy: in such a case, we should use herbs that simultaneously invigorate Blood and stop bleeding (e.g. San Qi Radix Notoginseng, Pu Huang Pollen Typhae, Qian Cao Gen Radix Rubiae). The Women’s Treasure remedy, Invigorate Blood and Stem the Flow, does exactly that, i.e. it invigorates Blood and stops bleeding.
Phase 2 Nourish Blood and tonify the Kidneys. During phase 2, it is a good time to nourish Blood as Blood is relatively Empty at this time. As menstrual blood is part of Tian Gui, we must also tonify the Kidneys. Phase 2 is a very important phase to establish a good basis of a menstrual cycle. If I need to nourish Blood in a woman, I often do so in phases 2 and 3 even in nongynecological problems. It certainly would not make sense to nourish Blood in phase 1 when a woman is bleeding. Phase 3 Tonify the Kidneys, strengthen Governing, Directing and Penetrating Vessels, if necessary resolve Dampness and tonify the Spleen. During phase 3, it is a good time to continue tonifying the Kidneys as we do in phase 2. If there is Dampness, phase 3 is also a good time to eliminate it. Phase 4 Move Qi, invigorate Blood, warm the Uterus, if necessary expel Cold, resolve Damp-Phlegm. Phase 4 is the best time to move Qi and Blood before the period. It is also a good time to warm the Uterus to expel Cold or to resolve Damp-Phlegm. Summary The four phases and treatment principles
• Phase 1: Invigorate (‘move’) Blood. If the period is heavy: invigorate Blood and stop bleeding
• Phase 2: Nourish Blood and tonify the Kidneys • Phase 3: Tonify the Kidneys, strengthen Governing, Directing and Penetrating Vessels, if necessary resolve Dampness and tonify the Spleen • Phase 4: Move Qi, invigorate Blood, warm the Uterus, if necessary expel Cold, resolve Damp-Phlegm • From the point of view of Extraordinary Vessels, in a nutshell: • Phase 1 = Penetrating Vessel (Chong Mai) • Phase 2 = Directing Vessel (Ren Mai) and Kidney-Yin • Phase 3 = Directing and Governing Vessels (Ren and Du Mai) and Kidney-Yin and Kidney-Yang • Phase 4 = Penetrating Vessel (Chong Mai)
Menstruation and the internal organs
Kidneys The Kidneys are the root of Pre-Natal Essence and the root of the Original Qi. They store the Essence which is the material basis for the formation of menstrual blood. In particular the Kidney-Essence is the origin for the formation of the Tian Gui, the material substance of menstrual blood. At puberty, the Heavenly Gui is crystallized and gives rise to the periods. Chapter 1 of the Simple Questions says: “At 14 the Tian Gui arrives, the Directing Vessel [Ren Mai] is open and the Penetrating Vessel [Chong Mai] flourishing, the period arrives and the girl can conceive.”15 Menstrual blood is called ‘Heavenly Gui’ because it represents the descending of Heavenly Gui materializing into Water: in fact, the 10th heavenly stem Gui pertains to Water. The Great Treatise of Beneficial Formulae for Women (1237) explains: When a girl is 14 the Heavenly Gui arrives, the Directing Vessel is open, the Penetrating Vessel is flourishing and the period arrives. ‘Heavenly’ indicates the descending of the True Qi of Heaven; ‘Gui’ indicates Water [as this stem pertains to Water]: [menstrual Blood is therefore] like heavenly clouds generating water.16 Fu Qing Zhu (1607–1684) holds that menstrual blood is not Blood but Heavenly Gui which originates from the Kidneys. He says it is formed from Kidney-Yin but with the participation of Heart-Yang (another way in which the Heart influences menstruation) and that despite being blood red in colour it is not Blood; hence its name of Heavenly Gui.17 He also says that the generation of the Heavenly Gui has nothing to do with Heart, Liver or Spleen: these organs only help its transformation into Blood. To repeat his original passage: Menstrual blood is not Blood but Heavenly Water, originating within the Kidneys, it is the essence of extreme Yin and Qi of extreme Yang. It is red like blood but it is not blood. That is why it is called
Heavenly Gui. People nowadays regard menstrual blood as Blood, a mistake perpetuated for 1000 years … in fact it is not called bloodwater [Xue Shui] but menstrual water [Jing Shui] … the generation of Kidney Water [and therefore menstrual blood] has nothing to do with Heart, Liver and Spleen, but the transformation of Kidney Water is helped by Heart, Liver or Spleen.18 It should be emphasized that while in women menstrual blood is a form of Tian Gui; in men, sperm is also Tian Gui. Thus, the Kidney Essence, being the basis of Tian Gui, greatly influences the physiology of women and especially puberty, fertility, conception, pregnancy and menopause. The Water of the Kidneys, or Kidney-Yin, is the material basis for menstrual blood. Fu Qing Zhu makes this point by saying that it is not by chance that menstrual blood is called Jing Shui, i.e. ‘period’s water’, rather than Jing Xue (‘period’s blood’).19 Tang Zong Hai, in his Discussion of Blood Syndromes (1885), has a slightly different view of the formation of menstrual blood and he says: Fluids transformed by Qi turn red and form Blood which, following the Directing and Penetrating Vessels, joins the Heavenly Gui Water below in both men and women. Men pertain to Qi and, in them, Blood is transformed from Water to make Sperm; women pertain to Blood and, in them, Blood is transformed from Water to make menstrual blood. Thus, in men there is Blood within Water and, in women there is Water within Blood, forming menstrual blood.20 Thus, the Heavenly Gui is found in both men and women; in men it forms sperm, and in women menstrual blood (Fig. 2.17).
Figure 2.17 The formation of menstrual blood according to Tang Zong Hai. Another way in which the Kidneys influence menstruation is simply through the connection of mutual nourishment between Blood and Essence and that between Liver and Kidneys. On the one hand, Blood, as a form of Post-Natal Qi, integrates and replenishes the Essence; on the other hand, the Essence contributes to making Blood by facilitating the transformation of Gathering Qi (Zong Qi) into True Qi (Zhen Qi) and by being the origin of Bone Marrow which also makes Blood. It is for this reason that, when nourishing Blood in gynecological conditions, we usually tonify not only the Kidneys but also the Liver. Indeed, many of the gynecological herbs that tonify the Kidneys also tonify the Liver (e.g. Shu Di Huang Radix Rehmanniae preparata, Shan Zhu Yu Fructus Corni, Sheng Di Huang Radix Rehmanniae, Gou Qi Zi Fructus Lycii, etc.). The Kidneys influence women’s reproductive systems also through the Governing, Directing and Penetrating Extraordinary Vessels which will be discussed below. Finally, the role of the Gate of Life (Ming Men) in women’s physiology should be discussed. While the Water of the Kidneys is the origin of menstrual blood, the Kidneys are also the source of physiological Fire, which also plays its part in menstruation. The Fire of the Gate of Life represents the
physiological Fire within the Kidneys. It arises from the area between the two kidneys and is closely related to the Original Qi (Yuan Qi) and the Motive Force (Dong Qi) from which the Governing, Directing and Penetrating Vessels originate (Fig. 2.18).
Figure 2.18 The Minister Fire and the Extraordinary Vessels. Under physiological conditions, the Fire of the Gate of Life warms the Uterus and balances the Yin influences: it makes conception possible because it promotes the maturation of the follicles and the production of the ova (Fig. 2.19). It is also related to sexual desire. In fact, some doctors say that “it is through Kidney-Yang [and therefore the Fire of the Gate of Life] that the Tian Gui turns red [i.e. it turns into Blood].”21
Figure 2.19 The Uterus and Kidney-Water and Kidney-Fire. The Fire of the Gate of Life is the origin of the ‘formless’ Minister Fire which also generates Water, hence the Kidneys are the source of both Water and Fire. The Minister Fire is called ‘formless’ because it is a non-substantial Fire which actually generates Water rather than overcoming it. It is a prenatal type of Fire formed at conception on the Governing/Directing Vessel axis. In fact, the Golden Mirror of Medicine (1742) says: The Pre-Natal Tian Gui originates from the mother and father, the Post-Natal Essence and Blood are derived from food and water, a girl’s Tian Gui matures at 14, the Directing Vessel is open, the Penetrating Vessel is flourishing and the periods arrive22 (Fig. 2.20). The commentary then explains: At 7 the Motive Force [Dong Qi] is flourishing. At 14 the Tian Gui matures: this is the Motive Force [i.e. the Minister Fire] within the Pre-Natal Water of Tian Gui, crystallizing in a girl’s uterus.23
Figure 2.20 Pre-natal origin of Minister Fire. This last passage is interesting as it confirms that the Motive Force and the Minister Fire are pre-natal and present before the onset of the periods
(Figs 2.21 and 2.22). It also highlights the close integration of the Minister Fire and the Heavenly Gui (the Yang and Yin aspects of the Kidneys). Zhang Jing Yue says: The Gate of Life is the Root of the Original Qi [Yuan Qi] and the residence of [both] Water and Fire. The Yin of the 5 Yin Organs cannot nourish without it and their Yang cannot develop without it.24
Figure 2.21 Yin and Yang aspects of Essence (Jing).
Figure 2.22 The Minister Fire in conception. This passage clearly shows how the Fire of the Gate of Life can be the source of both Fire and Water. Thus, the Minister Fire is the Fire within Water, interdependent with Water and inseparable from it. The Emperor Fire is called ‘with form’, i.e. it is a substantial Fire which overcomes Water, is formed after birth and is therefore post-natal. The Minister Fire pertains to Heaven and the Emperor Fire to human beings (Fig. 2.23).
Figure 2.23 Emperor Fire and Minister Fire. Thus, the Kidneys are the origin of both Water and Fire: the KidneyWater is the source of menstrual blood and both Kidney-Water and KidneyFire influence the Uterus which stores Blood. Since Blood is part of Water but the Uterus is also warmed by the Minister Fire of the Kidneys, in women a deficiency of the Kidneys very often involves a deficiency of both Water (Yin) and Fire (Yang) (Fig. 2.24).
Figure 2.24 Simultaneous deficiency of Kidney-Yin and Kidney-Yang. Under pathological circumstances, the Fire of the Gate of Life can become either deficient or excessive. When it is deficient, it fails to warm the Uterus, which becomes obstructed by Cold: this may lead to infertility, dysmenorrhoea and lack of sexual desire. When it is excessive, it heats the Blood causing excessive menstrual bleeding, infertility or miscarriage (Fig. 2.25).
Figure 2.25 Pathology of Minister Fire. Finally, the Minister Fire plays an important role in the transformation of Kidney-Water into Tian Gui. We have stressed above that Kidney-Water is the origin of Tian Gui: however, the Minister Fire of the Kidneys plays a role in its formation. One of the ancient texts says that “Tian Gui is the crystallization of Kidney-Water under the influence of the Minister Fire.” The use of the word crystallization is interesting and it lends itself to an interesting illustration of this principle. If we prepare a saturated solution of
water with salt and apply a source of heat to it, after some time the water will evaporate and salt crystals will be formed (Fig. 2.26). In this analogy, the solution of water and salt is Kidney-Water, the source of heat is Kidney-Fire (Minister Fire) and the salt crystals are Tian Gui.
Figure 2.26 Analogy between Tian Gui and salt crystals.
Summary Kidneys
• The Kidney-Essence is the origin for the formation of the Tian Gui, the material substance of menstrual blood • Menstrual blood is called ‘Heavenly Gui’ because it represents the descending of Heavenly Gui materializing into Water
• Fu Qing Zhu (1607–1684) holds that menstrual blood is not Blood but Heavenly Gui which originates from the Kidneys • The Heavenly Gui is found in both men and women; in men it forms sperm, and in women menstrual blood • The Kidneys influence women’s reproductive systems also through the Governing, Directing and Penetrating Extraordinary Vessels • The Fire of the Gate of Life represents the physiological Fire within the Kidneys: it arises from the area between the two kidneys and is closely related to the Original Qi (Yuan Qi) and the Motive Force (Dong Qi) from which the Governing, Directing and Penetrating Vessels originate • The Fire of the Gate of Life warms the Uterus and balances the Yin influences: it makes conception possible because it promotes the maturation of the follicles and the production of the ova • The Minister Fire is a pre-natal type of Fire formed at conception on the Governing/Directing Vessel axis • The Motive Force and the Minister Fire are pre-natal and present before the onset of the periods • The Kidneys are the origin of both Water and Fire, the Kidney-Water is the source of menstrual blood and both Kidney-Water and Kidney-Fire influence the Uterus which stores Blood • When the Minister Fire is deficient, it fails to warm the Uterus which may lead to infertility, dysmenorrhoea and lack of sexual desire • When it is excessive, it heats the Blood causing excessive menstrual bleeding, infertility or miscarriage • The Minister Fire plays an important role in the transformation of KidneyWater into Tian Gui
Liver The Liver has a paramount importance in women’s physiology and menstruation, mostly through its relationship with the Uterus and Blood. The Uterus stores Blood and this is received mostly from the Liver, hence with regard to menstruation the Uterus and the Liver’s function of Blood storage are one and the same (although Liver-Blood has many other nongynecological functions). For this reason, Liver-Blood has a paramount importance in menstruation. The Blood stored in the Liver is both menstrual blood and therefore Tian Gui deriving from the Kidneys, but also the PostNatal Blood made by the Post-Natal Qi of Stomach and Spleen. For this reason, when nourishing Liver-Blood, we often need to tonify the Liver itself, the Kidneys (especially in gynecological conditions) and the Spleen to promote the formation of Post-Natal Qi and Blood (Fig. 2.27).
Figure 2.27 Liver-Blood and the Uterus.
Clinical Note To nourish Liver-Blood in gynecological conditions, I generally reinforce Ren-4 Guanyuan, LIV-8 Ququan, ST-36 Zusanli and SP-6 Sanyinjiao. This combination tonifies Kidneys, Liver and Spleen. To nourish Liver-Blood in non-gynecological conditions, one can either reinforce the couple BL-18 Ganshu and BL-17 Geshu or the couple BL-20 Pishu and BL-23 Shenshu to tonify Spleen and Kidneys.
Therefore, when nourishing Blood in gynecological conditions, we always need to nourish Liver-Blood, even though, as mentioned above, menstrual blood is Tian Gui that derives from the Kidneys. Indeed, this is reflected in Chinese herbal medicine as some herbs have a dual function of tonifying the Kidneys (and therefore Tian Gui) and nourishing Liver-Blood. For example: Shu Di Huang Radix Rehmanniae preparata, Sheng Di Huang Radix Rehmanniae and Gou Qi Zi Fructus Lycii. The Liver has an important influence on menstruation also through Qi. Liver-Qi has the very important function of moving Blood via Qi. Especially in the pre-menstrual phase, Liver-Qi needs to move Blood in preparation for the period. If Liver-Qi stagnates it may cause irregular periods, dysmenorrhoea and pre-menstrual syndrome. Liver-Qi and Liver-Blood are the Yang and Yin part of the Liver and, as such, they are interrelated. Yin needs to root and embrace Yang, and if Liver-Blood is deficient it can cause a secondary stagnation of Liver-Qi: the fact that it is secondary is evident from the symptoms of Liver-Qi stagnation together with a Pale tongue and Choppy pulse (Fig. 2.28). A deficiency of Liver-Blood is often at the root of Liver-Qi stagnation and the formula Xiao Yao San Free and Easy Wanderer Powder illustrates this principle in its composition. In fact, in the formula, Chai Hu Radix Bupleuri and Bo He Herba Menthae haplocalycis move Liver-Qi while Dang Gui Radix Angelicae sinensis and Bai Shao Radix Paeoniae alba nourish Liver-Blood.
Figure 2.28 Interrelationship between Liver-Blood and Liver-Qi.
Clinical Note Although Liver-Qi stagnation is an important and frequent pathological condition in gynecology, in my opinion it is somewhat overemphasized both in China and in the West. The Liver also represents the connection between the menstrual blood (which is part of Tian Gui) and the ‘normal’ Blood (the one which nourishes hair, nails, sinews, eyes, etc.). If Liver-Blood is deficient there may be amenorrhoea, scanty periods or late periods together with other Blood deficiency symptoms related to hair, nails, Summary Liver
• The Uterus stores Blood and this is received mostly from the Liver • The Blood stored in the Liver is both menstrual blood and therefore Tian Gui deriving from the Kidneys, but also the Post-Natal Blood made by the Post-Natal Qi of Stomach and Spleen • When nourishing Blood in gynecological conditions, we always need to nourish Liver-Blood • Liver-Qi has the very important function of moving Blood via Qi • Liver-Qi and Liver-Blood are the Yang and Yin part of the Liver and, as such, they are interrelated. Yin needs to root and embrace Yang, and if Liver-Blood is deficient it can cause a secondary stagnation of Liver-Qi: the fact that it is secondary is evident from the symptoms of Liver-Qi stagnation together with a Pale tongue and Choppy pulse
• The Liver also represents the connection between the menstrual blood (which is part of Tian Gui) and the ‘normal’ Blood (the one which nourishes hair, nails, sinews, eyes, etc.)
sleep, sinews and eyes, such as dry hair, brittle nails, excessive dreaming, cramps and blurred vision. If Liver-Blood is hot, there may be menorrhagia (Fig. 2.29).
Figure 2.29 Overlap between menstrual blood (as Tian Gui) and ‘normal’ LiverBlood.
Spleen The Spleen makes Blood which is then stored in the Liver. Therefore the ‘Blood’ of the Liver is both the gynecological blood expression of Tian Gui of the Kidneys and the Post-Natal Blood deriving from the Post-Natal Qi of Stomach and Spleen. A deficiency of Liver-Blood in women therefore may refer to the Tian Gui (in which case both Liver and Kidneys need to be strengthened) or to Post-Natal Blood which may also be called ‘SpleenBlood’ (in which case Liver and Spleen need to be tonified; see Fig. 2.30).
Figure 2.30 Liver-Blood and Spleen-Blood. The Secret Records of Master Feng’s Brocade Bag says: The Spleen is the source of Qi and Blood and the Heart governs the Blood of all channels. When the Heart and Spleen function well the periods are normal … Blood is produced by the Spleen and is transformed into sperm in men and menstrual blood and breast milk in women. Although the Heart governs Blood and the Liver stores Blood, Blood is controlled by the Spleen. To nourish Blood, one must tonify the Spleen and pacify the Stomach … the Heart and Spleen should be treated before the arrival of the Heavenly Gui and the Liver and Kidneys after its arrival. Menstrual blood and breast milk are both produced by the Spleen and Stomach. After being
digested by the Stomach, the pure part of water and food goes to the Heart channel where it changes its colour becoming red, thus forming Blood. The excess of Blood goes to the Directing and Penetrating Vessels producing the menses … Soon after delivery the pure part of food goes to the Lungs and then flows into the breasts to become milk, which is white in colour, white being the colour of the Lungs. When breastfeeding is stopped, the pure part of food turns into Blood again.25 This passage is interesting as it says that, to tonify Blood in women, before puberty one should tonify Spleen and Heart and, after puberty, Liver and Kidneys. The Spleen influences women’s physiology and pathology also through Qi. Spleen-Qi has an ascending movement and it keeps the uterus in place. Thus, sinking of Spleen-Qi may cause prolapse of the uterus or bladder. With regard to sinking of Spleen-Qi, it should be noted that prolapse is not its only manifestation. Sinking of Spleen-Qi is also a factor in menorrhagia and chronic urinary symptoms such as interstitial cystitis (Fig. 2.31). Moreover, in such gynecological and urinary conditions, it is not only Spleen-Qi that sinks but also Kidney-Qi.
Figure 2.31 Sinking of Spleen-Qi.
Clinical Note Sinking of Spleen- and Kidney-Qi is a factor in menorrhagia and chronic urinary symptoms such as interstitial cystitis. To tonify and lift Spleen- and Kidney-Qi in such conditions, I use LU-7 Lieque on the right together with KI-6 Zhaohai on the left (to open the Directing Vessel) plus Du-20 Baihui and either Ren-4 Guanyuan for menorrhagia or Ren-3 Zhongji for urinary conditions. Spleen-Qi also ‘gathers’ Blood and, if it is deficient, Blood may leak out causing menorrhagia: this is a major cause of deficient-type menorrhagia. Please note that in gynecology, Kidney-Qi also ‘gathers’ Blood and therefore it should be tonified and lifted in menorrhagia. Summary Spleen
• The Spleen makes Blood which is then stored in the Liver • The ‘Blood’ of the Liver is both the gynecological Blood expression of Tian Gui of the Kidneys and the Post-Natal Blood deriving from the Post-Natal Qi of Stomach and Spleen • A deficiency of Liver-Blood in women therefore may refer to the Tian Gui (in which case both Liver and Kidneys need to strengthened) or to Post-Natal Blood (in which case Liver and Spleen need to be tonified) • Spleen-Qi has an ascending movement and it keeps the uterus in place. Thus, sinking of Spleen-Qi may cause prolapse of the uterus or bladder • Sinking of Spleen-Qi may cause not only prolapse, as sinking of Spleen-Qi is also a factor in menorrhagia and chronic urinary symptoms such as interstitial cystitis
• In such gynecological and urinary conditions, it is not only Spleen-Qi that sinks but also Kidney-Qi • Spleen-Qi also ‘gathers’ Blood and, if it is deficient, Blood may leak out causing menorrhagia: this is a major cause of deficient-type menorrhagia
Heart As mentioned above, the Heart influences menstruation in various ways: • The Heart governs Blood and therefore has a general influence on Blood. • The Heart is connected to the Uterus via the Uterus Vessel (Bao Mai): due to this connection, Heart-Blood plays a role in gynecological conditions. • According to Fu Qing Zhu, the Kidney-Essence forms the Heavenly Gui with the help of Heart-Yang. • The Heart controls the transformation of Yang to Yin occurring when the period starts and that of Yin to Yang at ovulation. • The descending of Heart-Qi to the Uterus promotes the descending of menstrual blood with the period and that of the ovum (or ova) at ovulation. Fu Qing Zhu was not the only gynecologist that attributed an important function to the Heart with regard to menstruation. In fact, the Secret Records of Master Feng’s Brocade Bag (1702) says: Menstrual Water in women is rooted in four channels: the Directing and Penetrating vessels, the Small Intestine and the Heart. The Penetrating Vessel is the Sea of Blood and the Directing Vessel controls the Uterus and fetus; if these two vessels are flourishing the woman is fertile. The Small Intestine channel pertains to a Yang organ which controls the Exterior and the Yang [energies], the Heart channel pertains to a Yin organ and controls the Interior and the Yin [energies]. Above, these two channels produce breast milk; below, they produce menstrual Blood.26 This passage is interesting because it connects the Small Intestine channel with breast milk: this could explain the use of S.I.-1 Shaoze for agalactia (lack of milk after childbirth).
The General Treatise on the Aetiology and Symptomatology of Diseases (AD 610) says something similar: The Directing and Penetrating Vessels originate from the Uterus and they are the Sea of the Channels. The Small Intestine and Heart channels are exteriorly–interiorly related and they govern the downward [infusion] of menstrual Blood.27 The connection between the Heart, the Uterus and menstruation explains the strong influence of emotional stress on this function. For example, deficiency of Blood in the Uterus after childbirth can affect the Heart and cause depression, while stasis of Blood in the Uterus after childbirth may cause post-natal psychosis. The influence of the Heart on the menstrual function can also be seen when an emotional shock affecting the Heart may lead to amenorrhoea. Indeed, Heart-Blood affects menstruation in a similar way to LiverBlood: Heart-Blood deficiency may cause scanty periods or amenorrhoea; Heart-Blood stasis may cause painful periods; and Heart-Blood Heat may cause menorrhagia. Summary Heart
• The Heart governs Blood and therefore has a general influence on Blood • The Heart is connected to the Uterus via the Uterus Vessel (Bao Mai): due to this connection, Heart-Blood plays a role in gynecological conditions • According to Fu Qing Zhu, the Kidney-Essence forms the Heavenly Gui with the help of Heart-Yang • The Heart controls the transformation of Yang to Yin occurring when the period starts and that of Yin to Yang at ovulation
• The descending of Heart-Qi to the Uterus promotes the descending of menstrual blood with the period and that of the ovum (or ova) at ovulation • Heart-Blood affects menstruation in a similar way to Liver-Blood: Heart-Blood deficiency may cause scanty periods or amenorrhoea; Heart-Blood stasis may cause painful periods; and Heart-Blood Heat may cause menorrhagia
Lungs The Lungs have only a minor influence on the menstrual function. Because they govern Qi, they can therefore influence some pathological conditions, such as prolapse of the uterus or menorrhagia, due to Qi deficiency, usually in conjunction with Spleen-Qi deficiency. Their influence on menstruation can be seen in cases when sadness and grief induce a depletion of Qi and stoppage of the menses.
Stomach The Stomach is connected to the Uterus via the Penetrating Vessel (Chong Mai). In fact, this Extraordinary Vessel arises from the Uterus and goes through the Stomach, passing through the important Stomach point ST-30 Qichong. The connection between the Penetrating Vessel and the Stomach explains the development of morning sickness during the early stages of pregnancy. The Stomach also influences breastfeeding in nursing mothers in two ways. First, the Stomach channel flows through the breast. Second, although breast milk is a transformation of menstrual Blood occurring within the Penetrating Vessel, it is supplemented by the Post-Natal Qi extracted from food which, itself, depends on the Stomach (Fig. 2.32).
Figure 2.32 The Penetrating Vessel and the transformation of menstrual blood into breast milk.
The Stomach is very important in gynecology as it is, together with the Spleen, the source of Qi and Blood. The Correct Purpose of Gynecology says: The Simple Questions says [in Chapter 7] “The two Yang channels affect the Heart and Spleen and their malfunction causes impotence
in men and amenorrhoea in women”. The two Yang channels are the Stomach and Large Intestine channels: these channels transform food and drink and the Heart and Spleen rely on them. The lower part of the Stomach communicates with the upper part of the Small Intestine; when the Stomach is healthy the Small Intestine can transform and transport [food essences] and therefore Heart-Qi flows properly and no pathogenic factor can attack it. When the Large Intestine is healthy it can transform and transport, food is transformed and digested and the Spleen cannot be injured. When the two Yang channels [Stomach and Large Intestine] are diseased, therefore, food is not digested and transformed and the disease affects the Heart and Spleen so that Qi and Blood cannot be produced.28 This passage illustrates the importance of the Stomach and the digestive system in general (including Small Intestine and Large Intestine) for the production of Qi and Blood: a deficiency of Qi and Blood affects the Heart (which governs Blood) and the Spleen and may therefore cause menstrual problems, especially scanty periods or amenorrhoea. Summary Stomach
• The Stomach is connected to the Uterus via the Penetrating Vessel (Chong Mai) which arises from the Uterus and goes through the Stomach, passing through the important Stomach point ST-30 Qichong • The connection between the Penetrating Vessel and the Stomach explains the development of morning sickness during the early stages of pregnancy • The Stomach also influences breastfeeding in nursing mothers in two ways: • First, the Stomach channel flows through the breast • Second, breast milk is supplemented by the Post-Natal Qi extracted from food
• The Stomach is very important in gynecology as it is, together with the Spleen, the source of Qi and Blood
Figure 2.33 illustrates the connection between the internal organs and menstruation.
Figure 2.33 Internal organs and menstruation.
Menstruation and the extraordinary vessels The menstrual function depends on the three Extraordinary Vessels: the Governing, Directing and Penetrating Vessesls (Du, Ren and Chong Mai). The Governing Vessel governs the Yang within the menstrual cycle, the Directing Vessel the Yin and the Penetrating Vessel the Blood. All three vessels arise from the space between the Kidneys where the Motive Force throbs and they then flow through the uterus in women (and the ‘Room of Sperm’ in men). These three vessels can be considered as three branches of the same vessel. The Mirror of Medicine abstracted by Master Luo says: The Penetrating, Directing and Governing Vessels are three branches from the same source. The Penetrating Vessel is the Sea of Blood, the Directing Vessel governs all Yin channels and the Governing Vessel governs all Yang channels. The Blood of the Internal Organs flows to the Penetrating Vessel which is the foundation of the menses. However, the flourishing of the Penetrating Vessel depends on the Stomach which is its foundation. For this reason, all Blood disorders should be treated with sweet and warm herbs as bitter and cold herbs may damage Stomach-Qi.29 Figure 2.34 illustrates the connection between the Extraordinary Vessels, the Motive Force, the Uterus, the Kidneys and Heart.
Figure 2.34 The Extraordinary Vessels and the Uterus.
Penetrating Vessel (Chong Mai) The Penetrating Vessel is probably the most important of the Extraordinary Vessels and could be considered the origin of them all. It has a deep influence on menstruation both because it originates from the Kidneys and because it is the Sea of Blood. This vessel influences the supply and proper movement of Blood in the Uterus and controls menstruation in all its aspects. The trajectory of the Penetrating Vessel is quite complex (Fig. 2.35). It starts in the area between the kidneys where the Motive Force (Dong Qi) throbs. Passing through the uterus, it flows down to Ren-1 Huiyin; this part of its trajectory is common to all three vessels – Penetrating, Governing and Directing – which is why Li Shi Zhen calls them “three branches of one vessel”. From Ren-1, the Penetrating Vessel emerges at ST-30 Qichong and then flows with the Kidney channel up to KI-21 Youmen (some authors say up to KI-27 Shufu). It continues its flow up to the throat, circles around the mouth and goes up to the forehead where it “oozes into the Yang and irrigates the Yin”.30 From Ren-1, a branch flows inside the spine (some authors say up to the level of BL-23 Shenshu). Another branch flows down from ST-30 in the inner side of the leg to the medial side of the foot, where it splits into two branches following the Kidney and Spleen channels (the latter reaching the big toe). Thus the Penetrating Vessel influences the whole body except the arms.
Figure 2.35 The Penetrating Vessel. The spinal branch of the Penetrating Vessel explains how a woman can experience menstrual pain in the sacrum and lower lumbar vertebrae. The descending branch of the Penetrating Vessel explains how menstrual pain can
sometimes irradiate down to the inner thighs. The changes that take place in the Governing, Directing and Penetrating vessels determine the hormonal changes that occur in women at intervals of 7 years or thereabouts, as described in the first chapter of the Simple Questions which says: At 14 the Heavenly Gui comes into play, the Directing Vessel circulates strongly, the Penetrating Vessel is flourishing, the menses come at regular intervals and the girl can conceive … at 49 the Directing Vessel becomes deficient and the Penetrating Vessel depleted, the Heavenly Gui dries up, menstruation stops and she can no longer conceive.31 Some authors say that the Penetrating Vessel is the Sea of Blood and, for this reason, the Sea of Blood points, BL-11 Dashu, ST-37 Dajuxu and ST-39 Xiajuxu, are Penetrating Vessel points (Fig. 2.36). Being the Sea of Blood, it has a paramount importance in the menstrual function. It provides and moves Blood, oozes into the Yang and irrigates the Essence.
Figure 2.36 The Penetrating Vessel and the points of the Sea of Blood. The Penetrating Vessel is related to Blood and body hair. When its Blood is abundant it moistens the skin and promotes the growth of body hair. Chapter 35 of the Spiritual Axis says:
The Penetrating and Directing Vessels go to the throat, lips and mouth. If both Qi and Blood are abundant the skin is filled and the muscles warmed, if only Blood is abundant it will penetrate into the skin and beard grows. Women have more Qi than Blood because they lose some of it with the periods, hence the Penetrating and Directing Vessels carry less Blood to chin and lips and therefore no beard grows.32 The Penetrating Vessel, together with the Directing Vessel, regulates the uterus and menstruation and it nourishes and moves Blood. It can be used in such conditions as dysmenorrhoea, irregular periods, pre-menstrual tension and menorrhagia. If the Penetrating Vessel is Empty, there may be amenorrhoea, scanty periods or late periods. Stagnant Qi and/or Blood in the Penetrating Vessel may cause dysmenorrhoea. The Classic of Categories has an interesting summary of the energetic sphere of action of the Penetrating Vessel and explains more in depth the meaning of this vessel’s being the ‘Sea of the 12 Channels’: The Penetrating Vessel is the Sea of the 12 Channels, it goes upwards to connect with BL-11 Dashu and downwards to connect with ST-37 Shangjuxu and ST-39 Xiajuxu. The Penetrating Vessel goes down to ST-30 Qichong and up to connect with the Kidney channel. It goes up to the eyes and head and down to the feet; it goes to the back [in the lumbar spine] and to the front in the abdomen. It goes into the Interior in the rivers and valleys [the big and small muscles of the abdomen] and into Exterior in the skin and muscles. It therefore connects with both Yin and Yang and both Interior and Exterior … 100 diseases originate from the Penetrating Vessel because it is the most ‘penetrating’ [of the channels]. It controls the Qi and Blood of the 12 Channels which nourish the whole body and for this reason it is called the Sea of the 5 Yin and 6 Yang Organs.33 This energetic sphere of action is illustrated in Figure 2.37.
Figure 2.37 Energetic sphere of the Penetrating Vessel.
Summary Penetrating Vessel (Chong Mai)
• The Penetrating Vessel has a deep influence on menstruation both because it originates from the Kidneys and because it is the Sea of Blood • This vessel influences the supply and proper movement of Blood in the Uterus and controls menstruation in all its aspects
• The changes that take place in the Governing, Directing and Penetrating Vessels determine the hormonal changes that occur in women at intervals of 7 years or thereabouts, as described in the first chapter of the Simple Questions • The Penetrating Vessel is the Sea of Blood and, for this reason, the Sea of Blood points, BL-11 Dashu, ST-37 Dajuxu and ST-39 Xiajuxu, are Penetrating Vessel points • Being the Sea of Blood, it has a paramount importance in the menstrual function • The Penetrating Vessel is related to Blood and body hair. When its Blood is abundant it moistens the skin and promotes the growth of body hair • The Penetrating Vessel, together with the Directing Vessel, regulates the uterus and menstruation and it nourishes and moves Blood
Directing Vessel (Ren Mai) The Directing Vessel is very closely related to the Uterus and to the whole female reproductive system including internal and external genitalia in women. All problems of cervix, vagina and vulva are related to the Directing Vessel. The Directing Vessel starts from the space between the kidneys where the Motive Force throbs. Passing through the uterus, it emerges at Ren-1 Huiyin. It then flows upwards through all the Directing Vessel’s points up to Ren-24 Chengjiang. It then circles the mouth and enters the eyes from ST-1 Chengqi (Fig. 2.38).
Figure 2.38 The Directing Vessel. In terms of energies, the Directing Vessel is connected to Yin, Essence and fluids (as opposed to the Penetrating Vessel, which is related mostly to Blood and Qi); in fact, it is called the ‘Sea of the Yin channels’. This means that the Directing Vessel provides the Yin substances (including Essence, Blood and fluids) for all women’s physiological processes and hormonal gateways, including puberty, conception, pregnancy, childbirth and menopause. The Penetrating Vessel, on the other hand, is related more to Blood and menstruation and its pathology is dominated by Blood stasis and Qi stagnation. The Directing Vessel can be used to nourish the Yin energy of the body, particularly in women after menopause, and to reduce the effects of EmptyHeat symptoms deriving from Yin deficiency. The main difference between the Penetrating Vessel and the Directing Vessel in relation to menstruation is that the former controls Qi and can be used to tonify and nourish, whereas the latter controls Blood and is mostly used to move Qi and Blood and remove obstructions. Thus the Directing Vessel has more responsibility for conception, fertility, menarche, pregnancy and menopause, the Penetrating Vessel for menstruation and most of its irregularities. Summary Directing Vessel (Ren Mai)
• The Directing Vessel is very closely related to the Uterus and to the whole female reproductive system including internal and external genitalia • All problems of cervix, vagina and vulva are related to the Directing Vessel • The Directing Vessel is connected to Yin, Essence and fluids
• The Directing Vessel provides the Yin substances (including Essence, Blood and fluids) for all women’s physiological processes and hormonal gateways, including puberty, conception, pregnancy, childbirth and menopause
Governing Vessel (Du Mai) The Governing Vessel also arises from the space between the kidneys. Passing through the uterus, it emerges in the perineum at Ren-1 Huiyin. From here it goes to Du-1 Changqiang and flows up the spine to the base of the skull where it enters the brain. From the vertex, it flows in the midline down to the upper lip ending at Du-28 Yinjiao. However, its internal pathway is more complex than this outline may suggest. There is a contradiction between the Classic of Difficulties, which has the Governing Vessel running upwards, and the Spiritual Axis (Ch. 16), which has it running downwards as a branch of the Liver channel and which, after describing the pathway of the Liver channel, says: … its separating branch travels upwards to the forehead, then to the vertex, then downward in the midline of the occiput, travelling along the spine to enter the sacrum: this [separating branch] is the Governing Vessel. It then flows to the genitals, passing upward through the pubis to enter the umbilicus, moving upwards in the abdomen to enter the clavicle area and downward to enter the lungs.34 Thus this pathway of the Governing Vessel flows not only down the spine but also up the abdomen. Chapter 60 of the Simple Questions has the following pathway for the Governing Vessel: it starts near the uterus and goes down to the pubic bone and, in women, to the vagina. Its connecting channel goes around the vagina, passes to the perineum, then the buttocks, down to meet the Kidney and Bladder channels inside the upper thighs; it then rises up the spine to wrap around the kidneys (Fig. 2.39). In men it goes around the penis and then the perineum. The ‘main vessel’ starts in the abdomen and goes up to the umbilicus, past the heart, throat and chin, and around the lips to reach the eyes (Fig. 2.40).35 Some see this ‘main vessel’ as being the Directing Vessel, others as a branch of the Governing Vessel; in fact, Li Shi Zhen considered it
a branch of the Governing Vessel flowing with the Directing Vessel: Another branch [of the Governing Vessel] starts in the lower abdomen, comes up the abdomen, to the umbilicus, the heart, enters the throat, goes to the chin and to the centre of the eyes, following the pathway of the Directing Vessel.36
Figure 2.39 Genital branch of the Governing Vessel.
Figure 2.40 Abdominal branch of the Governing Vessel.
Figure 2.41 illustrates the secondary channels of the Governing Vessel from the Simple Questions (Ch. 60) and from the Study of the Eight Extraordinary Vessels by Li Shi Zhen.
Figure 2.41 The secondary channels of the Governing Vessel. The implication of the above pathway is that the Governing and Directing vessels are almost like two branches of the same vessel, one Yang and one Yin, intersecting inside. Li Shi Zhen says: The Directing and Governing Vessels are like midnight and midday,
they are the polar axis of the body … there is one source and two branches, one goes to the front and the other to the back of the body … we can make connections between them. When we try to divide these, we see that Yin and Yang are inseparable. When we try to see them as two, we see that it is an indivisible whole.37 Literally translated, the last sentence says: “They are one but two, they are two but one.” Thus the ‘main vessel’ that the Simple Questions describes may be seen either as the Directing Vessel or as a branch of the Governing Vessel and, given the close connection between these two vessels, in practice it does not make much difference which one it is. However, the important implication of the above pathways in gynecology is that the Governing Vessel extends a branch to the front of the body curling around the vagina; when a woman has problems of the genitalia the Directing Vessel is the obvious choice but the Governing Vessel can be used too, and if there is a marked deficiency of Kidney-Yang, it should be chosen in preference to the Directing Vessel. In relation to menstruation, the Governing Vessel influences the tide of Yang (Kidney-Yang) that decreases with the onset of the period and increases from ovulation. In other words, arising from the uterus like the Directing and Penetrating vessels, it represents the Yang aspect of women’s reproductive functions. As we have seen above, the Governing Vessel represents the influence of the Fire of the Gate of Life (Ming Men) and the Minister Fire in women’s physiology. The Governing and Directing vessels can be seen as two branches, one Yang and one Yin, of the same continuous energetic circuit arising from the space between the kidneys, flowing through the uterus, emerging at the perineum and flowing upwards, one at the back, the other at the front, to reach the head and the brain, connecting with the heart on the way (Fig. 2.42). Thus, from a Chinese perspective, these two vessels connect the Uterus with the Kidneys, the Heart and the Brain, which goes some way to explaining the influence of mental–emotional problems on the menstrual and ovarian functions and vice versa. In terms of vital substances, the Governing and Directing vessels’ circuit connects the Essence (Kidneys), Blood (Uterus
and Heart), Marrow (spine and Kidneys) and Sea of Marrow (Brain). Seen from a Western perspective, the Governing and Directing Vessels clearly represent the hypothalamus–pituitary–ovarian axis which is responsible for ovulation (Fig. 2.43).
Figure 2.42 Circuit of Governing and Directing Vessels.
Figure 2.43 Governing and Directing Vessels as hypothalamus–pituitary–ovarian axis.
Summary Governing Vessel (Du Mai)
• The Governing Vessel also arises from the space between the kidneys • The Governing Vessel has a branch going to the front of the body in the genital area: it goes to the vagina in women and penis in men
• The Governing Vessel also has an abdominal branch that follows the same pathway as that of the Directing Vessel • The Governing and Directing Vessels are almost like two branches of the same vessel, one Yang and one Yin, intersecting inside • In relation to menstruation, the Governing Vessel influences the tide of Yang (Kidney-Yang) that decreases with the onset of the period and increases from ovulation • Arising from the uterus like the Directing and Penetrating Vessels, the Governing Vessel represents the Yang aspect of women’s reproductive functions • The Governing Vessel represents the influence of the Fire of the Gate of Life (Ming Men) and the Minister Fire in women’s physiology
Girdle Vessel (Dai Mai) The Girdle Vessel is the only horizontal channel of the body. Its pathway is simply a belt-like channel encircling the waist and passing through G.B.-26 Daimai, G.B.-27 Wushu and G.B.-28 Weidao. Some authors say it also connects with LIV-13 Zhangmen. In the back, it intersects the Kidney divergent channel (Fig. 2.44).
Figure 2.44 Girdle Vessel. The Girdle Vessel has an important influence in women’s physiology and pathology. Encircling the leg channels, it interrelates with and restrains the Liver’s smooth flow of Qi (through LIV-13 Zhangmen), and harmonizes the ascending and descending of both Spleen and Kidneys. Hence the Kidney’s nourishment of the Essence and descending of Qi, the Spleen’s raising of Qi and the Liver’s smooth flow of Qi all rely on the Girdle Vessel being ‘relaxed and stretched’: these are all very important aspects of women’s physiology and pathology. Because of this, the Girdle Vessel guides and supports the Qi of the Uterus and the Essence. If the Girdle Vessel does not exercise enough restraint, Damp-Heat, usually deriving from a chronic Spleen deficiency, may infuse downwards causing leucorrhoea. Because the Girdle Vessel connects with LIV-13 Zhangmen (FrontCollecting point of the Spleen) and BL-23 Shenshu (Back-Transporting point of the Kidneys), it connects the Post-Natal with Pre-Natal Qi (in a similar way to that of the Penetrating Vessel). Because of the gynecological sphere of influence of the Girdle Vessel, some doctors say that in terms of energy it is part of the Directing Vessel and the Penetrating Vessel: its deficiency pathology is related to the Directing Vessel while its excess pathology is related to the Penetrating Vessel. Deficiency of the Girdle Vessel makes it too ‘slack’. This slackness leads to Kidney and Liver deficiency. The Girdle Vessel fails to restrain the Essence, Spleen-Qi sinks and the Post-Natal Qi is unsupported, so that the Directing, Governing and Penetrating Vessels all become deficient. When the Girdle Vessel is slack, Qi cannot rise, the organs sag and there may be prolapse of the uterus or miscarriage, due to long-term Qi deficiency, Post- and Pre-Natal Qi deficiency and clear Qi descending. The fetus depends not only on the Kidneys and the Directing Vessel, but also on the Girdle Vessel. If the Girdle Vessel is slack, Qi cannot rise, the fetus is not stabilized and the mother may miscarry. The Governing and Directing vessels cut across the Girdle Vessel linking it with the Heart above, the genital system below, the umbilicus in front and
the Penetrating Vessel in the middle. This emphasizes why these four vessels (Governing, Directing, Penetrating and Girdle) are interlinked for the production, circulation, discharge and regeneration of the Essence. When these vessels are blocked, the Essence cannot be produced properly and all kinds of gynecological problems ensue. Figure 2.45 illustrates the relationship among the Governing, Directing, Penetrating and Girdle vessels in gynecology.
Figure 2.45 Relationship among Governing, Directing, Penetrating and Girdle vessels.
Summary
Girdle Vessel (Dai Mai)
• The Girdle Vessel is the only horizontal channel of the body • Its pathway is simply a belt-like channel encircling the waist and passing through G.B.-26 Daimai, G.B.-27 Wushu and G.B.-28 Weidao • Encircling the leg channels, the Girdle Vessel interrelates with and restrains the Liver’s smooth flow of Qi (through LIV-13 Zhangmen), and harmonizes the ascending and descending of both Spleen and Kidneys • The Kidney’s nourishment of the Essence and descending of Qi, the Spleen’s raising of Qi and the Liver’s smooth flow of Qi all rely on the Girdle Vessel being ‘relaxed and stretched’ • If the Girdle Vessel does not exercise enough restraint, Damp-Heat, usually deriving from a chronic Spleen deficiency, may infuse downwards causing leucorrhoea • Its deficiency pathology is related to the Directing Vessel while its excess pathology is related to the Penetrating Vessel • Deficiency of the Girdle Vessel makes it too ‘slack’. This slackness leads to Kidney and Liver deficiency. The Girdle Vessel fails to restrain the Essence, Spleen-Qi sinks and the Post-Natal Qi is unsupported, so that the Directing, Governing and Penetrating Vessels all become deficient
Yin Stepping Vessel (Yin Qiao Mai) The Yin Stepping Vessel starts from KI-6 Zhaohai. It ascends along the medial surface of the leg and thigh and then goes over the abdomen, passing through the external genitalia, and ascending to the chest, the clavicle, the throat and face to end at the inner canthus of the eye (Fig. 2.46).
Figure 2.46 The Yin Stepping Vessel. The Yin Stepping Vessel influences the reproductive system and the lower abdomen in women. It is particularly used for excess patterns of the Lower Burner such as abdominal masses, fibroids, difficult delivery and
retention of placenta. Since it passes through the external genitalia, it may also be used for problems that occur in this area, provided there is a background of excess. Figure 2.47 summarizes the interrelationship among the internal organs, the Vital Substances, the Uterus and the Extraordinary Vessels.
Figure 2.47 Interrelationship among the internal organs, the Vital Substances, the Uterus and the Extraordinary Vessels.
Conception As described above, conception relies on an abundant supply of Blood and Essence, the flourishing of Kidneys and Liver, and healthy Penetrating and Directing Vessels, factors which depend on the mother; other factors depend on the father. Thus both the Pre-Natal Qi, in the form of Essence, and the Post-Natal Qi, in the form of Blood, are essential for conception to occur. However, Blood and Essence are only the Yin essences of the body and conception depends also on the Yang energies of the Fire of the Gate of Life. This is the formless Minister Fire which is intrinsically and indissolubly related to Water. The Minister Fire (related to the Governing Vessel) provides the spark necessary for the Essence and Blood to form a new being (Fig. 2.48).
Figure 2.48 Factors in conception. However, the Essence of the mother is only one aspect of the necessary energies for conception to occur. The mother’s Corporeal Soul (Po) also plays an important role in conception. A physical type of soul that pertains to Earth, it is Yin in nature, is stored in the Lungs and comes from the mother; it dies with the body at the end of a life. The Corporeal Soul interacts closely with the Essence: it could be said that it brings the Essence into play in all physiological processes. In fact, Chapter 8 of the Spiritual Axis says: “The Corporeal Soul is the entering and exiting of the Essence.”38 In
particular, the fetus’s Corporeal Soul is formed at conception from the mother’s: thus the father plays no role in this particular aspect of conception. Thus, from this point of view, the influence of the mother’s energies on conception is stronger than that of the father. This also implies that the hereditary constitution of a baby depends not only on the parents’ Kidneys, but also on the mother’s Lungs.
Pregnancy Pregnancy is a time of change. As a result of the stopping of the menses, the Penetrating and Directing Vessels undergo many changes, which are typical of pregnancy and do not occur at other times. During pregnancy there is an abundance of Yin, because there is no longer a monthly loss of blood and because there is a gradual increase in fluids (amniotic fluid); there is also a plethora of Yang, because the absence of periods leads also to an accumulation of Minister Fire (as the Water and the Fire within the Kidneys are inseparable). After conception, Blood is gradually transformed into milk and also transfers its location from the Lower to the Upper Burner. During the first 3 months, because of the profound changes taking place in the Penetrating Vessel and because of the transformation of Blood into milk with its upward movement to the breasts, rebellious Qi often goes up in the Penetrating Vessel. This causes not only morning sickness in the first 3 months but also a general feeling of heat above and distension of the breasts. From an energetic point of view, pregnancy has a dual effect on the Kidneys. On the one hand, it poses a strain on the Kidneys as their Qi and Essence go to feed the fetus. However, the stoppage of the menses also means that menstrual blood (which is not actually ‘Blood’ as seen above, but Tian Gui) can now go to feed the body itself (as well as the fetus). It could be said that during pregnancy, Blood is transformed into Essence which nourishes the body (and the fetus). In fact, under normal circumstances and a healthy pregnancy, a pregnant woman looks very florid and healthy and not at all Blood deficient (especially between the fourth and seventh months). The transformation of Blood into Essence during pregnancy is mirrored, from a Western point of view, by the secretion of large amounts of oestrogen, progesterone and chorionic gonadotropin by the placenta, which explains why some women are healthier in pregnancy and others deteriorate; the difference depends both on the pre-existing state of Kidney-Qi and on how well the woman looks after herself during the pregnancy. Two examples of
health problems that often improve during pregnancy are asthma and migraine. The increased pigmentation along the midline of the body and round the nipples is due to changes occurring in the Directing Vessel. Another change taking place during pregnancy is a certain increase in Heat. The Qing dynasty gynecologist, Chen Jia Yuan, explains: During pregnancy the Emperor and Minister Fire gradually nourish the fetus and there is normally a feeling of heat and a certain restlessness [in the mother]. The Heart governs Blood [during pregnancy], Blood protects the fetus and cannot irrigate the Sea of Blood.39 This passage is interesting because it confirms that Blood deficiency can cause hot flushes and a feeling of heat in a similar way to Yin deficiency. The passage is interesting also because it states that during pregnancy, although the Blood is abundant (as the menses stop), it is directed to nourish and protect the fetus rather than flowing into the Sea of Blood. This may explain the fact that, from a Western point of view, although during pregnancy there is a substantial increase in the volume of fluids, including those in the plasma (to a total of about 3300 ml), a 30% increase in the volume of blood and an increase in the total absolute number of red blood cells (by about 20%), there is a decrease in the haemoglobin content because the haemoglobin concentration and the red blood cell count fall in relation to the large increase in blood volume. Seen from a Chinese perspective, these physiological changes of pregnancy are mirrored in the idea that the Blood increases (because the menses stop) but it is deviated away from the Sea of Blood to nourish and protect the fetus. Hence, while from a Western point of view the mother may be said to suffer from anaemia (due to the fall in red cell count and haemoglobin in relation to the increased volume of blood), she cannot be said to suffer from Blood deficiency in a Chinese sense. Interestingly, a study conducted on 153 602 pregnant women by three English medical colleges showed that women with low haemoglobin levels were more likely to carry the pregnancy to full term and give birth to healthy
babies. In fact, risks of a pre-term baby or one born with a low birth weight increased seven times in women whose haemoglobin levels failed to fall during pregnancy. In other words, the widely seen drop in iron blood levels in pregnant women is perfectly normal, signifying good expansion in blood volume, not anaemia.40 This confirms what was said above, i.e. that the haemoglobin level of pregnant women is lower only in relation to the increased blood and fluid volume. Birth weight is the single biggest determinant of mortality in the first year of life and is therefore a good indicator of the efficiency with which a woman has supported her fetus. The authors of the above-mentioned study conclude that the mechanism by which expansion of the plasma volume enhances fetal growth is not known, but it may be that reduced blood viscosity favours blood flow in the low-velocity flow system of the maternal intervillous space. This last observation ties in well with Chinese views as, although the mother’s Blood goes to nourish the fetus, there is more of it due to the cessation of menses. In Chinese medicine, pregnancy is considered to last 10 lunar months (roughly equivalent to 9 calendar months) and each month corresponds to an internal organ as follows: 1. Liver 2. Gall Bladder 3. Pericardium 4. Triple Burner 5. Spleen 6. Stomach 7. Lungs 8. Large Intestine
9. Kidneys 10. Bladder. The use of points on a particular channel in theory was prohibited in the relevant month, but this rule is not followed nowadays. The correspondence between the tenth month and the Bladder is interesting: this would provide an explanation for the use of the point BL-67 Zhiyin in the last month of pregnancy to turn the fetus. The fact that it has the effect of moving the fetus would confirm the idea that, under normal circumstances, points from that channel should not be used in the tenth month and, by inference, neither should the other channels be needled in the relevant months. However, the Qing dynasty gynecologist Chen Jia Yuan has a different correspondence between the months of pregnancy and internal organs: 1. Gall Bladder 2. Liver 3. Pericardium 4. Heart 5. Stomach 6. Spleen 7. Large Intestine 8. Lungs 9. Bladder 10. Kidneys. The Thousand Golden Ducat Prescriptions of the Tang dynasty describes the changes occurring at each month of pregnancy. It says that in
the first month the conceived being is called embryo (some ancient doctors compared it to ‘dew’), in the second month ‘fat’ (Gao), in the third month ‘fetus’ (Bao); in the fourth month it acquires a body shape, in the fifth it can move, in the sixth the sinews and bones are formed, in the seventh the skin and hair are formed, in the eighth the organs are fully formed, in the ninth the Food Qi (Gu Qi) enters the Stomach, in the tenth month the Shen is fully established and childbirth occurs.41
Menopause Chapter 1 of the Simple Questions says: At 49 [in a woman] the Directing Vessel becomes deficient, the Penetrating Vessel depleted, the Tian Gui dries up, the fluids in the channels are exhausted, her body becomes old and she can no longer become pregnant.42 Thus, the most important change occurring around this age is a decline of the Kidney energy and the Directing and Penetrating Vessels, together with a general drying up of fluids and Blood. This is consistent with the symptoms of menopausal problems. ‘Menopause’ indicates the complete or permanent cessation of menstruation: an interval of 6 to 12 months is usually necessary to establish the diagnosis. ‘Climacteric’ indicates the phase in a woman’s life during which she makes the transition from a reproductive to a non-reproductive stage: this transition is a period of declining ovarian function which usually spans 2 to 5 years around the menopause. Thus, when we refer to the discomfort and symptoms appearing during these years, it would be more appropriate to call them climacteric syndrome rather than menopausal syndrome: however, since the latter term is more generally used and understood, I shall use it throughout this book. Menopause usually occurs between the ages of 48 and 55 and the median age in industrialized countries is about 51. It will be remembered that the very first chapter of the Simple Questions describes the 7-year cycles of women, according to which menopause occurs at 49 (7 × 7): this is not far from the above-mentioned median age of 51. Furthermore, data analyses indicate that the menopausal age has remained unchanged for centuries.43 Indeed, the mean age at menopause is just over 50 and this is remarkably constant not only throughout the Western world but also other countries. A survey of Malaysian women showed a mean age at menopause of 50.7 years, and another of seven Asian countries found that most women reached
menopause at around 50.44 The primary basis for the progressive decline of reproductive power in women is in the ovary itself, as ovarian follicles are greatly depleted by the time of the menopause. There are about 300 000 follicles at menarche and about 10 000 at the time of the menopause. As the follicle activity decreases and then ceases, there is a lack of oestrogen and therefore a cessation of the menses. Menopause is not a disease, it is the normal physiological transition in a woman’s life from a reproductive to a non-reproductive age: indeed, many women experience no ‘symptoms’ during this time. From a Chinese perspective, menopausal symptoms (if there are any) are generally due to a decline of Kidney-Essence in its Yin or Yang aspect; however, within this basic pathology there can be many variations of pattern. Moreover, the deficiency of the Kidneys may often be combined with excess patterns, especially Phlegm, stagnation of Qi, stasis of Blood, Empty-Heat, or LiverYang rising (Fig. 2.49).
Figure 2.49 Pathology of menopause. For a discussion of menopausal problems, see Chapter 58. End notes 1. Elementary Medicine (Yi Xue Ru Men) 1575 cited in Zhang Qi Wen 1995 Menstrual Diseases (Yue Jing Bing Zheng
), People’s Hygiene Publishing House, Beijing, p. 10..
2. Feng Tao Zhang 1702 Secret Records of Master Feng’s Brocade Bag (Feng Shi Jin Nang Mi Lü) cited in Menstrual Diseases, p. 13..
3. Cited in Chinese Medicine Research Institute and Guangzhou College of Chinese Medicine 1980 Concise Dictionary of Chinese Medicine (Jian Ming Zhong Yi Ci Dian
), People’s Health Publishing House, Beijing, p. 186..
4. 1979 The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen
), People’s Health Publishing House, Beijing, p. 259. First published c. 100 BC..
5. Ibid., p. 197..
6. Ann McPherson 1993 Women’s Problems in General Practice, Oxford University Press, Oxford, p. 201..
7. Whincup P H, Gilg J A, Odoki K et al 2001 Age of Menarche in Contemporary British Teenagers: Survey of Girls Born between 1982–1986, British Medical Journal 322: 1095–1096..
8. Chumlea W C, Schubert C M, Roche A F et al 2003 Age at Menarche and Racial Comparisons in US Girls, Pediatrics 111: 110–113..
9. Wu Da Zhen 1994 Hundred Methods for the Treatment, Prevention and Dietary Therapy of Menstrual Irregularities (Yue Jing Bing Fang Zhi He Shi Liao 100 Fa
100 Beijing, p. 12..
), China Medicinal Herbs Scientific Publishing House,
10. Ibid., p. 194..
11. Simple Questions, p. 5..
12. Chen Zi Ming 1237 Great Treatise of Beneficial Formulae for Women (Fu Ren Liang Fang Da Quan) cited in Menstrual Diseases, p. 10..
13. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p. 27. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
14. Ibid., p. 27..
15. Simple Questions, p. 5..
16. Chen Zi Ming 1237 Great Treatise of Beneficial Formulae for Women (Fu Ren Liang Fang Da Quan) cited in Menstrual Diseases, p. 10..
17. Fu Qing Zhu’s Gynaecology, p. 27..
18. Ibid., p. 27..
19. Ibid., p. 55..
20. Pei Zheng Xue 1980 A Commentary on the Discussion of Blood Syndromes (Xue Zheng Lun Ping Shi
), People’s Health Publishing House, Beijing, p. 159. The Discussion of Blood Syndromes (Xue Zheng Lun
), by Tang Zong Hai was originally published in 1885..
21. Cong Chun Yu 1989 Chinese Medicine Gynaecology (Zhong Yi Fu Ke Xue
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 11..
22. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian
), People’s Health Publishing House, Beijing, Vol. 3, p. 7. First published in 1742..
23. Ibid., p. 7..
24. Zhang Jing Yue 1986 The Complete Works of Jing Yue (Jing Yue Quan Shu
), Shanghai Science and Technology Press, Shanghai, p. 19. First published in 1624..
25. Cited in Menstrual Diseases, p. 13..
26. Ibid., p. 13..
27. Chao Yuan Fang AD 610 General Treatise on the Aetiology and Symptomatology of Diseases (Zhu Bing Yuan Hou Zong Lun) cited in Menstrual Diseases, p. 179..
28. Ibid., p. 27..
29. Luo Guo Gang 1789 Mirror of Medicine abstracted by Master Luo (Meng Shi Hui Yue Yi Jing) cited in Menstrual Diseases, p. 15..
30. 1981 Spiritual Axis (Ling Shu Jing
), People’s Health Publishing House, Beijing, p. 79. First published c. 100 BC..
31. Simple Questions, p. 5..
32. Spiritual Axis, p. 120..
33. Zhang Jing Yue 1982 Classic of Categories (Lei Jing
), People’s Health Publishing Company, Beijing, p. 281. The Classic of Categories was first published in 1624..
34. Spiritual Axis, p. 49..
35. Simple Questions, p. 320..
36. Wang Luo Zhen 1985 A Compilation of the Study of the Eight Extraordinary Vessels (Qi Jing Ba Mai Kao Jiao Zhu
), Shanghai Science Publishing House, Shanghai, p. 81. The Study of the Eight Extraordinary Vessels (Qi Jing Ba Mai Kao
) by Li Shi Zhen was published in 1578..
37. Ibid., p. 81..
38. Spiritual Axis, p. 23..
39. Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 13. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang
)..
40. Steer P, Alam M A, Wadsworth J et al 1995 Relation between Maternal Haemoglobin Concentration and Birth Weight in Different Ethnic Groups, British Medical Journal 310: 489–491..
41. Sun Si Miao 652 Thousand Golden Ducat Prescriptions (Qian Jin Yao Fang) cited in Luo Yuan Kai 1986 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Shanghai Science and Technology Press, Shanghai, p. 14..
42. Simple Questions, p. 5..
43. Clarke-Pearson D L, Dawood M Y 1990 Green’s Gynaecology: Essentials of Clinical Practice, Little, Brown and Company, Boston, p. 457..
44. Women’s Problems in General Practice, p. 198..
CHAPTER 3 Women’s Pathology
PATHOLOGY OF THE INTERNAL ORGANS 49 Kidneys 49 Liver 52 Spleen 60 Heart 61 Lungs 64 Stomach 64 QI AND BLOOD PATHOLOGY 64 Qi rebellious 65 Blood-Cold 65 PATHOLOGY OF THE EXTRAORDINARY VESSELS 67 Penetrating Vessel (Chong Mai) 67 Directing Vessel (Ren Mai) 71 Governing Vessel (Du Mai) 71 Girdle Vessel (Dai Mai) 72 Yin Stepping Vessel (Yin Qiao Mai) 73 Yin Linking Vessel (Yin Wei Mai) 74 Women’s pathology will be discussed under three main headings: 1. Pathology of the internal organs. 2. Qi and Blood pathology.
3. Pathology of the Extraordinary Vessels.
Pathology of the internal organs
Kidneys
Kidney deficiency Kidney deficiency, one of the major pathologies in gynecology, is at the root of many women’s problems. It is probably more common in women because of the triple relationship of Blood–Uterus–Kidneys: a deficiency of Blood, which often occurs in women, affects the Uterus, and since this is functionally related to the Kidneys, the Kidneys also become deficient. Hence, in women, a Blood and a Kidney deficiency are often overlapping. Clinical Note In women, Blood and Kidney deficiencies are often overlapping. In women more than men, a Kidney deficiency often involves both Yin and Yang, albeit one will always be predominant. The tongue illustrates clearly which is predominant: if it is Pale, Kidney-Yang deficiency predominates; if it lacks a coating, Kidney-Yin deficiency predominates. The reason why Kidney-Yin deficiency and Kidney-Yang deficiency often occur simultaneously in women is three-fold: 1. Because of the connection between Penetrating Vessel–Blood–Uterus– Kidneys (the Penetrating Vessel is the Sea of Blood, it arises from the Uterus and pertains to the Kidney channel), a deficiency of Kidney-Yang will affect the Penetrating Vessel, which affects the Blood, itself part of Yin, hence a Yin deficiency arises. Or, a deficiency of Kidney-Yin affects the Uterus, which stores Blood; this affects the Penetrating Vessel which is the Sea of Blood and which originates from the space between the kidneys where the Motive Force (Dong Qi) throbs. This Motive Force itself originates from the Fire of the Gate of Life (Ming Men) and therefore a Kidney-Yang deficiency results.
2. The Minister Fire is the source of both Fire and Water. Water forms menstrual blood, hence when the Kidneys are deficient, both Water and Fire are deficient. 3. In men as well as women, a deficiency of Kidney-Yin or Kidney-Yang may simply arise and develop simultaneously into the other because Yin is the material substance of Yang and Yang is the function of Yin and the two are indissolubly connected. Kidney-Yin and Kidney-Yang are like an oldfashioned Chinese oil lamp: Kidney-Yin is the oil, Kidney-Yang the flame at the end of the wick. If the oil is decreased, eventually the flame dies down; vice versa, if the flame dwindles, less oil is burned, and eventually it will coagulate and dry up (Fig. 3.1).
Figure 3.1 Kidney-Yin and Kidney-Yang as an oil lamp. In women, a simultaneous deficiency of Kidney-Yin and Kidney-Yang is far more common after age 40. As Kidney-Yin and Kidney-Yang can both be deficient, in women this causes the very common situation when there are both Hot and Cold symptoms. This is because the Yin-deficient part of the Kidneys can give rise to Empty-Heat even if there is a predominance of Yang deficiency. For example, a woman may have backache, frequent, pale urination, swollen ankles, cold feet, Pale tongue (symptoms of Kidney-Yang
deficiency) and hot flushes. Vice versa, a woman may suffer from backache, dizziness, night sweating, a Red-Peeled tongue, hot flushes (symptoms of Kidney-Yin deficiency), but cold feet and frequent urination. Figures 3.2 and 3.3 illustrate the above clinical situations when there is a deficiency of both Kidney-Yin and Kidney-Yang with a predominance of Kidney-Yang and Kidney-Yin respectively.
Figure 3.2 Simultaneous deficiency of Kidney-Yin and Kidney-Yang with a predominance of the latter.
Figure 3.3 Simultaneous deficiency of Kidney-Yin and Kidney-Yang with a predominance of the former.
This clinical situation is so common in women aged over 40 that I think it is the rule rather than the exception. Over the years I have made a note of all the cases presenting with contradicting Hot and Cold symptoms stemming from a simultaneous deficiency of both Kidney-Yin and Kidney-Yang (there are other causes of contradicting Hot and Cold symptoms not related to the Kidneys, which will be explained later). The following is a partial list of the most glaring examples, with the patient’s age indicated at the start of each entry. • 42: cold feet, pale urine, Pale tongue, hot feet in bed at night. • 44: night sweating, frequent urination, Pale tongue, cold hands, hot feet, dry throat. • 46: always feeling very cold, needs to wear socks in bed, pale urine, Red tongue without coating, poor memory, hot flushes.
• 48: hot flushes, Pale tongue. • 53: hot flushes, Pale tongue, feeling cold, cold feet. • 42: Red, Peeled tongue, dry mouth, feeling very cold. • 44: Pale tongue, feeling cold, very hot feet at night. • 38: feeling very cold, backache, Pale tongue, hot feet at night. • 52: backache, dizziness, tinnitus, night sweating, Red tongue, feeling cold. • 53: night sweating, Red tongue, dryness of vagina, feeling cold, oedema. • 49: Pale tongue, feeling cold, dry throat, scanty urine, hot in bed (husband says she is ‘boiling in bed’). • 51: hot flushes, feeling of heat, Pale tongue. • 43: hot and red face, sweating, dry mouth, Pale tongue. • 44: backache, oedema, feeling cold, extremely Pale tongue, hot at night. • 65: Pale tongue, oedema of ankles, no thirst, feeling of heat, scanty urination, constipation. • 43: night sweating, hot flushes, Pale tongue (helped by moxa on Ren-4). • 42: hot flushes, Pale tongue, likes a hot-water bottle on her back, backache. • 46: Pale tongue, hot flushes (helped by moxa on KI-3 Taixi). • 42: Pale tongue, hot flushes, feeling of heat at night, hot feet in bed at night, but very cold feet in daytime.
• 42: Red tongue, feeling of heat, tinnitus, likes a hot-water bottle on her back. • 47: feeling cold during her periods, Pale tongue, hot chest and face at night. • 44: hot flushes, night sweating, Pale tongue. • 45: Pale tongue, feeling of heat, hot in bed. • 45: Red tongue which feels sore and dry, night sweating, hot soles, cold back. • 42: feeling very cold, red tip of tongue, bitter taste, night sweating, frequent urination. • 52: night sweating, dry mouth, constipation, Pale tongue. • 83: Red, Peeled tongue, knee-ache, tinnitus, night sweating, oedema of ankles. • 46: very Pale tongue, Deep pulse, legs feeling cold up to the knees, very hot at night, insomnia. • 54: very Pale tongue, pale urine, backache, hot flushes. A few interesting observations can be made analysing the above list. First, all the women listed (bar one) are over 40, and the overwhelming majority are in their 40s. This is because, before 40, as the pathology is less long-standing, there is usually a clear-cut deficiency of either Kidney-Yang or Kidney-Yin. As the energy of the Kidney starts declining after 40 and it is often intertwined with a Blood pathology, a deficiency of Yang begins to induce a deficiency of Yin or vice versa, hence the overlapping of KidneyYin and Kidney-Yang deficiency (Fig. 3.4). After this time, in a woman over 60, whichever deficiency is primary will start to settle in and predominate over the other. Another observation that can be made is that the overlapping
symptoms of Heat and Cold usually manifest in the feet with cold feet or hot feet at night, or in the face with a feeling of heat (the face does not usually have a feeling of cold).
Figure 3.4 Symptoms of simultaneous deficiency of Kidney-Yin and KidneyYang.
The above are only few of the presenting symptoms to illustrate the presence of Hot and Cold symptoms from a simultaneous deficiency of Kidney-Yin and Kidney-Yang. There are other causes of the simultaneous occurrence of Hot and Cold symptoms and they are discussed below, under the ‘Qi and Blood Pathology’ heading. As explained in the chapter on physiology (Ch. 2), the waxing and waning of Kidney-Yin and Kidney-Yang are responsible for the menstrual cycle. However, Kidney-Yin and Kidney-Yang are also interdependent and, because a deficiency of one often implies a deficiency of the other, often both
are tonified, especially in the treatment of infertility. For example, Dr Lian Fang advocates adding Yin Yang Huo Herba Epimedii to Kidney-Yin tonics and Nu Zhen Zi Fructus Ligustri lucidi and Han Lian Cao Herba Ecliptae to Kidney-Yang tonics when treating infertility.1 Indeed, the two important formulae You Gui Wan Restoring the Right [Kidney] Pill and Zuo Gui Wan Restoring the Left [Kidney] Pill, which tonify Kidney-Yang and KidneyYin respectively, contain herbs that tonify Kidney-Yin and Kidney-Yang respectively. In fact, You Gui Wan (which tonifies Kidney-Yang) contains Gou Qi Zi Fructus Lycii which nourishes Kidney-Yin, and Zuo Gui Wan (which nourishes Kidney-Yin) contains Tu Si Zi Semen Cuscutae and Lu Jiao Jiao Colla Cornu Cervi which tonify Kidney-Yang. Table 3.1 summarizes the Kidney patterns in gynecology. Table 3.1 Kidney patterns in gynecology
Summary Kidney deficiency
• Kidney deficiency, one of the major pathologies in gynecology, is at the root of many women’s problems • In women more than men, a Kidney deficiency often involves both Yin and Yang, albeit one will always be predominant • In women, a simultaneous deficiency of Kidney-Yin and Kidney-Yang is far more common after the age of 40 • As Kidney-Yin and Kidney-Yang can both be deficient, in women this causes the very common situation when there are both Hot and Cold symptoms • The overlapping symptoms of Heat and Cold usually manifest in the feet with cold feet or hot feet at night, or in the face with a feeling of heat (the face does not usually have a feeling of cold) • The waxing and waning of Kidney-Yin and Kidney-Yang are responsible for the menstrual cycle
Liver After the Kidneys, the Liver has the most important influence in gynecology. A deficiency of Liver-Blood is extremely common in women and so is LiverQi stagnation. The Liver more than any other organ has a particular characteristic in that patterns often occur together. For example, it would not be at all unusual for a woman to suffer from deficiency of Liver-Blood combined with Liver-Qi stagnation, with Liver-Yang rising (as a consequence of Liver-Blood deficiency) and some Liver-Fire. It is even possible to have five patterns. For example, Liver-Blood deficiency may lead to Liver-Qi stagnation and this may lead to Liver-Blood stasis. On the other hand, Qi stagnation may give rise to Heat and therefore Liver-Heat. On the other hand, Liver-Heat may also generate Liver-Yang rising (Fig. 3.5).
Figure 3.5 Example of five Liver patterns overlapping.
Summary
Liver
• After the Kidneys, the Liver has the most important influence in gynecology • Liver-Blood deficiency and Liver-Qi stagnation are very common in women • More than other organs, Liver patterns often occur together
Liver-Qi stagnation Liver-Qi stagnation is extremely common in gynecology. Because it provides the Yang action of moving Qi and Blood in phase 4, Liver-Qi plays an important role in menstruation; it is particularly active in the pre-menstrual phase when it prepares to move Blood with the onset of the menses. The most common cause of Liver-Qi stagnation is emotional stress related to anger, suppressed anger, resentment, worry, shame and guilt. In pathology, if Liver-Qi stagnates, its effect is particularly noticeable in the pre-menstrual phase, causing pre-menstrual tension, distension of breasts, irritability, depression, abdominal distension, etc. However, please note that not all cases of pre-menstrual problems are due to Liver-Qi stagnation. Liver-Qi stagnation may also cause an irregular cycle and painful periods. With Liver-Qi stagnation the tongue may not change; in severe cases, it may be slightly Red on the sides, and the pulse Wiry (which may be only on the left). The most defining symptom of Liver-Qi stagnation is a feeling of distension (zhang in Chinese). This is a bloating feeling of the lower abdomen, epigastrium or breasts. Clinical Note The most defining symptom of Liver-Qi stagnation is a feeling of distension (zhang in Chinese). This is a bloating feeling of the lower abdomen, epigastrium or breasts.
Closely related to Liver-Qi stagnation in gynecology is Liver-Yang rising, which is often associated with it. Liver-Yang rising typically causes headaches before or during the menses. Prolonged stagnation of Liver-Qi may also give rise to Liver-Heat and this to Liver-Fire as stagnant Qi may turn into Heat after a long period of time. Liver-Heat or Liver-Fire will cause a complex pathology; on the one hand, it may heat the Blood and cause Blood-Heat; on the other, Fire may injure Yin, eventually leading to EmptyHeat. Liver-Qi stagnation may also give rise to Liver-Blood stasis manifesting with painful periods with large, dark clots and dark menstrual blood (Fig. 3.6).
Figure 3.6 Consequences of Liver-Qi stagnation. It is important to note that Liver-Qi and Liver-Blood represent the Yang and Yin aspect of the Liver sphere: they need to be harmonized, i.e. Yin should root and ‘embrace’ Yang. Very often, if Yin is deficient (i.e. LiverBlood deficiency), it fails to restrain and root Yang (Liver-Qi) so that LiverQi stagnates. I therefore distinguish two types of Liver-Qi stagnation: one I call ‘primary’ and this derives from emotional stress and manifests with a pulse that is Wiry all over; the other I call ‘secondary’ and that is Liver-Qi stagnation deriving from Liver-Blood deficiency and due to a combination of emotional stress, diet and overwork (Table 3.2). Table 3.2 Comparison of primary and secondary Liver-Qi stagnation
Primary Liver-Qi stagnation
Emotional origin Arises ‘by itself’ Pronounced irritability, moodiness, depression Pulse all Wiry Tongue normal or slightly Red sides Yue Ju Wan GardeniaChuanxiong Pill
Secondary Liver-Qi stagnation
Arises as a consequence of or associated with Liver-Blood deficiency Aetiology emotional but also dietary and overwork Not so much irritability, more depression and crying Pulse all Choppy, or Fine on the right and Wiry on the left or all Fine and very slightly Wiry Tongue normal or Pale Xiao Yao San Free and Easy Wanderer Powder
That this stagnation is secondary to Liver-Blood deficiency is clear from
the tongue being Pale and the pulse either not Wiry or only very slightly Wiry on the left side. In women, this situation is very common. This explains the very common clinical situation of a woman who has many typical symptoms of Liver-Qi stagnation such as pre-menstrual tension, distension of breasts and abdomen, or irritability, but whose pulse and tongue do not reflect this, i.e. the pulse is not Wiry and the tongue is not Red or Purple on the sides. If the tongue is Pale and the pulse Choppy or Fine and only slightly Wiry on the left, this clearly means that the Liver-Qi stagnation is secondary to LiverBlood deficiency. Please note that most modern Chinese books say that in Liver-Qi stagnation the tongue is Purple on the sides: I do not agree with this view. In my opinion, a Purple colour of the tongue body always indicates Blood stasis rather than Qi stagnation. ! A Purple colour of the tongue body always indicates Blood stasis rather than Qi stagnation. In my opinion, Liver-Qi stagnation is somewhat overdiagnosed both in Chinese and in Western books. Yes, Liver-Qi stagnation is very common but not as common as it is made out to be. Also, it is forgotten that Liver-Qi stagnation is often secondary to other patterns and notably a Liver-Blood deficiency or a Kidney deficiency. Moreover, it is important to note that Qi stagnation affects other organs besides the Liver, e.g. Heart, Lungs, Stomach, Intestines. In gynecology, for example, Lung-Qi stagnation affects the breasts and may cause a feeling of distension of the breasts or even breast lumps. As for the emotional origin of Qi stagnation, this may derive from emotions other than anger, e.g. resentment, frustration, worry, sadness, grief, guilt, etc. In my opinion, anger tends to be overemphasized in China due to the Confucian influence (which sees anger as the most dangerous and disruptive of the emotions because it induces people to ‘rebel’). I also find that Qi stagnation is automatically considered to be the consequence of
‘stress’, i.e. a person is under stress, therefore we can assume that he or she suffers from Liver-Qi stagnation. As a consequence of the above, in my opinion the formula Xiao Yao San Free and Easy Wanderer Powder is somewhat overused. Clinical Note • In my opinion, Liver-Qi stagnation is somewhat overdiagnosed both in Chinese and in Western books • Liver-Qi stagnation is secondary to other patterns and notably a Liver-Blood deficiency or a Kidney deficiency • Qi stagnation affects other organs besides the Liver, e.g. Heart, Lungs, Stomach, Intestines • In gynecology, Lung-Qi stagnation affects the breasts and may cause a feeling of distension of the breasts or even breast lumps • Qi stagnation may derive from emotions other than anger, e.g. resentment, frustration, worry, sadness, grief, guilt, etc. • Anger is overemphasized in China due to the Confucian influence (which sees anger as the most dangerous and disruptive of the emotions because it induces people to ‘rebel’) • Qi stagnation is often automatically (and wrongly) considered to be the consequence of ‘stress’ • As a consequence of the above, in my opinion the formula Xiao Yao San Free and Easy Wanderer Powder is somewhat overused
Summary Liver-Qi stagnation
• Liver-Qi plays an important role in menstruation; it is particularly active in the pre-menstrual phase when it prepares to move Blood with the onset of the menses • The most common cause of Liver-Qi stagnation is emotional stress related to anger, suppressed anger, resentment, worry, shame and guilt • In pathology, if Liver-Qi stagnates, its effect is particularly noticeable in the pre-menstrual phase, causing pre-menstrual tension, distension of breasts, irritability, depression, abdominal distension, etc. It may also cause an irregular cycle and painful periods • Prolonged stagnation of Liver-Qi may also give rise to Liver-Heat and this to Liver-Fire • Liver-Qi stagnation may also give rise to Liver-Blood stasis manifesting with painful periods with large, dark clots and dark menstrual blood
Liver-Blood deficiency Liver-Blood deficiency is fundamental in gynecology. The Liver stores Blood and provides Blood to the Uterus in close co-ordination with the Penetrating Vessel. Women are very prone to Blood deficiency, partly from the monthly loss of blood occurring with the periods themselves, and partly from diet, overwork and emotional stress. Liver-Blood deficiency can cause infertility, scanty periods, delayed cycle or amenorrhoea. Please note that ‘scanty period’ is not a symptom that would be reported by most women as they would be more alarmed by heavy rather than scanty periods. It is therefore important to ask about the duration of the period in days. This is discussed more at length in Chapter 5 on Diagnosis. As explained in Chapter 2, although menstrual blood is Tian Gui and therefore not ‘Blood’ but ‘Water’, there is an overlap between Tian Gui and ‘normal Blood’ (see Fig. 2.29 in Ch. 2). This overlap takes place thanks to
the Liver which partakes both of Tian Gui and of ‘ordinary Blood’. For this reason, when there are gynecological symptoms of Blood deficiency such as scanty periods or amenorrhoea, there often are also symptoms of deficiency of ‘ordinary Blood’, i.e. the Liver-Blood that nourishes the hair, eyes, skin, nails and sinews: these would be dry hair, blurred vision, dry skin, brittle nails and cramps. In Liver-Blood deficiency, the pulse would be Choppy or Fine and the tongue Pale and possibly Thin (although the tongue is seldom Thin, due to the common presence of Dampness or Phlegm which make it Swollen). One important characteristic of Liver-Blood deficiency is that it is often the origin of many other pathologies as evidenced by Figure 3.7. The following is a brief explanation of these pathologies with one or more representative prescriptions for each. 1. Liver-Blood deficiency leading to Liver-Yang rising. This is extremely common in women. The symptoms and signs are throbbing headaches either on the vertex or sides of the head occurring around the period time (but also occasional dull vertical or frontal headaches from Blood deficiency), nausea, vomiting, dizziness, vision disturbances, Pale and Thin tongue, Choppy pulse. Representative prescriptions: Tian Ma Gou Teng Yin Gastrodia-Uncaria Decoction or Bu Gan Tang Tonifying the Liver Decoction. Among the Three Treasures remedies, Bend Bamboo nourishes Liver-Blood and subdues Liver-Yang. 2. Wind-Heat in skin. Liver-Blood nourishes and moistens the skin. When Liver-Blood is deficient the skin may become dry and itchy: this often happens during the menopause when women complain of itchy skin without any apparent rash. Representative prescriptions: Yang Xue Ding Feng Tang Nourishing Blood and Subduing Wind Decoction or Yang Xue Run Fu Yin Nourishing Blood and Moistening the Skin Decoction. Among the Three Treasures remedies, Glorious Sea nourishes Liver-Blood and expels WindHeat from the skin. 3. Empty-Heat. Although strictly speaking Empty-Heat arises from Yin
deficiency, in women it can actually develop from Blood deficiency too. This explains many cases of hot flushes without Yin deficiency and with a Pale tongue. Representative prescription: Qin Lian Si Wu Tang ScutellariaCoptis Four Substances Decoction. 4. Heart-Blood deficiency. Liver-Blood deficiency often causes HeartBlood deficiency due to the relationship of Mother–Child within the FiveElement scheme. Besides this, the Liver stores Blood and the Heart governs Blood, hence a deficiency in the storage of Blood by the Liver naturally affects Heart-Blood. Representative prescription: Gui Pi Tang Restoring the Spleen Decoction. Among the Three Treasures, it is Calm the Shen. 5. Kidney-Yin deficiency. Liver-Blood and Kidney-Yin are closely connected and influence each other due to the relationship of mutual nourishment between Blood and Essence and that between Liver and Kidneys. Representative prescriptions: Dang Gui Di Huang Yin AngelicaRehmannia Decoction and Ba Wei Di Huang Wan Eight Ingredients Rehmannia Pill, both variations of Liu Wei Di Huang Wan Six Ingredients Rehmannia Pill. Within the Women’s Treasure line, it is the remedy Growing Jade. 6. Kidney-Yang deficiency. A deficiency of Kidney-Yang is often associated with Liver-Blood deficiency due to the interrelationship KidneyYang–Penetrating Vessel–Uterus–Blood–Liver. Representative prescriptions: You Gui Wan Restoring the Right [Kidney] Pill or Zan Yu Dan Aiding Fertility Pill. Within the Women’s Treasure line, it is the remedy Unicorn Pearl. 7. Cold limbs. Cold limbs can be caused by various conditions. One of these, by far more common in women, is Liver-Blood deficiency (others are Yang deficiency and Qi stagnation). The representative prescription for cold hands and feet from Blood deficiency in women is Dang Gui Si Ni Tang Angelica Four Rebellious Decoction.
8. Cold in Uterus. When Liver-Blood is deficient, the Uterus is Empty and in a vulnerable condition so that it can be easily invaded by Cold. Vice versa, when Cold obstructs the Uterus, Liver-Blood cannot be stored properly and this may lead to a Blood deficiency. Thus, Liver-Blood deficiency and Cold often coexist. The representative prescription (especially for the latter condition) is Wen Jing Tang Warming the Menses Decoction. Within the Women’s Treasure range, Warm the Menses, Warm the Palace and Warm the Mansion nourish Blood and warm the Uterus. 9. Qi deficiency. As Blood is the mother of Qi, Liver-Blood deficiency almost inevitably leads to Qi deficiency. In fact, the representative prescription for this condition is the well-known Ba Zhen Tang Eight Precious Decoction. Among the Three Treasures remedies, Brighten the Eyes tonifies Qi and nourishes Liver-Blood. Within the Women’s Treasure range, Precious Sea tonifies Qi and nourishes Blood. 10. Liver-Blood stasis. When Liver-Blood is deficient, Blood naturally fails to move properly and this may lead to Blood stasis. Representative prescription: Tao Hong Si Wu Tang Persica-Carthamus Four Substances Decoction. Among the Women’s Treasure remedies, Stir Field of Elixir invigorates Liver-Blood and eliminates stasis. 11. Liver-Qi stagnation. Liver-Blood and Liver-Qi represent the Yin and Yang aspect of the Liver respectively. Yin should ‘embrace’ and hold Yang; the two need to be harmonized. When Liver-Blood is deficient, Yin fails to hold Yang, the harmony between the two is lost and Liver-Qi may stagnate. As mentioned above, this is very common in women; when it occurs, a woman shows many symptoms of Qi stagnation although the pulse is not Wiry but Choppy or Fine and the tongue sides are not Red but Pale or normal-coloured. That this situation is very common is evident from the fact that its representative prescription is one of the most commonly used gynecological formulae, i.e. Xiao Yao San Free and Easy Wanderer Powder. Among the Women’s Treasure remedies, Freeing the Moon nourishes Liver-Blood and moves Liver-Qi.
Figure 3.7 Pathologies deriving from Liver-Blood deficiency.
Summary Liver-Blood deficiency
• Liver-Blood deficiency is fundamental in gynecology • Women are very prone to Blood deficiency • Liver-Blood deficiency can cause infertility, scanty periods, delayed cycle or amenorrhoea • Although menstrual blood is Tian Gui and therefore not ‘Blood’ but ‘Water’, there is an overlap between Tian Gui and ‘normal Blood’. This overlap takes place thanks to the Liver which partakes both of Tian Gui and of ‘ordinary Blood’
• In Liver-Blood deficiency, the pulse would be Choppy or Fine and the tongue Pale and possibly Thin
Liver-Blood stasis Liver-Blood stasis develops from Liver-Qi stagnation and causes painful periods with dark blood and dark clots. Liver-Blood stasis may also cause pain in the pre-menstrual phase and this may be relieved by the onset of the menses. It may also cause abdominal masses such as cysts, endometriosis or myomas. Liver-Blood stasis is extremely common in women: this was explained in Chapter 2 on physiology. As their Lower Burner houses the Uterus which stores Blood, Blood easily stagnates in the lower abdomen. Indeed, I would go so far as saying that in chronic and complicated gynecological conditions, one should always suspect Blood stasis. ! In chronic and complicated gynecological conditions, always suspect Blood stasis. Although Liver-Qi stagnation plays a prominent role in modern Chinese books and also many Western ones, Liver-Blood stasis is far more important because it potentially gives rise to serious diseases such as endometriosis, cervical cancer, uterine cancer, polycystic ovary syndrome and myomas. Liver-Qi stagnation by itself cannot cause any of the above diseases. Moreover, although it may seem paradoxical, Liver-Blood stasis may even cause heavy menstrual bleeding. This happens because, when Liver-Blood stagnates, the blood vessels in the Uterus are obstructed by stagnant Blood. On the other hand, new Blood is being made all the time; this cannot take its place in the Uterus because it is obstructed by stagnant Blood, and it therefore spills out of the Uterus causing heavy menstrual bleeding (with dark blood and dark clots; see Fig. 3.8).
Figure 3.8 Liver-Blood stasis causing heavy menstrual bleeding. Like Liver-Qi stagnation, Liver-Blood stasis also affects the Mind; it causes the Mind to be Unsettled leading to insomnia, excessive dreaming, mental restlessness and agitation. In severe cases, Blood stasis may also lead to Mind Obstructed with more serious symptoms and a certain loss of insight such as, for example, in post-natal psychosis. The pulse in Liver-Blood stasis is Wiry, Firm or Choppy (the last if it is associated with a deficiency of Blood), and the tongue is Purple, sometimes only on the sides. Clinical Note A Purple colour of the sides of the tongue in women usually reflects Blood stasis in the Uterus rather than in the Liver itself. Clinical Note The main points I use for Liver-Blood stasis in gynecological conditions are SP-4 Gongsun on the right with P-6 Neiguan on the left (Penetrating Vessel), plus KI-14 Siman, SP-10 Xuehai and LIV-3 Taichong.
Summary Liver-Blood stasis
• Liver-Blood stasis develops from Liver-Qi stagnation and causes painful periods with dark blood and dark clots • Liver-Blood stasis is extremely common in women • Liver-Blood stasis potentially gives rise to serious diseases such as endometriosis, cervical cancer, uterine cancer, polycystic ovary syndrome and myomas • Liver-Blood stasis may even cause menstrual bleeding • Like Liver-Qi stagnation, Liver-Blood stasis also affects the Mind causing insomnia, excessive dreaming, mental restlessness, agitation.
Liver-Blood Heat Liver-Blood Heat may develop from prolonged stagnation of Liver-Qi or directly from aetiological factors which cause Blood-Heat (such as emotional stress and diet). Liver-Blood is also heated by the flaring of pathological Minister Fire. As mentioned in Chapter 2 on physiology, the formless Minister Fire within the Kidneys is essential to all physiological processes. A special type of Fire, it generates Water rather than drying it. However, it may become pathological, especially when emotional problems (notably anger, frustration, resentment, hatred or guilt) stir it up. Pathological Minister Fire easily affects the Liver since this organ is naturally ‘restless’ and readily agitated. Because the physiological Minister Fire is essential to all bodily processes while the pathological one consumes the vital substances, it is said that “small Fire generates Qi, excessive Fire eats Qi.”2 Fu Qing Zhu says:
Although the Liver pertains to Wood, within Wood there is a dragonthunder Fire which is the Minister Fire. The Minister Fire should be quiet and not agitated: if it is quiet, there is tranquillity, if it is agitated, it burns. Because Wood has such Fire within it, it is easily agitated and seldom quiet. In people’s lives not a day goes by that this Fire is not stirred. Violent anger stirs this Fire even more.3 The pathological Minister Fire affects the Liver also through the Pericardium. When pathological Minister Fire is stirred by emotional stress, it has the tendency to flare upwards affecting the Pericardium and Heart (Fig. 3.9). Since the Liver is connected to the Pericardium within the Terminal Yin (Jue Yin), it is also affected by the pathological Minister Fire. In ancient texts, the flaring of pathological Minister to the Liver and Pericardium was compared to a “Fire Dragon flying to the top of high mountains” while the flaring of pathological Minister Fire in the Kidneys was compared to a “Fire Dragon immersing in the deep sea” (Fig. 3.10).
Figure 3.9 Flaring of Minister Fire.
Figure 3.10 Pathological Minister Fire as ‘Fire Dragon’. Liver-Blood Heat is a major cause of the excess type of menorrhagia, from reckless Blood pushing out of the blood vessels. The pulse will be Rapid and possibly Overflowing in the left Middle position. It may also feel slightly Wiry or Hard in the Middle level in all positions. Summary Liver-Blood Heat
• Liver-Blood Heat may develop from prolonged stagnation of Liver-Qi or directly from aetiological factors which cause Blood-Heat (such as emotional stress and diet) • Liver-Blood is also heated by the flaring of pathological Minister Fire • The pathological Minister Fire affects the Liver also through the Pericardium
• Liver-Blood Heat is a major cause of the excess type of menorrhagia, from reckless Blood pushing out of the blood vessels
Damp-Heat in the Liver channel Damp-Heat in the Liver channel is a relatively common pattern in gynecological conditions. In fact, the occurrence of genital symptoms in the presence of Damp-Heat allows us to diagnose Damp-Heat in the Liver channel (as opposed to Damp-Heat in the Gall Bladder). Damp-Heat in the Liver channel in women causes urinary and/or genital symptoms such as difficult and/or painful urination, excessive vaginal discharge, vaginal itching and/or soreness. Please note that modern Chinese books place excessive emphasis (in my opinion) on Damp-Heat as opposed to Dampness without Heat. In my experience, it is very common to see Dampness in the Lower Burner without Heat in Western patients. Clinical Note The main points to resolve Dampness from the Liver channel in urinary and genital problems in women are LIV-5 Ligou, SP-9 Yinlingquan, Ren-3 Zhongji, ST-28 Shuidao and BL-22 Sanjiaoshu. Liver-Yang rising In gynecology, Liver-Yang rising causes menstrual headaches. These headaches may occur before or during the period and they are located on the sides of the head or over the eyes; they are usually unilateral and with a throbbing character. They may be accompanied by nausea and vomiting and visual disturbances. The most common origin of Liver-Yang rising in menstrual headaches is Liver-Blood deficiency; however, they may also derive from Liver-Yin
and/or Kidney-Yin deficiency. Liver-Wind In gynecology, the most important manifestation of Liver-Wind is that which may be seen during pregnancy. In eclampsia or pre-eclampsia, there is usually Liver-Wind. Indeed, the development of Liver-Wind in pregnancy is always a serious sign that should be treated immediately. Table 3.3 summarizes the Liver patterns in gynecology. Table 3.3 Liver patterns in gynecology
Spleen
Spleen-Qi deficiency Spleen-Qi deficiency is not a direct cause of gynecological problems but it is involved in them because Spleen-Qi is the origin of Post-Natal Qi and Blood and thus Blood deficiency may occur. For this reason, when nourishing Blood in gynecology, we treat both Liver and Kidneys (to treat Tian Gui) and the Spleen to nourish the Post-Natal Blood. Spleen-Qi deficiency is also important in gynecology because it leads to Dampness, a major pathogenic factor in women’s problems. Moreover, deficient Spleen-Qi which fails to hold Blood is a major cause of menorrhagia of the deficient type although it should be remembered that in such cases deficient Kidney-Qi also plays a role. Spleen-Qi also raises Qi and holds the internal organs in place. Sinking of Spleen-Qi may therefore cause prolapse of the uterus or bladder. Besides actual prolapse, sinking of Spleen-Qi is also frequently a factor in chronic urinary or genital problems. Again, in such cases, Kidney-Qi also plays a role. The pulse is Empty or Weak, and the tongue is Pale. If there is Phlegm, the tongue is definitely Swollen; if there is Dampness, the tongue has a thick, sticky coating. Summary Spleen-Qi deficiency
• Spleen-Qi deficiency may lead to deficiency of Blood and this affects the Uterus as Post-Natal Blood plays a (secondary) role in menstrual blood formation
• Spleen-Qi deficiency is also important in gynecology because it leads to Dampness, a major pathogenic factor in women’s problems • Deficient Spleen-Qi which fails to hold Blood is a major cause of menorrhagia of the deficient type • Spleen-Qi also raises Qi and holds the internal organs in place. Sinking of Spleen-Qi may therefore cause prolapse of the uterus or bladder • Besides actual prolapse, sinking of Spleen-Qi also frequently is a factor in chronic urinary or genital problems
Spleen-Blood deficiency Although there is no pattern of this name, Spleen-Blood deficiency does occur in women. It occurs when the Spleen is deficient and does not make Blood: this affects the Liver and causes Liver-Blood deficiency. For this reason, when Liver-Blood is deficient, the Spleen as well as the Liver should always be tonified. The pulse is Weak, Fine or Choppy and the tongue is Pale and Thin (unless there is Dampness, which is nearly always the case). Spleen-Qi sinking Spleen-Qi sinking is a type of Spleen-Qi deficiency and is characterized by Spleen-Qi strongly descending. This causes prolapse of the uterus or bladder. It also plays a role in chronic urinary and genital problems. The pulse is Weak and the tongue is Pale. Table 3.4 summarizes the Spleen patterns in gynecology. Table 3.4 Spleen patterns in gynecology
Heart The Heart has an influence on gynecological problems, as it plays a role in the formation of menstrual blood and it is connected to the Uterus via the Uterus Vessel. Due to this connection and since the Heart houses the Mind and governs Blood, mental–emotional problems have a direct and profound influence on the menstrual function, pregnancy, childbirth and menopause. The connection between the Heart, the Uterus and menstruation explains the strong influence of emotional stress on this function. For example, deficiency of Blood in the Uterus after childbirth can affect the Heart and cause depression, while stasis of Blood in the Uterus after childbirth may cause post-natal psychosis. The influence of the Heart on the menstrual function can also be seen when an emotional shock affecting the Heart may lead to amenorrhoea. In fact, Chapter 33 of the Simple Questions says: When the period does not come, it is due to the Uterus Vessel being shut; this vessel connects the Uterus to the Heart. When Qi rises to harass the Lungs, Heart-Qi cannot get through downwards, hence the period does not come.4 The sentence about Qi rising to harass the Lungs is a clear reference to emotional problems such as sadness, worry and grief which affect both Heart and Lungs and therefore the menstrual function through the Uterus Vessel. As mentioned in Chapter 2 on physiology, the Heart governs Blood and therefore has a general influence on Blood. Many gynecologists emphasize the need to nourish Heart-Blood in women’s problems caused by Blood deficiency. This is necessary also because, as Fu Qing Zhu maintains, the Kidney-Essence forms the Tian Gui with the help of Heart-Yang. As will be remembered, other doctors also stressed the importance of the Heart in women’s physiology and pathology: the Secret Records of Master Feng’s Brocade Bag (1702) connects the Small Intestine and Heart channel with breast milk and menstruation. It says: “The Small Intestine and Heart
channels are exteriorly–interiorly related: they control menstrual water below and breast milk above.”5 Heart-Blood has a similar influence on the gynecological system as that of Liver-Blood. For instance, Heart-Blood deficiency may lead to scanty periods; Heart-Blood Heat may lead to menorrhagia; and Heart-Blood stasis may lead to painful periods. The Heart influences the menstrual function also because the descending of its Qi and Blood promotes the discharge of blood at the period time and the discharge of the eggs at ovulation. Thus, if Heart-Qi does not descend, the onset of the period or ovulation may be delayed; conversely, it Heart-Qi descends too soon, the period or ovulation may come early. Summary Heart
• The Heart plays a role in the formation of menstrual blood and it is connected to the Uterus via the Uterus Vessel • Due to this connection and since the Heart houses the Mind and governs Blood, mental–emotional problems have a direct and profound influence on the menstrual function, pregnancy, childbirth and menopause • The Heart governs Blood and therefore has a general influence on menstrual blood too • Heart-Blood has a similar influence on the gynecological system as that of Liver-Blood. For instance, Heart-Blood deficiency may lead to scanty periods; Heart-Blood Heat may lead to menorrhagia; and Heart-Blood stasis may lead to painful periods • The Heart influences the menstrual function also because the descending of its Qi and Blood promotes the discharge of blood at the period time and the discharge of the eggs at ovulation. Thus, if Heart-Qi does not descend, the onset of the period or ovulation may be delayed; conversely, it Heart-Qi descends too
soon, the period or ovulation may come early
Clinical Note To stimulate the descending of Heart-Qi to the Uterus, I use the point HE-5 Tongli. Dr Yao Shi An mentions several patterns of the Heart which affect the gynecological functions.6 Heart-Fire Long-term stagnation of Qi of the Heart often turns into Heart-Fire; Fire harasses downwards and disturbs the Directing and Penetrating Vessels, the Sea of Blood becomes reckless and this may result in heavy periods or Flooding and Trickling (Beng Lou). The Ji Yin Gang Mu says: “Fire burns the Heart, Blood becomes reckless and causes bleeding downwards.”7 The Great Dictionary of Chinese Acupuncture mentions HE-5 Tongli for heavy periods or Flooding and Trickling, especially in combination with LIV2 Xingjian and SP-6 Sanyinjiao (Great Compendium of Acupuncture, 1601).8 When there is Fire in the Heart channel, it rises to harass the Heart and below it may cause excessive vaginal discharge or vaginal soreness. Chen Zi Ming says: “Vaginal sores in women are due to mental restlessness and chaotic Heart and weak Stomach-Qi resulting in stagnation of Qi and Blood.” The Simple Questions, in the chapter Zhi Zhen Yao Da Lun, says: “Pain, itching and sores are due to the Heart.”9 The book An Explanation of Acupuncture Points recommends tonifying HE-8 Shaofu for prolapse of the vagina or vaginal pain and itching.10 Summary
Heart-Fire
• Long-term stagnation of Qi of the Heart often turns into Heart-Fire • Fire harasses downwards and disturbs the Directing and Penetrating Vessels, the Sea of Blood becomes reckless and this may result in heavy periods or Flooding and Trickling (Beng Lou) • Fire in the Heart channel rises to harass the Heart and may also cause excessive vaginal discharge or vaginal soreness
Heart-Yin deficiency with Empty-Heat Sadness over a long period of time may cause Heart-Yin deficiency. The Mind has no residence and this causes Heart-Yang to float and may cause menorrhagia. The Simple Questions says in Chapter 44: “Sadness leads to severance of the Uterus Channel: when this is severed Yang Qi is agitated in the Interior and the Heart causes menorrhagia.”11 Overwork weakens Heart-Yin which leads to Empty-Heat: this may also cause amenorrhoea. The Secret Record of the Orchid Room (Lan Shi Mi Cang) says: “Mental strain and stress weakens the Heart, Heart-Fire rises and the periods do not come.”12 Summary Heart-Yin deficiency with Empty-Heat
• Long-term sadness may cause Heart-Yin deficiency. The Mind has no residence which causes Heart-Yang to float and may cause menorrhagia
• Overwork weakens Heart-Yin which leads to Empty-Heat. This may also cause amenorrhoea
Heart-Qi rebelling upwards When Heart-Qi rebels upwards, it impairs the descending of Lung-Qi and of Heart-Qi; Qi cannot descend and communicate with the Uterus Vessel and amenorrhoea results. The Simple Questions says in Chapter 33: “If the periods do not come it means the Uterus Vessel is shut … Qi rises to harass the Lungs, Heart-Qi does not descend and the periods do not come.”13 Pensiveness and worry agitate the Heart, the Emperor Fire moves and fails to communicate with the Kidneys, Water and Fire do not communicate and infertility may result. Wang Yu Tai says: Pensiveness and worry may make it difficult for a woman to conceive, the Heart houses the Mind, pensiveness makes the Heart turn towards the outside, the Emperor Fire cannot descend, Above and Below do not communicate, Water and Fire do not communicate and infertility may result.14 Summary Heart-Qi rebelling upwards
• When Heart-Qi rebels upwards, it impairs the descending of Lung-Qi and of Heart-Qi; Qi cannot descend and communicate with the Uterus Vessel and amenorrhoea results • Pensiveness and worry agitate the Heart, the Emperor Fire moves and fails to communicate with the Kidneys, Water and Fire do not communicate and
infertility may result
Heart-Blood Heat in pregnancy After conception, Blood is deviated to the nourishment of the fetus, Fire easily rises, this disturbs the Heart and causes mental restlessness. The Discussion of Gynecology (Nu Ke Jing Lun) says: “When the Heart is affected by Blood-Heat, Heart-Qi is not clear and this causes mental restlessness.”15 Worry agitates the Heart and causes a difficult birth. The Gynecology of the Bamboo Grove (Zhu Lin Nu Ke) says: “When the Heart is affected by worry and pensiveness, Qi and Blood stagnate or flow in the wrong direction, in many cases this causes a difficult birth.”16 Summary Heart-Blood heat in pregnancy
• After conception, Blood is deviated to the nourishment of the fetus, Fire easily rises, this disturbs the Heart and causes mental restlessness • Worry agitates the Heart and causes a difficult birth
Heart-Qi and Heart-Blood deficiency Heart-Qi and Heart-Blood need to flow down to the Kidneys and Uterus: their doing so means that the Heart assists in the formation of menstrual blood and also in the discharge of blood at period time and ovum at ovulation. Thus, deficiency of Heart-Qi and/or Heart-Blood may indirectly
lead to a deficiency of Blood, when they fail to communicate with the Kidneys, and to stasis, when they fail to move Blood. In this latter sense, Heart-Qi and Heart-Blood assist Liver-Qi and Liver-Blood. Thus, a deficiency of Heart Qi or Blood may lead to amenorrhoea, scanty periods, or a delayed cycle. A deficiency of Heart-Qi and Heart-Blood may also lead to scanty period or delayed ovulation as they fail to descend to the Uterus to promote the discharge of menstrual blood and of ova. Summary Heart-Qi and Heart-Blood deficiency
• Heart-Qi and Heart-Blood need to flow down to the Kidneys and Uterus. Their doing so means that the Heart assists in the formation and discharge of menstrual blood and of ovum at ovulation • Deficiency of Heart-Qi and/or Heart-Blood may indirectly lead to a deficiency of Blood when they fail to communicate with the Kidneys, and to stasis when they fail to move Blood • A deficiency of Heart-Qi or Blood may lead to amenorrhoea, scanty periods, a delayed cycle or delayed ovulation
Heart-Blood stasis Since Heart-Blood flows down to the Uterus, stasis of Heart-Blood may influence menstruation causing an irregular cycle or dysmenorrhoea. The important effect of the acupuncture point P-6 Neiguan in gynecology in moving Blood is an example of the influence of the Heart on menstrual irregularities.
Lungs The Lungs do not play an important role in the pathology of gynecological problems. Lung-Qi deficiency is often associated with Spleen-Qi deficiency and it may therefore play an indirect role in menorrhagia from Qi deficiency, in prolapse of the uterus or in chronic urinary and genital problems. Stagnation of Lung-Qi from emotional stress plays an indirect role in pre-menstrual tension because in the chest area it affects the breasts in women and may therefore cause breast distension, slight breathlessness, sighing, etc. This is an often overlooked factor; Qi stagnation is invariably related to the Liver only, while, in fact, it does affect the Lungs too. Worry, grief and sadness may all lead to stagnation of Lung-Qi in the chest and contribute to the above-mentioned pre-menstrual symptoms. The importance of the point LU-7 Lieque in moving Qi in the chest in premenstrual tension is an example of the influence of the Lungs in Qi stagnation in gynecology.
Stomach The Stomach is connected to the Uterus via the Penetrating Vessel. In fact, the Penetrating Vessel emerges from ST-30 Qichong and it also enters the stomach in the epigastrium. When Qi rebels in the Penetrating Vessel it often affects the Stomach and causes Stomach-Qi to rebel upwards: this pathological process explains morning sickness during pregnancy and also generally nausea in the context of gynecological problems such as premenstrual tension or painful periods. The herb Ban Xia Rhizoma Pinelliae preparatum harmonizes Stomach-Qi and is often used in gynecological prescriptions for this purpose (see, for example, Wen Jing Tang Warming the Menses Decoction). The Stomach is also involved in lactation problems as milk is partly produced by the Post-Natal Qi and Blood and Stomach and Spleen. Figure 3.11 summarizes the pathology of the internal organs.
Figure 3.11 Pathology of the internal organs in gynecology.
Qi and blood pathology The conditions of Qi and Blood pathology in gynecology are: • Qi deficiency • Qi stagnation • Qi sinking • Qi rebellious • Blood deficiency • Blood-Heat • Blood stasis • Blood-Cold. These have all been discussed under the relevant organs (i.e. the Spleen for Qi deficiency and Qi sinking, and the Liver for Qi stagnation, Blood deficiency, Blood-Heat and Blood stasis) except for Qi rebellious and Blood-Cold.
Qi rebellious Rebellious Qi in the context of gynecology indicates Qi rising in counterflow in the Penetrating Vessel. Taking the main channels into account, it involves also the Liver channel. It may occur in pre-menstrual syndrome causing nausea, vomiting and a feeling of oppression in the chest, with a feeling of energy rising from the lower abdomen. Mild morning sickness in the first 3 months of pregnancy is due to Qi of the Penetrating Vessel flowing up to the Stomach and making Stomach-Qi ascend. This is generally due to the profound changes occurring in the Penetrating Vessel in the Lower Burner. Such mild morning sickness is almost physiological and could not be described as ‘rebellious Qi of the Penetrating Vessel’. However, if there is a pre-existing condition of rebellious Qi of the Penetrating Vessel, this would aggravate the morning sickness so that this becomes very severe and may last beyond the initial 3 months: this is definitely a pathology and would aptly be described as ‘rebellious Qi of the Penetrating Vessel’. The pulse typical of Qi rebellious in the Penetrating Vessel is Firm on all three positions especially on the left side, or only on the Middle position of both sides. Rebellious Qi will be discussed in greater detail below, under the Penetrating Vessel’s pathology. Summary Qi rebellious
• Rebellious Qi in the context of gynecology indicates Qi rising in counterflow in the Penetrating Vessel which involves the Liver channel • It may occur in pre-menstrual syndrome causing nausea, vomiting and a feeling of oppression in the chest, with a feeling of energy rising from the lower abdomen
• Mild morning sickness in the first 3 months of pregnancy is due to Qi of the Penetrating Vessel making Stomach-Qi ascend
Blood-Cold Blood-Cold occurs when Cold invades the Uterus and settles there. Cold in the Uterus may either come from the Exterior or be a consequence of Kidney-Yang deficiency. It frequently leads to stasis of Blood causing infertility, a delayed cycle or painful periods characterized by red blood with small dark clots. Cold in the Uterus is a very frequent cause of dysmenorrhoea especially in young girls and young women. The pulse is Choppy and Slow or Tight and Slow and the tongue is Bluish-Purple. Finally, it should be noted that, in women, Hot and Cold syndromes acquire a different meaning from those they have in men and the symptoms may often be contradictory. This is because, in many cases, Hot and Cold symptoms are not due to Hot and Cold syndromes. A very common cause of simultaneous and contradictory Hot and Cold symptoms is a simultaneous deficiency of Kidney-Yin and Kidney-Yang as explained above. Of course, there can be reasons unrelated to the Kidneys for the simultaneous occurrence of Hot and Cold symptoms: for example, it is perfectly possible for someone to suffer from Spleen-Yang deficiency (giving rise to Cold) and Damp-Heat in the Bladder or from Kidney-Yang deficiency and Heart-Heat (Fig. 3.12).
Figure 3.12 Hot and Cold symptoms from Heart-Heat and Kidney-Yang deficiency.
Another cause of mixed Hot and Cold symptoms is Yin-Fire, which arises from a deficiency of the Original Qi (Yuan Qi): this deficiency may give rise to Cold symptoms while the Yin-Fire causes Hot symptoms (Fig. 3.13).17 Yet another reason for the overlapping of Hot and Cold symptoms is severe stagnation of Qi: when Qi stagnates for a long time it may give rise to some Heat (e.g. Red sides on the tongue, a feeling of heat in the face, etc.) but, because stagnant Qi obstructs the circulation of Qi in the channels, the patient may also have cold hands and feet (Fig. 3.14).
Figure 3.13. Yin Fire.
Figure 3.14 Hot and Cold symptoms in Qi stagnation. Yet another cause of coexistence of Hot and Cold symptoms in women is rebellious Qi of the Penetrating Vessel (Chong Mai). When the Qi of the Penetrating Vessel rebels upwards, it rushes over the abdomen, chest, throat
and face causing a feeling of heat in the face; on the other hand, as it rushes upwards, not enough of its Qi flows down to the descending branch and the feet feel cold. The feeling of heat of the face in this case is neither Full- nor Empty-Heat: it is just a disharmony of the Penetrating Vessel (Fig. 3.15).
Figure 3.15 Hot and Cold symptoms from Rebellious Qi of the Penetrating Vessel.
Finally, another cause of contradictory Hot and Cold symptoms in women is Empty-Heat deriving from Blood deficiency. In women, Blood deficiency often gives rise to Cold symptoms such as cold hands and/or feet: on the other hand, if the Blood deficiency is severe, there is some EmptyHeat developing from it causing a feeling of heat of the face and possibly red cheekbones on a pale face. To summarize, there are six conditions giving rise to contradictory Hot and Cold symptoms in women:
1. A simultaneous deficiency of Kidney-Yin and Kidney-Yang. 2. Severe Qi stagnation. 3. Yin Fire. 4. Rebellious Qi of the Penetrating Vessel. 5. Empty-Heat from Blood deficiency. 6. Simply a coexistence of Yang deficiency and Heat (e.g. Kidney-Yang deficiency causing cold feet and Heart-Heat causing hot and red face). Summary Blood-Cold
• Blood-Cold occurs when Cold invades the Uterus and settles there. Cold in the Uterus may either come from the Exterior or be a consequence of KidneyYang deficiency • It frequently leads to stasis of Blood causing infertility, a delayed cycle or painful periods characterized by red blood with small dark clots • Cold in the Uterus is a very frequent cause of dysmenorrhoea, especially in young girls and young women
Figure 3.16 summarizes the pathology of Qi and Blood in gynecology, Table 3.5 summarizes the Qi pathology in gynecology and Table 3.6 summarizes the Blood patterns in gynecology.
Figure 3.16 Pathology of Qi and Blood in gynecology.
Table 3.5 Qi patterns in gynecology
Table 3.6 Blood patterns in gynecology
Pathology of the extraordinary vessels
Penetrating Vessel (Chong Mai) The main symptomatology of the Penetrating Vessel is rebellious Qi rising from the abdomen towards the chest and face. This Penetrating Vessel symptom is called li ji which is difficult to translate and is interpreted differently by different authors. Chapter 29 of the Classic of Difficulties says: “The Penetrating Vessel’s symptomatology is rebellious Qi and internal urgency (li ji).”18 The more or less general consensus seems to be that, translated as ‘internal urgency’, li ji here indicates a feeling of anxiety deriving from rebellious Qi and manifesting in the chest with a sense of tightness or oppression and in the abdomen with distension and pain. The Penetrating Vessel is also the ‘Sea of the Channels’ and controls all the ‘avenues of Qi of the abdomen’ and thus stagnation and upwards rebellion of Qi within the vessel often manifest with abdominal distension and pain. Chapter 26 of the Spiritual Axis says: When Qi rebels upwards needle the depressions on the sides of the chest and the [places where] the arteries [can be palpated] in the lower chest. Abdominal pain should be treated by needling [the places where] the arteries [can be palpated] on the sides of the umbilicus . . . if pain is not relieved, needle ST-30 Qichong.19 The points on the chest are presumably Penetrating Vessel points on the Kidney channel and the points on the sides of the umbilicus are presumably KI-16 Huangshu, also a Penetrating Vessel point. Li Shi Zhen says: “When Qi [of the Penetrating Vessel] rebels upwards, there is a feeling of constriction of the throat, breathlessness with wheezing and the patient cannot lie down.”20 The stagnation and upward rebellion of Qi in the Penetrating Vessel can arise by itself from emotional stress or it can be the result of a deficiency of the Kidneys within the vessel: in the latter case, the Kidneys and Blood are deficient in the Lower Burner so that the Qi of the Penetrating Vessel rebels upwards towards the chest and face. This can cause a feeling of heat in the
face and cold feet: the former is due to the rushing of Qi upwards and the latter to the Kidney deficiency below. Neither heat above nor cold below is a true Heat or Cold symptom, and the feeling of heat in the face is not due to Empty-Heat: they are simply caused by the imbalance of Qi within the Penetrating Vessel with Emptiness of the Kidneys below and Qi rebelling upwards. The Emptiness of the Kidneys leads to cold feet because of the descending branch of the Penetrating Vessel which flows down the medial side of the leg and terminates at the big toe (see Figs 3.15 and 3.17). This situation is extremely common and explains many contradictory signs of apparent Heat and Cold in women. The hot face and cold feet therefore are purely due to a Penetrating Vessel imbalance with a deficiency of Qi below and the rebelling of Qi upwards. In other words, rebellious Qi in the Penetrating Vessel, possibly with an underlying deficiency of Blood and/or Kidneys, often epitomizes complicated situations of mixed Heat/Cold and Deficiency/Excess in women.
Figure 3.17 The rebellious Qi of the Penetrating Vessel. Thus, the main symptoms of rebellious Qi of the Penetrating Vessel are (from the top down and in addition to a feeling of anxiety): • headache • a feeling of heat of the face • a feeling of lump in the throat • breast distension/pain
• flutter in the chest or above the stomach, nausea • palpitations • slight breathlessness • tightness/oppression of chest • hypochondrial fullness/distension/pain • epigastric fullness/distension/pain • umbilical fullness/distension/pain • lower abdominal fullness/distension/pain • irregular/painful periods • hypogastric fullness/distension/pain. Of course, one should not expect to see all these symptoms in order to diagnose rebellious Qi of the Penetrating Vessel. The syndrome can be diagnosed in the presence of three or four of these symptoms occurring at different levels. Rebellious Qi in the Penetrating Vessel also accounts for many conditions in women characterized by abdominal pain, dysmenorrhoea, breast distension, a feeling of tightness of the chest with anxiety and a sensation of obstruction in the throat. The most characteristic symptom which would definitely indicate the use of the Penetrating Vessel opening points is a feeling of distension and fullness in the lower abdomen propagating upwards towards the chest and throat. Of course, a proper diagnosis of this symptom involves a certain skill in asking the patient the ‘right’ questions; no patient would ever spontaneously describe this symptom as a sensation propagating from the lower abdomen and reaching up to the chest and throat. The pattern of rebellious Qi of the Penetrating Vessel is akin to the ‘Running Piglet Syndrome’. The Running Piglet Syndrome is described in the
Synopsis of Prescriptions of the Golden Cabinet (Jin Gui Yao Lue) by Zhang Zhong Jing as follows: The Running Piglet Syndrome arises from the lower abdomen and rushes upwards towards the throat so that the patient feels he is close to death; the disease comes and goes and is caused by fear and shock.21 Interestingly, the aetiology of this syndrome is attributed to fear and shock, both of which injure the Kidneys. In practice, this syndrome, and its corresponding rebelling of Qi in the Penetrating Vessel, may be either of the Full type stemming from stagnation of Liver-Qi or of the Empty type stemming from a Kidney deficiency. This latter type is particularly common in women: the deficient Kidney within the Penetrating Vessel in the Lower Burner fails to root and anchor Qi so that this rebels upwards affecting both Kidney and Liver channels and causing a sensation of upsurge towards the chest and throat. Thus, the syndrome is a complex one, characterized by a deficiency of the Kidney and stagnation of the Liver with rebellious Qi in the Penetrating Vessel; in terms of areas, deficiency below (the lower abdomen) and excess above (the chest, throat and face). In gynecology, this syndrome is very common in women over 40, in menopausal problems or in dysmenorrhoea. The opening and associated points of the Penetrating Vessel (SP-4 Gongsun on the right and P-6 Neiguan on the left) are excellent to treat this condition. However, these points are usually associated with points along the Penetrating Vessel, such as ST-30 Qichong, KI-13 Qixue, KI-14 Siman, KI-16 Huangshu and KI-21 Youmen. The Penetrating Vessel flows to the chest and the heart and can therefore be used for palpitations and anxiety during the menopause, symptoms which are themselves often caused by the decline of the Blood and Kidneys in the Penetrating Vessel with consequent rebellious Qi escaping upwards along the vessel. Indeed, a pre-existing condition of rebellious Qi of the Penetrating Vessel often aggravates menopausal problems; conversely, the decline of Kidney-Essence occurring at the menopause, combined with
emotional stress, can trigger a condition of rebellious Qi of the Penetrating Vessel. The relationship of the Penetrating Vessel with the Uterus and the Stomach explains morning sickness in pregnancy, caused by Qi in the Penetrating Vessel rebelling upwards because of the profound changes taking place in the uterus in the first 3 months of pregnancy. As explained above, a mild feeling of nausea in the first 3 months of pregnancy is almost physiological and would not classify as ‘rebellious Qi of the Penetrating Vessel’. Women who suffer very severe morning sickness and vomiting, sometimes extended beyond the first 3 months, usually have a pre-existing condition of rebellious Qi in the Penetrating Vessel. As the Penetrating Vessel arises from the Uterus, is the Sea of Blood and flows to the head and face via all the Kidney channel points, it provides a link between the Uterus, Blood and the Kidneys. As Blood pertains to Yin, this explains why in women even a deficiency of Kidney-Yang will manifest with some Yin deficiency symptoms due to the connection between the Penetrating Vessel, Uterus, Blood and Kidneys. During nursing, Blood no longer flows downwards but is transformed into milk which flows upwards to the breasts via the Penetrating Vessel. The cessation of the downward flow of Blood and the commencing of the upward flow of milk are an added reason for the rising Qi sensation so common in pregnancy. The Penetrating Vessel’s control of all the Blood-Connecting (BloodLuo) channels explains the connection between disharmony of Blood in the Uterus and the development of muscular pains, something which often occurs after childbirth. It also explains why women often suffer external invasions during menstruation: the depletion of Blood in the Penetrating Vessel induces an Emptiness of the Blood-Connecting channels and therefore the space between skin and muscles (cou li) becomes Empty and prone to invasion of external pathogenic factors. The Penetrating Vessel is the Sea of Blood and it exerts an enormous influence on the menstrual physiology and pathology. Its chief pathology is of course stasis of Blood in the abdomen causing dysmenorrhoea. The Penetrating Vessel is also called ‘avenues of Qi of the abdomen’ as it
connects with the Kidney channel either side of the umbilicus. The Penetrating and Directing Vessels are related to the state of the zong muscles (zong jin) of the abdomen: if the Penetrating and Directing Vessels are not flourishing, the zong muscles are slack. A slackness of the zong muscles may cause prolapses in women. The Penetrating Vessel is primarily responsible for menstruation, the Directing Vessel for conception and pregnancy. Summary Penetrating Vessel (Chong Mai )
• The main symptomatology of the Penetrating Vessel is rebellious Qi rising from the abdomen towards the chest and face • The stagnation and upward rebellion of Qi in the Penetrating Vessel can arise by itself from emotional stress or it can be the result of a deficiency of the Kidneys within the vessel • The Emptiness of the Kidneys leads to cold feet because of the descending branch of the Penetrating Vessel which flows down the medial side of the leg and terminates at the big toe • The main symptoms of rebellious Qi of the Penetrating Vessel are (from the top down and in addition to a feeling of anxiety): • headache • a feeling of heat of the face • a feeling of lump in the throat • breast distension/pain • flutter in the chest or above the stomach, nausea • palpitations • slight breathlessness • tightness/oppression of chest • hypochondrial fullness/distension/pain • epigastric fullness/distension/pain • umbilical fullness/distension/pain • lower abdominal fullness/distension/pain
• irregular/painful periods • hypogastric fullness/distension/pain • The Penetrating Vessel flows to the chest and the heart and can therefore be used for palpitations and anxiety during the menopause • The relationship of the Penetrating Vessel with the Uterus and the Stomach explains morning sickness in pregnancy, caused by Qi in the Penetrating Vessel rebelling upwards because of the profound changes taking place in the uterus in the first 3 months of pregnancy • During nursing, Blood no longer flows downwards but is transformed into milk which flows upwards to the breasts via the Penetrating Vessel • The Penetrating Vessel’s control of all the Blood-Connecting (Blood-Luo) channels explains the connection between disharmony of Blood in the Uterus and the development of muscular pains, something which often occurs after childbirth • The Penetrating Vessel is the Sea of Blood and it exerts an enormous influence on the menstrual physiology and pathology. Its chief pathology is of course stasis of Blood in the abdomen causing dysmenorrhoea • The Penetrating Vessel is primarily responsible for menstruation, the Directing Vessel for conception and pregnancy
Directing Vessel (Ren Mai) The Directing Vessel has a very broad application in gynecology as it controls the Uterus, menarche, fertility, conception, pregnancy, delivery and menopause. Because of this very broad range of action, the Directing Vessel is one of the most widely used of the Extraordinary Vessels. It can be used to nourish the Yin energy of the body and the Kidneys. It promotes fertility and nourishes the fetus. Li Shi Zhen reports Wang Bing as saying “The Penetrating Vessel is the Sea of Blood, the Directing Vessel controls the fetus: [it is only when] the two support each other [that] conception can occur.”22 The Directing Vessel is therefore used to tonify the Uterus and the ovaries in amenorrhoea, scanty periods, delayed cycle and infertility. It is particularly useful to nourish Yin in women after menopause as the Directing Vessel controls the Uterus and determines a woman’s 7-year life cycles. It can therefore regulate the energy of the reproductive system and, after the menopause, nourish Blood and Yin to reduce the effects of EmptyHeat symptoms deriving from Yin deficiency. Thus, it can be used for such symptoms as night sweating, hot flushes, feelings of heat, mental irritability, anxiety, dry mouth at night, dizziness, tinnitus or insomnia, all symptoms of Kidney-Yin deficiency and Heart Empty-Heat. When used in this way, the opening and coupled points (LU-7 Lieque and KI-6 Zhaohai) are best combined with Ren-4 Guanyuan. The Directing Vessel moves Qi in the Lower Burner and Uterus, so that it can be used for lumps, fibroids and carcinoma of the uterus. In men, it is used for hernia. According to Chapter 29 of the Classic of Difficulties the Directing Vessel can be used to treat the “7 kinds of Lower Burner pain” in men and the “8 kinds of lumps in the lower abdomen” in women.23 Thus, the Directing Vessel can be used on the one hand to nourish the Kidneys and in particular (but not exclusively) Kidney-Yin and, on the other hand, to move Qi in the Lower Burner. In both cases the opening points LU7 Lieque and KI-6 Zhaohai should be needled, in the former case together
with Ren-4 Guanyuan, and in the latter with Ren-6 Qihai. The Directing Vessel goes through the throat and circles around the mouth and its pathology therefore includes a dry throat, bleeding gums, receding gums, etc., especially when such problems occur in conjunction with gynecological conditions or during pregnancy. A dry throat or hoarse voice in the context of gynecological problems would be a typical Directing Vessel symptom for which its opening points (LU-7 Lieque and KI-6 Zhaohai) can be needled. In fact, Chapter 47 of the Simple Questions says: Some women suffer from aphasia in the ninth month of pregnancy [the Yellow Emperor asks]. [Qi Bo replies] The Uterus Channel is severed: in fact this channel is connected to the Kidneys and the Kidney channel flows to the root of the tongue, hence the woman cannot speak.24 Qi Bo goes on to say that this condition does not need treatment as it will be resolved soon after childbirth when the connection between the Uterus and the Uterus Channel is restored. The Directing Vessel also influences the Qi of the Upper Burner through its important point Ren-17 Shanzhong. This vessel can therefore be used for asthma, wheezing and breathlessness, particularly when due to a deficiency of both Lungs and Kidneys. Summary Directing Vessel (Ren Mai)
• The Directing Vessel controls the Uterus, menarche, fertility, conception, pregnancy, delivery and menopause • It can be used to nourish the Yin energy of the body and the Kidneys. It promotes fertility and nourishes the fetus • It is particularly useful to nourish Yin in women after menopause as the
Directing Vessel controls the Uterus and determines a woman’s 7-year life cycles • The Directing Vessel moves Qi in the Lower Burner and Uterus, so that it can be used for lumps, fibroids and carcinoma of the uterus • The Directing Vessel goes through the throat and circles around the mouth and its pathology therefore includes a dry throat, bleeding gums, receding gums, etc., especially when such problems occur in conjunction with gynecological conditions or during pregnancy
Governing Vessel (Du Mai) As mentioned in Chapter 2, the menstrual cycle is the result of two tides: one of Kidney-Yin, one of Kidney-Yang. Kidney-Yin and Kidney-Yang go through an ebb and flow which determines the menstrual cycle. However, this sounds rather theoretical: how do Kidney-Yin and Kidney-Yang determine this ebb and flow? They do so through the Directing Vessel (Ren Mai) and Governing Vessel (Du Mai) respectively as these two vessels arise from the kidneys and flow through the uterus. Thus, the Governing Vessel is responsible for the Yang part of the menstrual cycle. I call this vessel the ‘forgotten vessel’ in gynecology because it is not often mentioned in connection with the menstrual cycle (always related to Directing and Penetrating Vessels). Without the Governing Vessel there would be no Yang influence on the menstrual cycle and therefore no menstruation: it is as important as the Directing and Penetrating Vessels. The Governing Vessel is closely related to the Directing Vessel: as mentioned in Chapter 2 on physiology, these two vessels could be seen as two branches, one Yin and one Yang, of the same circuit. Thus, if the Directing Vessel corresponds to the Kidneys and in particular to Kidney-Yin, the Governing Vessel corresponds to Kidney-Yang and the Minister Fire. The two vessels therefore nourish and balance each other. Therefore, a deficiency of the Governing Vessel and of Kidney-Yang may cause various gynecological problems such as heavy periods, scanty periods, delayed cycle and infertility. Bearing in mind that the Governing Vessel flows to the external genitalia and also has an abdominal branch, it is easy to see that this vessel’s pathology also has an influence on gynecological problems. In the same situations where one would normally use the Directing Vessel but when there is also a marked underlying deficiency of the Fire of the Gate of Life (Ming Men), the Governing Vessel can be used in women. Thus it could be used for amenorrhoea, delayed cycle or infertility which occur against a background of pronounced Kidney-Yang deficiency (manifesting with chilliness, a Pale and Wet tongue and a Deep and Slow pulse). In women, very often the
Directing and Governing Vessels can be used together, needling LU-7 Lieque, KI-6 Zhaohai, S.I.-3 Houxi and BL-62 Shenmai unilaterally (see Ch. 7). Bearing in mind that the abdominal branch of the Governing Vessel flows through the heart, the Governing Vessel has a strong influence on the mental–emotional state because it is the channel connection between Kidneys, Heart and Brain. One could therefore say that it influences the Mind in every way (according to a Western and Chinese perspective): through the Kidneys it influences the Will-Power (Zhi), through the Heart it influences the Mind and through the Brain (residence of the Mind according to several doctors such as Sun Si Miao, Li Shi Zhen and Wang Qing Ren) it also influences the Mind. Due to its relation with the Kidneys, Heart and Brain, the Governing Vessel is clinically often used for depression in gynecology, again often combined with Directing Vessel points (see Ch. 7). An example of a frequently used combination is Du-20 Baihui with Ren-4 Guanyuan for a woman suffering from Blood deficiency and depression (Fig. 3.18).
Figure 3.18 Governing Vessel connection of Kidneys, Heart and Brain.
Summary Governing Vessel (Du Mai)
• The menstrual cycle is the result of the ebb and flow of Kidney-Yin and Kidney-Yang • This ebb and flow occurs through the Directing Vessel (Ren Mai) and Governing Vessel (Du Mai) respectively as these two vessels arise from the kidneys and flow through the uterus • The Governing Vessel is responsible for the Yang part of the menstrual cycle • The Governing Vessel is closely related to the Directing Vessel: these two
vessels could be seen as two branches, one Yin and one Yang, of the same circuit • Therefore a deficiency of the Governing Vessel and of Kidney-Yang may cause various gynecological problems such as heavy periods, scanty periods, delayed cycle and infertility • Bearing in mind that the Governing Vessel flows to the external genitalia and also has an abdominal branch, it influences gynecological problems • The Governing Vessel has a strong influence on the mental–emotional state because it is the channel connection between Kidneys, Heart and Brain
Girdle Vessel (Dai Mai) One of the major symptoms of a pathology of the Girdle Vessel is its inability to raise Qi (or to ‘restrain’ the leg channels so that their Qi does not infuse downwards) so that Dampness may pour downwards causing leucorrhoea. In fact, the term for ‘leucorrhoea’ is dai xia and some doctors say that it is called so after the Girdle Vessel, i.e. Dai Mai (the character dai in ‘leucorrhoea’ is the same as that in the name of this vessel). Another symptomatology of the Girdle Vessel according to the Pulse Classic (Mai Jing) is abdominal pain: “Lower abdominal pain [dong ku tong] radiating to the Gate of Life, amenorrhoea in women or periods which stop and start, feeling of cold in the genital region, infertility, in men emissions.” Also “Umbilical pain like a line with backache radiating to thighs.”25 Thus, to summarize, the Girdle Vessel can be used in gynecology for irregular periods, dysmenorrhoea and leucorrhoea. Because of the gynecological sphere of influence of the Girdle Vessel, some doctors say that the Girdle Vessel is energetically part of the Directing Vessel or, at least, that its pathology is included in that of the Directing Vessel. The symptomatology of the Girdle Vessel in gynecology can be differentiated according to its deficiency or excess condition and some doctors say that, in its deficiency condition, the Girdle Vessel is part of the Directing Vessel’s sphere, while, in its excess condition, it is part of the Penetrating Vessel’s sphere. Deficiency This is due to Qi deficiency and to the Girdle Vessel being slack. It is related to Kidney and Liver deficiency and the Girdle Vessel not restraining the Essence, Spleen-Qi sinking, Girdle Vessel not propping up the Post-Natal Qi, so that Directing, Governing and Penetrating Vessels become deficient. When the Girdle Vessel is slack, Qi cannot rise, the organs sag, the
fetus may be miscarried and prolapses may occur. This is due to long-term Qi deficiency, Post- and Pre-Natal Qi deficiency, clear Qi descending, and the Girdle Vessel being slack. The treatment principle is to tonify Pre- and Post-Natal Qi, raise the clear Qi and consolidate the Girdle Vessel. The fetus depends not only on the Kidneys and the Directing Vessel but also on the Girdle Vessel. If the Girdle Vessel is slack, Qi cannot rise, the fetus is not stabilized and the mother may miscarry. Another consequence of a deficiency of the Girdle Vessel is infusing of Dampness down to the genitals causing excessive vaginal discharge or vaginal itching and soreness. The Deficiency pathology of the Girdle Vessel is related to the Directing Vessel. Excess Excess consists in the ‘Girdle Vessel not harmonized’, due to its being ‘tight’. The main symptomatology is as follows: • Fullness of the abdomen, back feels as if sitting in water. This is due to invasion of Damp-Cold in the Spleen channel. • Backache radiating to lower abdomen. • Feeling of heaviness of the body, coldness of the back, feeling as if sitting in water, feeling of heaviness of the abdomen as if carrying 5000 coins. This is due to exposure to dampness and rain. In gynecology, the Girdle Vessel is very useful for abdominal pain from Fullness, Dampness in the genital system and dysmenorrhoea.
Yin Stepping Vessel (Yin Qiao Mai) The Yin Stepping Vessel influences the reproductive system and the lower abdomen in women. It is particularly used for excess patterns of the Lower Burner such as abdominal masses, lumps, cysts, fibroids, difficult delivery and retention of placenta. In gynecology, this vessel is especially useful to resolve adhesions following gynecological operations such as those for endometriosis or hysterectomy. Summary Girdle Vessel (Dai Mai)
• One of the major symptoms of a pathology of the Girdle Vessel is its inability to raise Qi (or to ‘restrain’ the leg channels so that their Qi does not infuse downwards) so that Dampness may pour downwards causing leucorrhoea • Another symptom of the Girdle Vessel according to the Pulse Classic (Mai Jing) is abdominal pain • In deficiency conditions, the Girdle Vessel is slack so that Qi cannot rise, the organs sag, the fetus may be miscarried and prolapses may occur • Another consequence of a deficiency of the Girdle Vessel is infusing of Dampness down to the genitals causing excessive vaginal discharge or vaginal itching and soreness • The deficiency pathology of the Girdle Vessel is related to the Directing Vessel • In excess conditions, the Girdle Vessel is ‘tight’ • The main symptoms are fullness of the abdomen, back feels as if sitting in water, backache radiating to lower abdomen, feeling of heaviness of the body, coldness of the back, feeling as if sitting in water, feeling of heaviness of the abdomen as if carrying 5000 coins
• In gynecology, the Girdle Vessel is very useful for abdominal pain from Fullness, Dampness in the genital system and dysmenorrhoea
Yin Linking Vessel (Yin Wei Mai ) Unlike the other extraordinary vessels, the Yin Linking Vessel is used mostly to nourish, not to eliminate excess conditions as the others do. The Yin Linking Vessel is excellent to nourish Blood and calm the Mind in women. It affects the Heart and it can therefore be used for amenorrhoea, delayed cycle or scanty periods, especially when associated with depression, anxiety and a feeling of tightness of the chest. End notes 1. Lian Fang 1992 TCM Treatment of Luteal Phase Defect – An Analysis of 60 Cases, Journal of Chinese Medicine 38: 21..
2. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p. 39. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
3. Ibid., p. 39..
4. 1979 The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen
), People’s Health Publishing House, Beijing, p. 197. First published c. 100 BC..
5. Feng Tao Zhang 1702 Secret Records of Master Feng’s Brocade Bag (Feng Shi Jin Nang Mi Lu), cited in Zhang Qi Wen 1995 Menstrual Disease (Yue Jing Bing Zheng
), People’s Hygiene Publishing House, Beijing, p. 32..
6. Yao Shi An 1996 On the Relationship between the Heart and Women’s Diseases (Lun Xin Yu Nu Ke), Journal of Chinese Medicine (Zhong Yi Za Zhi
) 37(6): 328–329..
7. Ibid..
8. Yang Jia San 1988 Great Dictionary of Chinese Acupuncture (Zhong Guo Zhen Jiu Da Ci Dian
), Beijing Physical Training College Publishing House, Beijing, p. 827..
9. Ibid..
10. Yue Han Zhen 1990 An Explanation of Acupuncture Points (Jing Xue Jie
), People’s Hygiene Publishing Company, Beijing, p. 143. The text was first published during the early Qing dynasty..
11. Simple Questions, p. 247..
12. On the Relationship between the Heart and Women’s Diseases, p. 329..
13. Simple Questions, p. 197..
14. On the Relationship between the Heart and Women’s Diseases, p. 329..
15. Ibid., p. 329..
16. Ibid., p. 329..
17. The concept of Yin-Fire was introduced by Li Dong Yuan in his celebrated Discussion on Stomach and Spleen (Pi Wei Lun). According to Li Dong Yuan, irregular diet,
overwork and emotional stress weaken the Stomach and Spleen and the Original Qi. When the Original Qi declines, the Minister Fire becomes pathological and rises from the space between the Kidneys to harass the Heart and Pericardium: this Fire is what Li Dong Yuan called Yin-Fire (which is not to be confused with Empty-Heat). The pathological Minister Fire, i.e. the Yin-Fire, ‘displaces’ the Original Qi because they both occupy the same space in between the Kidneys: for this reason Li Dong Yuan says that the Yin-Fire is a ‘thief’ of the Original Qi. Thus, in this kind of pathology, there may be some Cold symptoms and signs arising from a deficiency of the Original Qi (such as cold feet, a feeling of cold and a Pale tongue) and some hot manifestations from the rising of the Yin-Fire (e.g. thirst, a feeling of heat in the face, etc.). Arousal of Yin-Fire is treated not by clearing Heat but by tonifying the Original Qi with sweet and warm herbs: the representative formula for this is Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction (Tonify Qi and Ease the Muscles in the Three Treasures range)..
18. Nanjing College of Traditional Chinese Medicine 1979 A Revised Explanation of the Classic of Difficulties (Nan Jing Jiao Shi
), People’s Health Publishing House, Beijing, p. 75. First published c. AD 100..
19. 1981 Spiritual Axis (Ling Shu Jing
), People’s Health Publishing House, Beijing, p. 64. First published c. 100 BC..
20. Li Shi Zhen 1985 A Compilation of the ‘Study of the Eight Extraordinary Vessels’ (Qi Jing Ba Mai Kao Jiao Zhu
), edited by Wang Luo Zhen, Shanghai Science Publishing House, Shanghai, p. 60. First published in 1578..
21. He Ren 1981 A New Explanation of the Synopsis of Prescriptions from the Golden Cabinet (Jin Gui Yao Lue Xin Jie
), Zhejiang Science Publishing House, p. 57. The Synopsis of Prescriptions from the Golden Cabinet was written by Zhang Zhong Jing c. AD 200..
22. A Compilation of the ‘Study of the Eight Extraordinary Vessels’, p. 77..
23. Classic of Difficulties, p. 74..
24. Simple Questions, p. 259..
25. Wang Shu He 1988 A Revised Explanation of the ‘Pulse Classic’ (Mai Jing Jiao Shi
), with commentary by the Fuzhou City People’s Hospital, People’s Health Publishing
House, Beijing, p. 90. First published in AD 280..
SECTION 2 Aetiology and Diagnosis
CHAPTER 4 Aetiology
EXTERIOR PATHOGENIC FACTORS 78 Cold 79 Dampness 79 Heat 79 EMOTIONAL STRESS 79 Sadness and grief 80 Worry 80 Anger 81 Fear 81 Shock 81 Guilt 81 IRREGULAR DIET 83 Cold foods 83 Hot foods 83 Diet lacking in nourishment 83 Greasy and sweet foods 83 EXCESSIVE PHYSICAL WORK/EXERCISE 84 OVERWORK 86 PREGNANCY AND CHILDBIRTH 86 Pregnancy 86 Childbirth 87
EXCESSIVE/INSUFFICIENT SEXUAL ACTIVITY 88 SURGERY AND HYSTERECTOMY 93 CONTRACEPTIVE PILL 94 PREVENTION AND HYGIENE 94 The main aetiological factors in women are obviously of the same type as in men but there are certain differences which should be noted. For example, the aetiological factor of ‘excessive sexual activity’ has quite a different meaning in men and women. In this chapter I shall therefore discuss aetiological factors with specific reference to women and to gynecological problems. The main aetiological factors are: • Exterior pathogenic factors • emotional stress • irregular diet • excessive physical work/exercise • overwork • pregnancy and childbirth • excessive/insufficient sexual activity • surgery and hysterectomy • contraceptive pill • prevention and hygiene.
Chinese medicine has always emphasized the importance for women to take extra care during the period and after childbirth. All the precautions that apply to the post-partum period also apply, albeit to a lesser degree, to each period time. During the period, the Uterus is in a vulnerable state because it is open; moreover, the loss of blood induces a state of relative Blood deficiency and therefore any aetiological factor at this time easily influences Blood, causing a deficiency or stagnation. A Qing dynasty text, Most Valuable Treasure of Women and Babies, talks at length about the necessity for women to take care during and immediately after the period: When the period arrives, new blood has not been produced and old blood is being discharged; at this time women become irritable and they should avoid overstrain, stress and emotional problems. It is also most important that they avoid cold food and sitting or lying in cold and damp places. During the period the pores are open, old blood enters the Penetrating Vessel in order to be discharged. Exposure to cold at this time stops old blood from moving downwards; it will instead accumulate in the body giving rise to stagnant Blood, palpable masses, dysmenorrhoea or short periods. New blood is produced 1–2 days after the end of the period; exposure to cold at this time prevents the production of new blood leading to exhaustion of Blood manifesting with a sallow complexion, lassitude, long cycle and leucorrhoea. This is why women suffer from more diseases that are difficult to cure. Women from rich families are arrogant and often hide their feelings. They cannot stop eating cold fruits if these are delicious; this causes Cold to invade the Stomach. These women cool themselves too much in summertime as they do not know that it is harmful to health. After some time, diseases will occur and they may suffer from infertility. It must be pointed out that women should avoid exposure to wind and cold and eating cold foods during the period. To eliminate Blood stasis, this is the best time to give treatment [during the period]. Tonics should be taken after the end of the period. By following these rules a weak woman
can get stronger, she will not suffer from diseases and will be able to give birth to many children.1 An interesting aspect of this passage is a reference to treatment according to menstrual phases when it says “To eliminate Blood stasis, this is the best time to give treatment [during the period]. Tonics should be taken after the end of the period.” This confirms the modern view according to which the period (bleeding time) is the best time to invigorate Blood and the post-menstrual phase (phase 2) the best time to tonify (the Kidneys). The Qing dynasty gynecologist Chen Jia Yuan classified the aetiological factors of women’s diseases into four groups: 1. Excessive physical work (including excessive sexual activity). 2. Mental depression. 3. Worry and pensiveness. 4. Dietary irregularities. He included excessive sexual activity with ‘overwork’ and considered physical overwork as an external cause and excessive sexual activity as an internal cause of disease (within the category of ‘overwork’). He said that ‘mental depression’ is different from the ‘Six Stagnations’ (stagnation of Qi, Blood, Heat, Food, Dampness and Phlegm) and that ‘worry and pensiveness’ are a non-substantial cause of disease while dietary irregularity is a substantial one. Dr Chen’s reference to ‘mental depression’ is interesting and very modern. He specifically says that is not equivalent to the depression caused by the Six Stagnations (defined by Zhu Dan Xi and for which Yue Ju Wan Gardenia-Chuanxiong Pill is used). By ‘mental depression’ he means a general state of unhappiness which may be due to many different patterns rather than purely stagnation; as we shall see below, by ‘depression’ he also means a state of mental frustration due to unfulfilled sexual desire (Fig. 4.1). Dr Chen said that overwork should be treated with the tonification method;
emotional depression be treated by moving and opening Qi; pungent herbs be used for worry and pensiveness; dietary irregularities should be treated by digestive herbs that dissolve retained food. Passages from his work will be discussed below.
Figure 4.1 Gynecological causes of disease according to Dr Chen Jia Yuan.
Exterior pathogenic factors Exterior pathogenic factors have a deep influence on gynecological problems. The Golden Mirror of Medicine (1742) says: When the climate is moderate and harmonized, the periods are calm. Cold congeals, Heat boils, Wind makes [the periods] surge; external pathogenic factors enter the Uterus and deplete the Directing and Penetrating Vessels causing menstrual problems.2 Shen Yao Feng, author of the Summary of Gynecology (1850), says: “Warm, harmonious weather makes the periods quiet; cold congeals them; heat makes them overflow; wind makes them surge.”3 The three most common Exterior pathogenic factors in gynecology are Cold, Dampness and Heat.
Cold Cold may mean either Wind-Cold invading the space between skin and muscles or Cold invading the Uterus directly. During menstruation and especially after labour, the Blood-Connecting (Blood-Luo) channels are open and the space between skin and muscles is especially vulnerable to invasions of Wind-Cold. Invasion of Wind-Cold during menstruation or after labour may cause aches in the joints and painful periods. External Cold can also invade the Uterus directly causing painful periods. Again, this happens especially during menstruation or after labour.
Dampness Dampness is a major pathogenic factor in gynecology. It invades the channels of the legs and creeps upwards to settle in the reproductive system in women, causing leucorrhoea, pain on ovulation or dysmenorrhoea. The invasion of Dampness too is facilitated during the menses or after labour. Once inside the body, Dampness becomes an internal pathogenic factor which easily combines with Heat to form Damp-Heat: this is a major pathogen in gynecology, usually causing abdominal masses, dysmenorrhoea, ovarian cysts, leucorrhoea, infertility or menorrhagia.
Heat Heat may be either Wind-Heat or Summer-Heat. After the Exterior stage, both these pathogenic factors can penetrate the Interior and enter the Blood portion causing Blood-Heat. This is a major cause of excessive menstrual bleeding. Summary Exterior pathogenic factors
Cold
• Cold may mean either Wind-Cold invading the space between skin and muscles or Cold invading the Uterus directly • Invasion of Wind-Cold during menstruation or after labour may cause aches in the joints and painful periods • External Cold can also invade the Uterus directly causing painful periods
Dampness
• Dampness invades the channels of the legs and creeps upwards to settle in the reproductive system in women, causing leucorrhoea, pain on ovulation or dysmenorrhoea • Once inside the body, Dampness becomes an internal pathogenic factor which easily combines with Heat to form Damp-Heat: this is a major pathogen in gynecology, usually causing abdominal masses, dysmenorrhoea, ovarian cysts, leucorrhoea, infertility or menorrhagia
Heat
• Heat may be either Wind-Heat or Summer-Heat • Both these pathogenic factors can penetrate the Interior and enter the Blood portion causing Blood-Heat. This is a major cause of excessive menstrual bleeding
Emotional stress Emotional stress has a profound influence on menstruation, pregnancy, labour and menopause. The Golden Mirror of Medicine (1742), when discussing emotional causes of disease in gynecology, says: “Worry, anger, depression injure the emotional life, Blood flows up rebelling upwards bringing Qi with it.”4 The Uterus Vessel connects the Uterus to the Heart: since the Heart is always affected by emotional problems, this connection explains the profound influence of emotional stress on the menstrual function. For example, Chapter 33 of the Simple Questions says: When menstruation does not come, this is due to the Uterus Vessel being blocked. The Uterus Vessel pertains to the Heart and connects with the Uterus; when Qi rebels upwards towards the Lungs, HeartQi cannot flow downwards and the periods do not come.5 ‘Qi rebelling upwards towards the Lungs’ describes in particular the effect of worry, sadness or grief. Although the Heart plays a pivotal role in emotional stress since it houses the Mind (Shen) that feels the emotions, of course all other organs may be affected by emotional stress that has repercussions on the Uterus. For example, the Liver especially is affected by emotional stress that affects menstruation. Liver-Qi stagnation, Liver-Blood stasis, Liver-Blood-Heat and Liver-Fire may all be caused by emotional stress and they all have a profound influence on menstruation, conception, pregnancy and labour. Emotional problems are all the more detrimental in women if they occur around the time of puberty. At this time, a girl’s health is particularly vulnerable and emotional problems will affect her body and mind deeply and with long-lasting effect. In particular, emotional stress at this time will deeply affect the Directing and Penetrating Vessels (Ren and Chong Mai) creating the imbalances that will cause gynecological problems later in life. Emotional stress influences menstruation by affecting first the movement
of Blood by Qi. In fact, the first effect of emotional stress is to impair or alter the circulation of Qi by depleting Qi, making Qi stagnant or making Qi rebellious. Each of these pathologies will affect Blood which follows Qi and becomes deficient, stagnant or rebellious and/or Hot (Fig. 4.2).
Figure 4.2 Effect of Qi derangement from emotional stress on the Uterus. The Golden Mirror of Medicine says:
Women cannot control themselves and are frequently affected by worry, pensiveness, anger or depression: these make the Blood move, stop, rebel or conform, which is all due to Qi movement.6 Of course, the part of the statement that says that ‘women cannot control themselves’ reflects a patronising Confucian attitude towards women: the emotional problems the book is referring to of course affect women and men equally.
Sadness and grief Sadness and grief deplete Heart and Lungs and can influence menstruation in two ways. By affecting the Heart, they may deplete Heart-Blood, which may affect the Uterus via the Uterus Vessel (Bao Mai). This may lead to amenorrhoea, scanty periods or delayed cycle. If they deplete Lung-Qi, Qi may fail to move Blood and this may also cause amenorrhoea. Deficient Lung-Qi and Spleen-Qi may also either fail to hold Blood and lead to menorrhagia, or fail to raise Qi, leading to prolapses. In women, sadness may sometimes affect the Liver directly, causing Liver-Blood deficiency. Chapter 8 of the Spiritual Axis says: “When sadness affects the Liver it injures the Ethereal Soul; this causes mental confusion … the Yin is damaged, the tendons contract and there is hypochondrial discomfort.”7 When sadness affects the Liver (which is fairly common in women), it easily causes gynecological problems such as amenorrhoea, scanty periods or delayed cycle, all associated with depression and a feeling of aimlessness due to the Ethereal Soul not being rooted in Liver-Blood.
Worry Worry knots the Qi of the Lungs, Heart and Spleen. It leads to stagnation of Qi which may cause delayed periods or painful periods. It is important to note that stagnation of Qi is not always synonymous with Liver-Qi stagnation, as the above-mentioned organs also may suffer from stagnation. In particular, Lung-Qi may stagnate as a result of worry. This will cause a slight breathlessness, a pale complexion, sighing, a feeling of tightness of the chest and, in terms of gynecology, pre-menstrual tensions and distension of the breasts. Since the Lung channel courses through the chest area, stagnation of Lung-Qi, deriving from worry or grief, is often involved in the aetiology of breast lumps. The Qing dynasty gynecologist Chen Jia Yuan wrote with regard to worry: Worry injures the Lungs and pensiveness injures the Spleen, when these two organs are injured Qi and Blood stagnate, there is a feeling of indignation, palpitations, a feeling of oppression of the chest and amenorrhoea.8 This passage confirms that stagnation of Qi affects not only the Liver but also the Lungs and Spleen (see below) and also that amenorrhoea may occur from stagnation as well as from a deficiency. Moreover, in my opinion, worry also affects the Liver and makes LiverYang rising: this may cause menstrual headaches. Indeed, Zhang Jing Yue says that worry affects the Liver: Worry pertains to the Lungs but it also affects the Heart. Worry makes Qi rise and can affect the Liver; the Liver becomes overactive and it invades the Spleen. The Spleen is then affected by worry and this injures the Intellect [Yi]. Hence worry affects the Lungs, Heart, Liver and Spleen.9
Anger Anger includes frustration, resentment, bearing grudges, irritation, hatred, etc. These emotions are a major cause of menstrual problems as they cause stagnation of Liver-Qi, which may lead to irregular periods, pre-menstrual tension and dysmenorrhoea, and which can cause further problems in two ways. First of all it can lead to Liver-Blood stasis which causes a more painful type of dysmenorrhoea or abdominal masses; second, stagnant Qi may develop into Fire which causes Blood-Heat and therefore menorrhagia. The Great Treatise of Beneficial Formulae for Women (1237) says of anger: Anger causes Qi to rebel upwards: Blood follows Qi and also rebels upwards. If the lower back and legs are affected, there will be pain and a sensation of heaviness there during the period, which will disappear at the end of the period … If anger damages the Liver, there will be dizziness, hypochondrial pain, spitting of blood, acute skin infections and prolonged uterine bleeding.10
Fear By ‘fear’ is meant either a sudden fright or a chronic state of anxiety. A sudden fright makes Kidney-Qi descend, but a chronic state of anxiety, especially when the Heart is weak, makes Qi rise. For example, fear (in the sense of chronic anxiety) may cause the Qi of the Penetrating Vessel to rebel upwards. This is a very common factor that aggravates menopausal problems. The Great Treatise of Beneficial Formulae for Women (1237) says about fear: Fear during the period causes disturbances of Blood, the blood vessels and channels become obstructed, Qi rebels upwards in the Blood portion, and this may lead to a severe deficiency.11 This passage states that a state of fear and anxiety during the period upsets the Blood system, causing Blood to rebel upwards; as it rebels upwards, this may induce a deficiency of Blood and, eventually, Yin. Obviously this will only happen when the emotional problem continues for years.
Shock Shock depletes Heart, Spleen and Kidneys. It may cause amenorrhoea or a delayed cycle. Shock typically manifests with a Moving pulse even many years after the event. The Moving pulse is rapid, short and shaped like a bean and it gives the impression of vibrating instead of pulsating.
Guilt Guilt is an extremely common and damaging emotion in Western patients. It may derive from breaking religious or social taboos or from doing something wrong which weighs on the conscience. Of course, guilt can also arise in those who always tend to blame themselves, even if they have done nothing wrong; for example, someone blaming himself or herself unnecessarily for the breakdown of their marriage. This attitude can sometimes be due to patterns established in childhood if a child is never praised and always reprimanded. Interestingly, there is no modern Chinese word for ‘guilt’ used in its emotional rather than its legal sense. There is, however, an ancient word for it called jiu: this character is based on the ‘disease’ radical and a radical that means ‘long time’, i.e. a feeling harboured for a long time leading to disease. Another old Chinese expression for guilt is xin li you gui, which means ‘an evil spirit harboured in the Heart’. In some cases, guilt may also arise from repressed and unrecognized anger which turns inwards and causes an attitude of self-punishment and guilt. Guilt affects the Heart, Liver, Lungs and Kidneys and it causes either stagnation or sinking of Qi, depending on the pre-existing condition of the woman. In gynecology, it is common to see conditions caused by sinking of Qi as a consequence of longstanding guilt. This brings about a sinking of Kidney-Qi with an ensuing bearing-down feeling or an actual prolapse of the uterus or bladder. Very often, urinary problems characterized by frequent urination, a bearing-down sensation and a slight urinary incontinence in women are due to longstanding guilt causing Kidney-Qi to sink. The tongue will have a red tip and the pulse will be vibrating as it pulsates. The eyes will look unstable and often flap shut while the woman is talking. When guilt results from repressed anger, the pulse will be Wiry. Case history A 42-year-old woman complained of a persistent bearing down, uncomfortable and achy feeling in the hypogastrium (just over the bladder).
Her periods were very heavy with bright-red blood without clots. Her complexion was pale, she looked very depressed and her pulse was very Weak on both Kidney positions. I diagnosed sinking of Kidney-Qi with sinking Qi unable to contain Blood. I enquired about her emotional and marital life. After a few sessions, she admitted that she felt very guilty about her second marriage and the impact it had had on her child from the first marriage. This is a clear example of the effect of guilt on the Kidneys and the menstrual function. Summary Emotional stress
• Emotional stress has a profound influence on menstruation, pregnancy, labour and menopause • The Uterus Vessel connects the Uterus to the Heart: since the Heart is always affected by emotional problems, this connection explains the profound influence of emotional stress on the menstrual function • All other organs may be affected by emotional stress that has repercussions on the Uterus • Emotional problems are all the more detrimental in women if they occur around the time of puberty
Sadness and grief
• Sadness and grief deplete Heart and Lungs and can deplete Heart-Blood leading to amenorrhoea, scanty periods or delayed cycle or Lung-Qi which fails to move Blood and leads to amenorrhoea • Deficient Lung-Qi and Spleen-Qi may also either fail to hold Blood and lead to
menorrhagia, or fail to raise Qi, leading to prolapses • In women, sadness may sometimes affect the Liver directly, causing LiverBlood deficiency
Worry
• Worry knots the Qi of the Lungs, Heart and Spleen • It leads to stagnation of Qi which may cause delayed periods or painful periods • Lung-Qi stagnation may cause pre-menstrual tensions, distension of the breasts and breast lumps • Worry also affects the Liver and makes Liver-Yang rising: this may cause menstrual headaches
Anger
• Anger includes frustration, resentment, bearing grudges, irritation, hatred • These emotions cause stagnation of Liver-Qi, which may lead to irregular periods, pre-menstrual tension and dysmenorrhoea
Fear
• A sudden fright makes Kidney-Qi descend, but a chronic state of anxiety, especially when the Heart is weak, makes Qi rise • A state of fear and anxiety during the period upsets the Blood system, causing Blood to rebel upwards
Shock
• Shock depletes Heart, Spleen and Kidneys • It may cause amenorrhoea or a delayed cycle
Guilt
• Guilt is an extremely common and damaging emotion in Western patients • In some cases, guilt may also arise from repressed and unrecognized anger which turns inwards and causes an attitude of self-punishment and guilt • Guilt affects the Heart, Liver, Lungs and Kidneys and it causes either stagnation or sinking of Qi, depending on the pre-existing condition of the woman • In gynecology, it is common to see conditions caused by sinking of Qi as a consequence of long-standing guilt
Irregular diet Diet is an important aetiological factor in gynecology. The Golden Mirror of Medicine says: “Blood is the essence refined from food and water, if the Stomach and Spleen are injured, fluids are not regulated, Blood dries up, and the periods become unregulated.”12 The Qing dynasty gynecologist Chen Jia Yuan said: Food can nourish but can also harm people … if a woman has not enough exercise, the digestion is slow, Cold is generated, the Stomach and Spleen are injured so that they cannot transport [food], stuffiness and fullness develop with accumulations and there may be vomiting and diarrhoea.13
Cold foods Excessive consumption of cold foods may create Cold in the Uterus: all the more likely to happen during puberty, during menstruation and after labour, this is a major cause of dysmenorrhoea and infertility. Cold foods include raw fruit and vegetables (with few exceptions) and iced drinks. This is a common cause of gynecological problems. The idea that an excessive consumption of salads and fruit can be detrimental to health runs counter to all modern ideas about diet, according to which, by eating raw vegetables and fruit, we can absorb all the minerals and vitamins contained in them. This is true to a certain extent and a moderate consumption of these foods can be beneficial. However, from a Chinese perspective, the Spleen likes dry and warm foods and dislikes cold and wet ones: an excessive consumption of raw foods, although in theory providing abundant vitamins and minerals, may be detrimental because such foods will be difficult for the Spleen, Stomach and Intestines to digest and absorb.
Hot foods Excessive consumption of hot foods may cause Blood-Heat and therefore menorrhagia: this is usually more likely to occur in an older woman than in a young woman or girl. Hot foods include most meats (but especially lamb and beef), spices, curry and alcohol (especially spirits).
Diet lacking in nourishment A diet lacking in nourishment (through following either a strict slimming diet or a vegetarian diet which does not pay adequate attention to procuring alternative sources of protein) may lead to Qi and Blood deficiency and therefore amenorrhoea, scanty periods or infertility. This is, in fact, a cause of gynecological problems which is becoming more and more common due to the increasing popularity of vegetarianism among young girls. Although it is perfectly possible to follow a vegetarian diet that is sustaining and that provides adequate nourishment, it does require a sophisticated knowledge of nutrition which is often beyond the capabilities of the very young. They therefore end up not having enough nourishment or eating excessive amounts of dairy foods which create Dampness. Furthermore, according to Li Shi Zhen, animal products are particularly beneficial to the Extraordinary Vessels and in particular the Governing, Directing and Penetrating Vessels. In fact, he says that the main substance for the Governing Vessel is Lu Rong Cornu Cervi pantotrichum and the main foods for it are the marrow and brain of beef and goat.14 The main substance for the Directing and Penetrating Vessels is Gui Ban Plastrum Testudinis.
Greasy and sweet foods Excessive consumption of greasy and sweet foods causes internal Dampness which often settles in the Lower Burner: this may cause an excessive vaginal discharge, dysmenorrhoea or cysts. Greasy and sweet foods that cause Dampness or Phlegm include milk, cheese, butter, cream, ice-cream, bananas, peanuts, fatty meats, fried foods, sweets and sugar. During gestation the fetus is pure Essence and Corporeal Soul (Po): this relies on the mother’s Corporeal Soul and Essence. The mother’s Essence is transformed into Blood which nourishes the fetus’s Essence and Corporeal Soul. The Corporeal Soul pertains to Earth, comes into being at conception and returns to Earth at death. Since the Corporeal Soul pertains to Earth, and since the fetus is ‘all Essence and Corporeal Soul’, it is understandable that food ingested by the mother during pregnancy has a direct influence on the baby’s Corporeal Soul and therefore its Lungs and skin (causing hereditary skin diseases such as atopic eczema). Table 4.1 lists the organs pertaining to each month of pregnancy (bearing in mind that in Chinese medicine pregnancy is considered to last 10 lunar months), the foods to avoid and the beneficial foods in each month. Table 4.1 Beneficial and contraindicated foods in pregnancy
Summary Irregular diet
• Excessive consumption of cold foods may create Cold in the Uterus • Excessive consumption of hot foods may cause Blood-Heat and therefore menorrhagia • A diet lacking in nourishment (through following either a strict slimming diet or a vegetarian diet which does not pay adequate attention to procuring alternative sources of protein) may lead to Qi and Blood deficiency and therefore
amenorrhoea, scanty periods or infertility • Excessive consumption of greasy foods causes internal Dampness or Phlegm which often settles in the Lower Burner: this may cause an excessive vaginal discharge, dysmenorrhoea or cysts
Excessive physical work/exercise Excessive physical work, exercise or sports can weaken the Spleen, Liver and Kidneys (and therefore muscles, sinews and bones) and adversely affect the Penetrating and Directing Vessels by causing stagnation of Qi and/or Blood leading to dysmenorrhoea. Chapter 23 of the Simple Questions says: “Excessive standing injures the bones [and therefore the Kidneys], excessive exercise and [physical] work injures the sinews [and therefore the Liver].”15 Excessive physical work is particularly detrimental if it occurs during the puberty years because at this time a girl’s body is especially vulnerable. In fact, during these years, the Directing and Penetrating Vessels are undergoing profound changes and are in a state of flux: this makes them more vulnerable to external influences. Excessive physical work may either weaken these two vessels or lead to stagnation, depending on the constitution of the girl. How could a young girl incur this particular cause of disease? She might be helping on a farm, or practising ballet, or training hard at a particular sport. Very often this cause of disease is combined with that due to external Cold: the typical example would be that of a girl playing a lot of sports in a Tshirt and shorts in a cold and damp climate such as that which is prevalent in Northern Europe, Canada or the North of the USA. Excessive exercise affects the Directing and Penetrating Vessels adversely and, because of this weakness, the external Cold invades the Lower Burner more easily (especially when a girl plays sports in shorts in winter) causing amenorrhoea or dysmenorrhoea. Excessive lifting of weights is also particularly harmful, again more so if it happens during puberty. It weakens the Kidneys but it also leads to stagnation in the Lower Burner and therefore dysmenorrhoea later in life. Excessive lifting may occur if a girl is helping her parents on a farm or in their business or during excessive gym work-outs. The following brief case history illustrates this point.
Case history A 36-year-old woman complained of painful periods since she was about 20. She had been diagnosed as having endometriosis. The pain was both central and bilateral in the iliac fossae. The menstrual blood was dark with dark clots and the pain was relieved by the application of a hot-water bottle. Her tongue was Purple and her pulse was Wiry. My diagnosis was stasis of Blood and retention of Cold in the Uterus occurring against a background of Kidney-Yang deficiency. On my asking her about the possible causes of disease, it emerged that she had started work at 18 becoming the manageress of a newsagent shop, thus lifting heavy bundles of newspapers every day. Coupled with this, there was also a sudden exposure to Cold since she had moved from Uganda (which has a very dry and warm climate) to England a year prior to that. Thus the aetiology was fairly typical: exposure to Cold around puberty time coupled with excessive lifting. Cold in the Uterus led to stasis of Blood which was aggravated by the stagnation caused by the lifting. Besides this, the excessive lifting also weakened the Kidneys and, much later in life when the Kidney energy starts to decline, her condition had been aggravated by the development of endometriosis. Excessive exercise is detrimental especially when it occurs during periods, when pregnant or after childbirth. During the period it weakens the Spleen and Kidneys and may lead to menorrhagia of the deficient type. During pregnancy, it weakens the Directing and Penetrating vessels and may cause the fetus to become unstable, with the danger of miscarriage. Chinese medicine stresses very much the importance of having adequate rest after childbirth. Excessive exercise after childbirth also weakens the Spleen and Kidneys and the Directing Vessel and may cause prolapse of the uterus. The Qing dynasty gynecologist Chen Jia Yuan includes both excessive physical work and excessive sexual activity under the same aetiological category in women, the former being an ‘outer’ and the latter an ‘inner’ factor. He says:
If the woman head of the household is too hard-working, it may injure her sinews and bones, whilst excessive sexual activity injures the spirit. Thus Blood, Qi and Body Fluids become depleted in the channels and lead to exhaustion of the internal organs … so that Yin and Yang become both deficient, there is steaming from the bones and Exhaustion [Xu Lao] develops.16 It is interesting that he says that while excessive exercise injures sinews and bones, excessive sexual activity injures the Spirit (see below). However, inadequate exercise may also become a cause of disease in women because it either causes or aggravates stagnation of Qi. The very same sentence of the Simple Questions that discusses excessive exercise also warns against lack of exercise: “Excessive lying down injures Qi [and therefore the Lungs], excessive sitting injures the muscles [and therefore the Spleen].”17 The Ye Tian Shi’s Secret Prescriptions of Gynecological Patterns and Treatment by Ye Tian Shi (1667–1746) says: “In the time before childbirth one should normally exercise; this makes Qi and Blood move freely, [so that] the fetus can move and turn and labour will be easy.”18 Summary
Excessive physical work/exercise
• Excessive physical work, exercise or sports can weaken the Spleen, Liver and Kidneys (and therefore muscles, sinews and bones) and adversely affect the Penetrating and Directing Vessels by causing stagnation of Qi and/or Blood leading to dysmenorrhoea • Excessive physical work is particularly detrimental if it occurs during the puberty years • Excessive lifting of weights weakens the Kidneys but it also leads to stagnation in the Lower Burner and therefore dysmenorrhoea later in life • Inadequate exercise may also become a cause of disease in women because it either causes or aggravates stagnation of Qi
Overwork By overwork I mean not physical overwork (which comes under ‘excessive physical exercise’), but working too long hours, without adequate rest and with an irregular diet. This causes Kidney-Yin deficiency and is a common factor that aggravates menopausal problems and a cause of menorrhagia. Overwork, in the sense intended above, is a common cause of disease in older women, while excessive physical work is more common in young women or girls.
Pregnancy and childbirth
Pregnancy All modern Chinese books include ‘pregnancy’ automatically as a cause of disease in gynecology. I do not agree with this view. Pregnancy may indeed become a cause of disease under certain circumstances, but not always and not automatically. Moreover, under certain circumstances, pregnancy may even improve some gynecological conditions (and also some nongynecological ones): this may happen especially with migraine, asthma and eczema. The following case history serves to highlight the fact that while pregnancy taxes the Kidneys, the stoppage of the menses has a nourishing effect on the mother; thus the net effect of the pregnancy on a woman’s health depends on the pre-existing state of her Kidneys. A Western medicine gynecology textbook confirms this when it says, with specific reference to asthma, that 25% of asthma cases improve during a pregnancy, 25% worsen, and the remainder are unaffected by it.19 Case history A 34-year-old woman had experienced a gradual hair loss for some years. During her first pregnancy, the hair loss actually stopped and the hair became thicker, while after the childbirth the hair loss started again. This is a striking example of how the Kidneys can actually get stronger during pregnancy and, in her case, nourish the hair. It should also be noted that pregnancy, or rather the lack of it, may even account for a weaker constitution of modern women compared with previous generations. In fact, although too many childbirths are weakening, so are menses occurring for several decades in a woman’s life. In other words, modern women, because they have fewer children, have children later and breastfeed for a shorter time, have many more menstrual cycles in the course of their fertile life than women of previous generations: it could be argued that menses are also weakening, occurring as they do over three decades. Assuming, for the sake of argument, menarche to occur at 14 and
menopause at 49, a woman would have 35 fertile years. If we compare two women, one having seven children and another having two, and assuming the former breastfeeds for 1 year (as was the custom in previous generations) and the latter for 6 months, the former woman will breastfeed for 84 months and the second for 12 months in total. Assuming they do not menstruate during breastfeeding, the first woman will have a total of 266 periods and the second one a total of 388, i.e. the first woman (with seven children) will have 122 fewer periods than the one with two children. It is arguable that the increased number of periods leads to Blood and/or Kidney deficiency which, of course, would have to be balanced against the weakening deriving from having seven children. It is interesting that from the Western point of view also, there is a correlation between breast cancer incidence and number of menstrual cycles. In fact, an early onset of menarche is associated with a two-fold increase in breast cancer risk. A study has shown that the combination of early menarche and early establishment of regular cycles is associated with more than a three-fold increase in breast cancer risk.20 Also menopause before the age of 45 leads to a two-fold reduction in risk of breast cancer. Pregnancy also has a protective effect: women who have their first child before 20 have approximately half the risk of breast cancer of nulliparous women. There is also an inverse correlation between the number of periods in a woman’s life and the risk of developing breast cancer. In particular, it seems that the number of menstrual cycles before the first pregnancy may be the ultimate determinant of breast cancer risk. In fact, both early age of onset of menstruation and later age at the menopause seem to increase the risk of breast cancer.21 Some doctors have also advanced the hypothesis that the increasing incidence of endometriosis may be correlated with the increased number of menstrual cycles between the time of menarche and that of the first pregnancy. In fact, until this century, women typically experienced only 2 or 3 years of menstruation between menarche and first pregnancy (assuming the menarche to occur at 16 and first pregnancy at 18–19). In modern times, the menarche is occurring earlier and earlier and women are having the first
pregnancy later and later: thus, while until this century a woman might have experienced about 36 menstrual cycles between menarche and first pregnancy, nowadays she is likely to have at least 150 menstrual cycles in the same time (that is assuming a menarche at 13 and first pregnancy at 25). Indeed, if a woman experienced her menarche at 13 and had her first pregnancy at, say, 35, she would have 264 menstrual cycles. There might well be a correlation between a high number of menstrual cycles and the migration of endometrial cells to other sites in the pelvis. There is also a theory that links the number of ovarian cycles with the development of ovarian cancer. According to this theory, the surface of the ovaries is damaged each time a woman ovulates and this damage may eventually lead to the development of ovarian cancer. There is, in fact, an inverse correlation between the number of ovulation cycles and the risk of ovarian cancer, i.e. women who have more pregnancies and fewer ovulation cycles have a lower risk of ovarian cancer. Another theory links the risk of ovarian cancer with the exposure to high levels of gonadotropins. Thus, in essence, anything that prevents ovulation, such as pregnancy, lowers the risk of ovarian cancer. It is for these reasons that the risk of ovarian cancer in women who took fertility drugs is three times that of women who did not.22 Case history A 45-year-old woman complained of aches in all joints and muscles. These were aggravated by exercise and improved by rest. She looked much older than 45 and she felt totally exhausted. Her tongue was very Pale and Swollen and her pulse was very Deep and Weak, especially so on both Kidney positions. I diagnosed a severe deficiency of Blood and of Kidney-Yang. Although aches such as these would be classified as Painful Obstruction Syndrome in Chinese medicine, I tend to consider this as ‘not real’ Painful Obstruction Syndrome: in other words, the aches are due more to deficient Blood not circulating properly and therefore not nourishing the sinews and channels than to invasion of Wind-Cold-Dampness. When I enquired about her
gynecological function, periods, pregnancy and childbirth, it transpired that she had had 10 children in about 15 years and her husband told me “She is not the same woman I married! ” I relate both an aggravation and an amelioration of symptoms with pregnancy to a Kidney deficiency: in the first case (aggravation) the Kidney deficiency gets worse with pregnancy and in the latter case (amelioration) the Kidney deficiency gets better with pregnancy.
Childbirth Childbirth is not necessarily a cause of disease in every case, but may become one in five circumstances: 1. When the mother does not have enough rest after labour, this induces a weakness of the space between skin and muscles which predisposes her to invasions of Wind. Besides this, lack of rest after labour causes Blood and Kidney deficiency. 2. If there is excessive loss of blood (over 200 ml) during labour, this obviously causes a sudden Blood depletion, which is often the cause of postnatal depression. 3. If a woman has a predisposition to mental–emotional problems and fails to bond with the baby, this may lead to psychosis. A predisposition to mental–emotional problems may manifest with a pulse that is Rapid and Overflowing in the Heart position, and a deep Heart crack on a tongue which is possibly also hammer shaped. A psychotic episode after childbirth may also be due to stasis of Blood developing after childbirth, affecting the Heart and causing the Mind to become obstructed. 4. If a woman has a pre-existing Blood and/or Kidney deficiency she may experience problems after childbirth even if she rests enough. This may include an exacerbation of previous problems such as backache, asthma, migraine, etc. 5. If a woman has too many children too close together without spacing out the pregnancies, this may cause problems (bearing in mind that abortions and miscarriages also count as ‘childbirth’). Wu Qian, author of the Golden Mirror of Medicine (1742), says that if the mother is strong and the fetus weak, there will be problems during the pregnancy, whereas if the mother is weak and the fetus strong, there will be
problems after childbirth.23 He also gives guidelines as to how the birth room should be prepared. He says that there should not be too many people in the room (no more than one or two) because this may frighten the mother and cause Heart-Qi deficiency; the room should not be too hot or too cold and it should be quiet.24 It should be noted that excessive childbirth includes miscarriage and abortion. There is, in fact, a saying in Chinese gynecology that “miscarriage is more serious than childbirth”. Summary Pregnancy and childbirth
Pregnancy
• Pregnancy may become a cause of disease under certain circumstances, but not always and not automatically • Under certain circumstances, pregnancy may even improve some gynecological conditions (and also some non-gynecological ones) • Pregnancy, or rather the lack of it, may even account for a weaker constitution of modern women compared with previous generations • In fact, although too many childbirths are weakening, so are menses occurring for several decades in a woman’s life • There is a correlation between breast cancer incidence and number of menstrual cycles • Increasing incidence of endometriosis may be correlated with the increased number of menstrual cycles between the time of menarche and that of the first pregnancy
• I relate both an aggravation and an amelioration of symptoms with pregnancy to a Kidney deficiency: in the first case (aggravation) the Kidney deficiency gets worse with pregnancy and in the latter case (amelioration) the Kidney deficiency gets better with pregnancy
Childbirth Childbirth may become a cause of disease when: 1. The mother does not have enough rest after labour 2. There is excessive loss of blood (over 200 ml) during labour 3. A woman has a predisposition to mental–emotional problems and fails to bond with the baby 4. A woman has a pre-existing Blood and/or Kidney deficiency 5. A woman has too many children too close together
Excessive/insufficient sexual activity Excessive sexual activity depletes the Kidneys and can therefore be the cause of gynecological problems such as amenorrhoea, scanty periods or a delayed cycle. Chinese medicine has traditionally always placed great emphasis on excessive sexual activity as a cause of disease because this may exhaust the Minister Fire by depleting the Essence: the former is the PreNatal and Yang aspect of the Pre-Natal Essence, and the latter is the PostNatal and Yin aspect of the Pre-Natal Essence. This is illustrated in Figure 4.3.
Figure 4.3 Minister Fire and Essence. Since depletion of the Essence through excessive sexual activity can exhaust the Pre-Natal Minister Fire, this cause of disease is considered particularly detrimental because it consumes both Fire and Water, i.e. the Minister Fire and the Essence. Thus sexual moderation preserves the Yin aspect of the Essence, while a tranquil mind preserves the Yang aspect of the Essence, i.e. the Minister Fire. However, excessive sexual activity does not affect women as much as men for various reasons. In men, ejaculation is a direct (albeit temporary) loss of Essence as sperm is derived directly from
the Essence. As there is no comparable loss in women, there is no equivalent depletion after sex. Quite simply, the Kidney-Essence is the origin of sperm in men and of menstrual blood and ova in women: while men lose sperm during sex, women do not lose menstrual blood or ova. Although some practitioners consider the lubricating fluids secreted by the Bartholin’s glands during sexual arousal in a woman to be also a manifestation of Essence comparable to sperm, I tend to disagree because such fluids are secreted by glands in the vagina and not by sex glands (such as the ovaries in women or testicles in men): I would therefore consider these fluids precisely as a form of Body Fluids (jin ye) rather than a direct manifestation of Essence. In fact, the Bartholin’s glands in the vagina are homologous to the Cowper’s glands in men and their function is purely lubricative. In other words, sperm is a direct manifestation of the Essence, the equivalent of which would be the ova and menstrual blood in women: the former is lost in men’s orgasm, the latter are not lost in women’s orgasm (Fig. 4.4).
Figure 4.4 Sexual differences between men and women. Furthermore, the Lower Field of Elixir (Dan Tian) in men contains the Room of Sperm which is directly related to the Essence, while in women it contains the Uterus which is related to Blood. The Room of Sperm is related to the Kidneys while the Uterus is related also to the Liver and Blood: hence sexual activity will weaken the Kidneys and the Essence in men but not in women. Because the Lower Field of Elixir in women contains the Uterus
rather than the Room of Sperm, in women excessive loss of blood after childbirth (or from chronic menorrhagia) would be equivalent to excessive sex for men. In men, the lower abdomen is occupied by the Room of Sperm and it is therefore ‘Empty’, also because sperm is easily discharged while Blood is not (see Fig. 2.1 in Ch. 2). The book Elementary Medicine (1575) says: The Room of Sperm in men suffers no accumulation or fullness, while the Blood Chamber in women suffers from accumulation and it overflows downwards in the period … [The Lower Dan Tian] in men stores Essence [=sperm] while in women it stores the Uterus and fetus. Men pertain to Qi and when it mixes with the Abysmal [the trigram corresponding to Water], Qi makes Water steam and produces sperm which is white … Women pertain to Blood, when this mixes with the Clinging [the trigram corresponding to Fire], Blood is transformed into the period which is red.25 In a nutshell, both men and women obviously have Essence, but in women this is not lost through the sexual act. Hence, compared to men’s, women’s sexual physiology is more complex. In men, sperm is a direct manifestation of Essence, it is responsible for fertility, it is ejaculated during orgasm and it may lead to conception. In women, the ova are a direct manifestation of Essence, they are responsible for fertility and the orgasm has no relation with them. Moreover, menstrual blood is also partly responsible for fertility and is an indirect manifestation of Essence (Tian Gui). Thus in men, Essence, sperm, orgasm and conception all occur in a single act along the same axis, while in women, fertility, conception and orgasm occur along three separate axes as follows: • Men: • Essence = sperm = fertility = orgasm = conception. • Women: • Blood = menses = fertility
• Essence = ova = fertility = conception • Orgasm. However, excessive sexual activity does affect women too, albeit to a much lesser degree than men. One particular case of excessive sexual activity in women is that occurring at a very early age around puberty. Excessive sexual activity (or indeed, any sexual activity) at an early age seriously weakens the Kidneys and injures the Directing and Penetrating Vessels from the point of view of Chinese medicine. When excessive and/or early sexual activity affects women, it has serious consequences because they lose blood monthly. The Secret Records of Master Feng’s Brocade Bag says: Excessive sexual activity greatly damages the Essence of both men and women. Diseases deriving from excessive sexual activity have more serious consequences in women as they are also subject to leucorrhoea and labour which damage Qi and Blood. Thus it is even more important for a woman to have a calm mind and restrain sexual activity.26 Interestingly, this coincides with the Western medical view according to which excessive sexual activity at an early age predisposes girls to cervical cancer. In fact, during the teenage years, with the onset of ovulation and the change in vaginal pH, active squamous metaplasia is taking place in the cervix; during this time of cellular immaturity and vulnerability, a carcinogen is most likely to have an influence on the squamous epithelium and this predisposes the girl to cervical cancer later in life.27 This is in perfect agreement with the Chinese view of puberty as a very vulnerable and delicate stage in a woman’s life. Another example of sexual activity as a cause of disease in women is when a woman has sex during her period. During menstruation there is a downward movement of Blood whereas during sexual intercourse there is an upward flow of Qi along the vagina towards the uterus, and, after ejaculation, a migration of sperm upwards along the vagina and tubes. The clash of these two forces gives rise to stagnation and, if this practice occurs regularly, it may cause dysmenorrhoea. Having sexual intercourse soon after the end of the
period (within 1 or 2 days) may cause irregular menstrual bleeding because sexual arousal causes the cervix to open and therefore may induce bleeding to start again. Fu Qing Zhu often mentions sexual intercourse during or soon after the end of the period as a cause of heavy menstrual bleeding. He says: Some women engage in sexual intercourse that leads to unstoppable bleeding … If a woman has sexual intercourse during the period, sperm travels upwards along the [woman’s] blood vessels … One should know that the blood vessels are tender and should be protected from injury by sperm … If sperm is ejaculated into the uterus when the menstrual flow is surging and gushing out, the blood will retreat and contract … and the sperm will gather and transform Blood.28 This passage clearly implies that sexual intercourse during the period causes stasis of Blood in the woman. In another chapter, commenting on the fact that some women develop profuse menstrual bleeding after the period, Fu Qing Zhu says: When a woman is aroused the uterus is wide open and the Imperial and Minister Fire are stirred … the Essence chamber is agitated and the Sea of Blood overflows and cannot be contained. The Liver, which likes storage, cannot store Blood; the Spleen, which likes containment, cannot contain Blood. Thus, menstrual flow follows sexual intercourse like an echo follows a sound.29 Chinese medicine texts also advise women against having sex in the first 3 and last 3 months of pregnancy, i.e. sexual activity is not detrimental in the fourth, fifth and sixth months of pregnancy. However, not all doctors agree with this. For example, Fu Qing Zhu advises against having sexual intercourse during pregnancy and says: Women should refrain from sexual intercourse during pregnancy; if one does not abstain, a miscarriage might occur. If a miscarriage
does not occur, the child might be difficult to rear. Take care! Guard against it!30 Chinese medicine has always stressed the importance of excessive sexual activity as a cause of disease but not insufficient sexual activity. Especially in Western women, this is often a cause of disease somewhat akin to emotional stress. Sexual desire depends on the Minister Fire and a healthy sexual appetite indicates that this Fire is abundant. When sexual desire builds up, the Minister Fire blazes up and Yang increases: the orgasm is a release of such accumulated Yang energy and, under normal circumstances, it is a beneficial discharge of Yang-Qi and it promotes the free flow of Qi. When sexual desire builds up, the Minister Fire is stirred: this affects the Mind and, in terms of organs, specifically the Heart and Pericardium. The Heart is connected to the Uterus via the Uterus Vessel and the orgasmic contractions of the uterus discharge the accumulated Yang energy of the Minister Fire. When sexual desire is present but does not have an outlet in sexual activity and orgasm, the Minister Fire can accumulate and give rise both to Blood-Heat and to stagnation of Qi in the Lower Burner. This accumulated Heat will stir the Minister Fire further and harass the Mind, while the stagnation of Qi in the Lower Burner can give rise to gynecological problems such as dysmenorrhoea. Of course, if sexual desire is absent, then lack of sexual activity will not be a cause of disease. Conversely, if one abstains from sexual activity but the sexual desire is strong, this will also stir up the Minister Fire. Thus, the crucial factor is the mental attitude. With regard to sexual frustration, Qing dynasty’s Chen Jia Yuan wrote very perceptively about some women’s emotional longing and loneliness. Among the emotional causes of disease, he distinguishes ‘worry and pensiveness’ from ‘depression’. He basically considers depression, with its ensuing stagnation, due to emotional and sexual frustration and loneliness. He says: In women … such as widows, Buddhist nuns, servant girls and concubines, sexual desire agitates [the Mind] inside but cannot
satisfy the Heart. The body is restricted on the outside and cannot expand with the mind [i.e. the mind longs for sexual satisfaction but the body is denied it]. This causes stagnation of Qi in the Triple Burner and the chest; after a long time there are strange symptoms such as a feeling of heat and cold as if it were malaria but it is not. This is depression.31 Although the above thoughts derive from Dr Chen’s clinical experience with servant girls, Buddhist nuns and concubines and should therefore be seen in the social context of the Qing dynasty, they also have relevance to our times as he is essentially talking about sexual frustration and loneliness and his reference to widows confirms this (in old China, widows were shunned and seldom remarried). He perceptively refers to sexual craving agitating the body but not finding a satisfaction in the Heart and Mind: besides sexual frustration, he is also referring to emotional frustration and craving for love. As sexual frustration in women is fairly common in our society (often deriving from men’s sexual inadequacy or inexperience), Dr Chen’s observations on the influence of sexual frustration on stagnation of Qi and depression acquire particular relevance. Finally, although Chinese medicine traditionally stresses the importance of excessive sexual activity as a cause of disease, the broader Daoist tradition also considers the beneficial effects of sexual activity. Briefly, these emanate from the meeting of Water (women) and Fire (men), i.e. the quintessential Yin and Yang. Water and Fire are opposites but complementary and the exchange of energy occurring during the sexual act can be such that women absorb Yang energy and men Yin energy. Specifically, through kissing and genital contact during sex, there is a beneficial exchange of energy and fluids between the Governing and Directing Vessels of the two partners. This also leads to the spanning of the ‘bridge’ in the Governing–Directing Vessel circuit in the mouth of both partners with a beneficial mobilization of energy in these two vessels (Fig. 4.5).
Figure 4.5 Intersection of Governing and Directing Vessels during sexual intercourse.
Summary
Excessive/insufficient sexual activity
• Excessive sexual activity depletes the Kidneys and can therefore be the cause of gynecological problems such as amenorrhoea, scanty periods or a delayed cycle • Sexual activity may exhaust the Minister Fire by depleting the Essence • Excessive sexual activity does not affect women as much as men • In men, ejaculation is a direct (albeit temporary) loss of Essence as sperm is derived directly from the Essence. As there is no comparable loss in women, there is no equivalent depletion after sex • In a nutshell, both men and women obviously have Essence, but in women this is not lost through the sexual act • Sexual activity at an early age (around puberty) seriously weakens the Kidneys and injures the Directing and Penetrating vessels • Having sex during the period may cause stagnation and dysmenorrhoea • Having sexual intercourse soon after the end of the period (within 1 or 2 days) may cause irregular menstrual bleeding because sexual arousal causes the cervix to open and therefore may induce bleeding to start again • Chinese medicine texts advise women against having sex in the first 3 and last 3 months of pregnancy, i.e. sexual activity is not detrimental in the fourth, fifth and sixth months of pregnancy • Insufficient sexual activity may also become a cause of disease • In women, this is often a cause of disease somewhat akin to emotional stress • Sexual desire depends on the Minister Fire and a healthy sexual appetite indicates that this Fire is abundant • When sexual desire is present but does not have an outlet in sexual activity and orgasm, the Minister Fire can accumulate and give rise both to Blood-Heat
and to stagnation of Qi in the Lower Burner. This accumulated Heat will stir the Minister Fire further and harass the Mind, while the stagnation of Qi in the Lower Burner can give rise to gynecological problems such as dysmenorrhoea • The Daoist tradition considers the beneficial effects of sexual activity • These emanate from the meeting of Water (women) and Fire (men), i.e. the quintessential Yin and Yang
Surgery and hysterectomy Abdominal surgery such as that following operations for the removal of ovarian cysts, hysterectomy or endometriosis, often leads to the formation of adhesions. From a Chinese medical perspective, women are particularly prone to stagnation of Qi and/or Blood after abdominal surgery. The reasons for this are two-fold: first, women are more prone to Blood disharmonies, and second, the Lower Field of Elixir (Dan Tian) in women contains the Uterus which stores Blood, while in men it is Empty. Thus stasis of Blood in the lower abdomen is much more common in women and it often occurs after abdominal surgery. As for hysterectomy, in addition to the possibility of adhesions discussed above, this surgical procedure has specific effects on women’s physiology. First of all, as the Uterus stores Blood, its removal induces a certain Blood deficiency. As the Uterus is related to the Kidneys in several ways (through the Kidney channel, through the Extraordinary Vessels and through the relationship between Essence and Blood), a hysterectomy also induces a Kidney deficiency: for this reason, the Kidney pulse becomes Weak and Deep after this surgical operation. Because a hysterectomy weakens Blood and the Kidneys, the woman may feel very tired for several months after it. However, if the cause of the hysterectomy was the presence of a large myoma (‘fibroid’) obstructing the proper movement of Blood in the Lower Burner, a woman often feels noticeably better after such an operation. If there was stagnation of Qi in the Uterus before the hysterectomy, with the removal of the uterus the Qi stagnation is simply ‘transferred’ to the nearest organ, i.e. the urinary bladder. It should be remembered that the uterus and bladder are anatomically contiguous and that for this reason the pathology of one organ is easily transferred to the other (Fig. 4.6). Also, the ureter passes under the uterine artery on its way to the bladder and is very close to the cervix (Fig. 4.7). From a Chinese point of view, the uterus and bladder are closely related, so much so that the word bao was used in the classics to mean both ‘uterus’ and ‘bladder’.
Figure 4.6 Anatomy of uterus and bladder.
Figure 4.7 Anatomy of ureter and uterine artery. It is for this reason that when there is stagnation of Qi in the Uterus, this stagnation is transferred to the Bladder after a hysterectomy and many women start experiencing urinary problems such as slight retention of urine, discomfort, frequency, slight incontinence, etc. Of course, such problems may also be due to a purely mechanical cause such as bladder nerve damage during the hysterectomy. These symptoms are usually wrongly diagnosed as ‘cystitis’ and the connection with the hysterectomy is invariably denied by the medical profession: antibiotics are prescribed unnecessarily, the problem usually persists and, in addition, the woman may develop candidiasis from the use of antibiotics. Seen from a Chinese medical perspective, such urinary problems would fall under the category of Qi-Painful Urinary Syndrome (Qi Lin) specifically from Qi stagnation. The third effect of hysterectomy is very often the development of occipital headaches. Although the pathology of this phenomenon is more difficult to explain, I have encountered it in practice very many times. It is probably due to the severing of the Kidney Channel following a hysterectomy so that the Kidney channel fails to nourish the Bladder channel causing dull headaches and stiffness along the course of this channel in the neck. Summary
Surgery and hysterectomy
• Women are particularly prone to stagnation of Qi and/or Blood after abdominal surgery • Hysterectomy induces a certain Blood deficiency and a Kidney deficiency • If there was stagnation of Qi in the Uterus before the hysterectomy, with the removal of the uterus the Qi stagnation is simply ‘transferred’ to the nearest organ, i.e. the urinary bladder, causing urinary problems such as slight retention of urine, discomfort, frequency, slight incontinence • The third effect of hysterectomy is very often the development of occipital headaches due to the severing of the Kidney Channel following a hysterectomy so that the Kidney channel fails to nourish the Bladder channel causing dull headaches and stiffness along the course of this channel in the neck
Contraceptive pill As one author puts it, the literature on the contraceptive pill is “copious, complex, confusing and contradictory”,32 and analysis of it is well beyond the scope of this book. Contraceptive pill use has been linked with an increased risk of breast cancer (although many studies do not show this), cervical cancer and cardiovascular disease, and a decreased risk of ovarian and endometrial cancer. Absolute contraindications to the use of the contraceptive pill are considered to be: • past or present circulatory disease • liver disease • undiagnosed genital tract bleeding • oestrogen-dependent neoplasms. From a Chinese perspective, long-term use of the contraceptive pill seems to induce a state of either Blood deficiency (more commonly) or Blood stasis. Women who stop using the contraceptive pill after some years of use very often develop amenorrhoea or a very irregular, late cycle. Although this is sometimes due to Blood stasis, in my experience it is more often due to Blood deficiency with women manifesting all the symptoms and signs of this condition: a Pale tongue, tiredness, blurred vision and a Choppy pulse. In such cases, it often takes a long time (several months) to restore the menstrual cycle to normality.
Prevention and hygiene Following on from everything that was said about the aetiology of gynecological problems, we can formulate certain hygiene rules for women aimed at preventing such problems. An important principle underlying many of these rules is the idea that the Uterus is in a vulnerable state during each menstrual period, during pregnancy and after childbirth. Every precaution that applies to the time of the period applies all the more so to the time after childbirth. • A woman should not have sex during the menstrual period as this practice can cause stagnation of Qi and Blood in the Uterus and heavy periods. • Exposure to cold and dampness during the menstrual period may cause Cold in the Uterus. • A woman should take care not to be exposed to cold after sex as this may also cause Cold to invade the Uterus. • A woman should not retain her urine and engage in sexual intercourse with a very full bladder as this may lead to stagnation in both the Uterus and the Bladder. • Lifting during or immediately after the end of the period may lead to sinking of Qi. • A pregnant woman should abstain from sex in the first 3 and last 3 months of pregnancy. • It is important that a woman has adequate rest after childbirth as resuming a normal routine of work too soon is very depleting to Qi and Blood and the Kidneys and Liver. However, too much rest and lying down
may also be harmful (leading to stagnation) and moderate exercise is beneficial. • A pregnant woman should avoid emotional stress, drugs and traumas during pregnancy. • It is important for a woman not to be exposed to Cold after childbirth as this may cause Cold to invade the Uterus leading to abdominal pain, or also the Blood-Connecting channels leading to body aches. • A woman should take care not to work too much or for too long hours during the period and after childbirth. Overwork at these times leads to deficiency and sinking of Kidney-Qi: this can cause either a prolapse or a slight incontinence of urine. • A woman should avoid the excessive consumption of cold liquids and foods during the periods as these may cause painful period or Painful Obstruction Syndrome. • A woman should not drink alcohol during the periods as these may cause reckless blood in the limbs (i.e. circulatory troubles in the limbs). • A woman should not get angry during the periods as this may cause the period to stop. • Women should consume Blood-nourishing foods during the periods, such as egg yolk, liver, beef, chicken, carrots, spinach, wood-ear mushrooms, peanuts and Chinese red dates. • Women should avoid eating sour foods during the periods as these, being astringent, may stop the period short. Examples of sour foods are yoghurt, vinegar, pickles, oranges and orange juice, grapefruit and their juice, gooseberries, blackcurrants and redcurrants. • Recommended foods during the menopause years are Shan Zha Fructus
Crataegi, Suan Zao Ren Semen Ziziphi spinosae, celery, Bai He Bulbus Lilii, chicken, eggs, fish, milk, soya beans and their products and lean meats. End notes 1. Xu Shi Hong 1750 Most Valuable Treasure of Women and Babies (Fu Ying Zhi Bao) cited in Zhang Qi Wen 1995 Menstrual Diseases (Yue Jing Bing Zheng
), People’s Hygiene Publishing House, Beijing, pp 29–30..
2. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian
), People’s Health Publishing House, Beijing, p. 9. First published in 1742..
3. Shen Yao Feng 1850 Summary of Gynaecology (Nu Ke Ji Yao
), 1988 reprint, People’s Health Publishing House, Beijing, p. 15..
4. Golden Mirror of Medicine, p. 9..
5. 1979 The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen
), People’s Health Publishing House, Beijing, p. 197. First published c. 100 BC..
6. Golden Mirror of Medicine, p. 9..
7. 1981 Spiritual Axis (Ling Shu Jing
), People’s Health Publishing House, Beijing, p. 24. First published c. 100 BC..
8. Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong
). Ancient Chinese Medical Books Publishing House, Beijing, p. 152. Chen’s book, written during the Qing dynasty (1644–1911) was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang
), and published in 1729..
9. Zhang Jing Yue 1982 Classic of Categories (Lei Jing
), People’s Health Publishing Company, Beijing, Chapter 216, p. 561. The Classic of Categories was first published in 1624..
10. Chen Zi Ming 1237 Great Treatise of Beneficial Formulae for Women (Fu Ren Liang Fang Da Quan) cited in Menstrual Diseases, pp 9–10..
11. Great Treatise of Beneficial Formulae for Women cited in Menstrual Diseases, p. 9..
12. Golden Mirror of Medicine, p. 9..
13. Eight Secret Books on Gynaecology, p. 152..
14. Obviously, in countries where bovine spongiform encephalopathy (BSE) is prevalent, marrow and brain of beef should not be eaten..
15. Simple Questions, p. 154..
16. Eight Secret Books on Gynaecology, p. 152..
17. Simple Questions, p. 154..
18. Ye Tian Shi 1817 Secret Prescriptions for Gynaecological Patterns and Treatment by Ye Tian Shi (Ye Tian Shi Nu Ke Zheng Zhi Mi Fang), cited in Luo Yuan Kai 1986 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Shanghai Science and Technology Press, Shanghai, p. 48..
19. E M Symonds 1994 Essential Obstetrics and Gynaecology, Churchill Livingstone, Edinburgh, p. 112..
20. McPherson A 1993 Women’s Problems in General Practice, Oxford University Press, Oxford, p. 18..
21. Baum M, Saunders C, Meredith S 1994 Breast Cancer, Oxford University Press, Oxford, p. 136..
22. Harris R, Whittemore A S, Itnyre J 1992 Characteristics Relating to Ovarian Cancer Risk: Collaborative Analysis of 12 US Case-Control Studies, American Journal of Epidemiology 136: 1184–1203..
23. Golden Mirror of Medicine, Vol. 3, p. 64..
24. Ibid., p. 72..
25. 1575 Elementary Medicine (Yi Xue Ru Men) cited in Menstrual Diseases, p. 10..
26. Feng Tao Zhang 1702 Secret Records of Master Feng’s Brocade Bag (Feng Shi Jin Nang Mi Lü) cited in Menstrual Diseases, p. 14..
27. Clarke-Pearson D L, Yusoff Dawood M 1977 Green’s Gynaecology: Essentials of Clinical Practice, Fourth Edition, Little, Brown and Co., Boston, p. 509..
28.
Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p. 10. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
29. Ibid., p. 13..
30. Ibid., p. 10..
31. Eight Secret Books on Gynaecology, p. 152..
32. Women’s Problems in General Practice, p. 59..
CHAPTER 5 Diagnosis
INTERROGATION 98 Menstruation 98 Pain 102 Vaginal discharge 103 Fertility and pregnancy 103 Childbirth 103 Miscarriage and abortion 103 PALPATION 104 Pulse 104 Skin 108 Abdomen 108 OBSERVATION 109 Complexion 109 Lips 111 Tongue 111 AUSCULTATION 117 Hearing 117 Smelling 117 Diagnosis in gynecology naturally follows the same basic principles as in other diseases and is articulated in the four methods of interrogation (‘asking’), palpation (‘touching’), observation (‘looking’) and auscultation
(‘hearing and smelling’). These diagnostic methods are aimed at identifying both the Chinese disease-symptom (bian bing) and the pattern (bian zheng). Chinese disease-symptoms of course differ from the Western concept of ‘disease’ and there is no direct correspondence between the two. In a Western sense, Chinese disease-symptoms are obviously not ‘diseases’. For example, ‘Painful Periods’ (Tong Jing) is a ‘disease’ category in Chinese gynecology but in Western medicine is a symptom, not a disease. The Western diseases which might cause this symptom are, for example, endometriosis, pelvic inflammatory disease or myoma. However, to diagnose a condition correctly and to find the appropriate strategy and method of treatment, it is essential to identify the Chinese disease-symptom first: this procedure is called bian bing, which literally means ‘differentiating the disease’. This should be done before identifying the pattern (bian zheng) because, even if this is diagnosed correctly, the treatment will not be focused if the disease is not identified too. For example, a case of abnormal uterine bleeding could fall into any of the following categories of Chinese disease-symptoms: ‘Early Periods’ (Yue Jing Xian Qi), ‘Late Periods’ (Yue Jing Hou Qi), ‘Irregular Periods’ (Yue Jing Xian Hou Wu Ding Qi), ‘Heavy Periods’ (Yue Jing Guo Duo), ‘Scanty Periods’ (Yue Jing Guo Shao), ‘Prolonged Periods’ (Jing Qi Yan Chang), ‘Bleeding between Periods’ (Jing Jian Qi Chu Xue), or ‘Menorrhagia/Metrorrhagia’ (Beng Lou). Each of these Chinese disease categories has its own peculiar aetiology, pathogenesis and therefore treatment method, and simply to identify the pattern in order to treat them would not suffice. For example, Blood-Heat is a pattern that might cause ‘Early Periods’, ‘Heavy Periods’, ‘Prolonged Periods’, ‘Bleeding between Periods’ or ‘Menorrhagia’, but the formula used to treat Blood-Heat would be different in each disease category. Thus, if one were to ask how to treat ‘endometriosis’, the answer would be that by identifying the Chinese ‘disease’ accurately (bian bing) and diagnosing the pattern correctly (bian zheng), one arrives at the appropriate treatment method.
Thus, for each Chinese ‘disease’ there are several patterns. For example, the disease of ‘Painful Periods’ may manifest with several patterns such as Liver-Qi stagnation, Liver-Blood stasis, Cold in the Uterus, DampHeat in the Uterus (Fig. 5.1). On the other hand, each pattern may be found in many different diseases and the important point is that, although the pattern is the same, its treatment will differ somewhat according to the disease with which it is manifesting. For example, the pattern of Liver-Blood stasis may be found in many different gynecological diseases such as ‘Heavy Periods’, ‘Flooding and Trickling’, ‘Painful Periods’, ‘Bleeding between Periods’, ‘Abdominal Masses’, etc. and its treatment will differ in each case (Fig. 5.2).
Figure 5.1 Identification of disease and identification of pattern: one disease, many patterns.
Figure 5.2 Identification of disease and identification of pattern: one pattern, many diseases.
However, there is a very important caveat here. Although I have just said that identification of the (Chinese) disease and pattern is sufficient to treat any gynecological condition, this does not mean that we can ignore the Western diagnosis. This is extremely important for prognosis. For example, dysmenorrhoea due to endometriosis is definitely more difficult to treat than purely functional dysmenorrhoea. Another obvious example would be that of uterine bleeding after the menopause: since this may be a sign of cervical cancer it would be totally wrong simply to treat it as menorrhagia without recourse to a proper Western diagnosis. Yet another example is that of a breast lump: we would definitely need to know whether it is benign or malignant. A Western diagnosis is also extremely important to identify cases which Chinese medicine cannot cure. For example, if heavy menstrual bleeding is due to a large myoma, it is unlikely that Chinese medicine can provide a lasting cure for this condition (even though it might help to a certain extent). The discussion of diagnosis in gynecology will be carried out according to the following topics: • Interrogation. • Palpation.
• Observation. • Auscultation.
Interrogation The main areas of questioning are: • menstruation • pain • vaginal discharge • fertility, pregnancy and childbirth • miscarriage, abortion.
Menstruation Asking about menstruation is of course an absolutely essential part of diagnosis. One should ask a female patient about the menarche, cycle, amount, colour, consistency, pain, pre-menstrual symptoms, and other symptoms occurring at period time. When describing the areas of questioning with regard to menstruation, I am assuming the woman is not on the contraceptive pill or other forms of hormones and has not been fitted with an intra-uterine device (IUD). Obviously, the answers to questions are unreliable if the woman is on the contraceptive pill or has an IUD. The contraceptive pill changes the cycle, amount, colour, consistency and pain of the period: it usually makes the cycle regular, the period scanty, the colour lighter, the consistency usually without clots and the period painless. The IUD makes the periods heavier and more painful. In such cases, it is important to ask the patient what her menstrual cycle was like before she began using the contraceptive pill or IUD. Menarche The age of menarche ranges between 10 and 16 with a mean at 12.8. Menarche tends to occur at a younger age in industrialized countries compared with developing, agricultural societies. Early menarche (i.e. before about 13) may indicate Blood-Heat while late menarche (after about 16) may indicate Blood and/or Kidney deficiency. Why do we need to ask about the menarche and how the periods were then? It might be argued that it does not matter how the periods were then because we must always treat a woman for the condition as it is at the time of treatment, not years earlier. However, it is important to ask about the menarche and how the periods were then. First of all, when forming an opinion about the menstrual history at the time of menarche, we should always ask how the periods were about 2 years after menarche. This is because it takes about that time for the periods to settle down into some kind
of regular cycle (if there is one). The reason it is important to ask about the menstrual history around the time of menarche is to form an idea about the menstrual constitution of a woman. This is also important when there are deviations from this constitution. For example, if a woman’s periods always lasted 5 days, then that means that 5 days is her menstrual constitution which has not changed over the years. But say we see a 40-year-old woman coming to us for infertility and she tells us that her periods now last 5 days. Five days is not abnormal and indeed it suggests normality. However, if her periods lasted 7 days when she was young about 2 years after the menarche and continued to last 7 days until she was about 32, this suggests that her menstrual constitution is 7 days and she is now deviating from this constitution. This indicates that she suffers from a slight Blood deficiency (because the periods have gone from lasting 7 days to lasting 5 days). By contrast, if a woman’s periods had always lasted 5 days, then we could not diagnose that she suffers from Blood deficiency. Summary Menarche
• The age of menarche ranges between 10 and 16 with a mean at 12.8 • Early menarche (i.e. before about 13) may indicate Blood-Heat while late menarche (after about 16) may indicate Blood and/or Kidney deficiency • We should always ask how the periods were about 2 years after menarche • It is important to ask about the menstrual history around the time of menarche to form an idea about the menstrual constitution of a woman • This is important when there are deviations from this constitution
Cycle
The length of the cycle is ideally 28 days but it may vary from this norm but this should not be interpreted too rigidly. The regularity of the cycle is somewhat more important than its absolute value; thus, if the cycle is consistently of 32 days, this can be deemed normal and would not be considered as ‘late periods’. Moreover, an occasional deviation from a regular cycle should not be considered abnormal as the menstrual cycle is influenced by many factors such as travelling, emotional stress, etc. The following are the main areas of questioning with regard to the cycle: • Always early (i.e. more than 5 days early): either Qi deficiency or BloodHeat. • Always late (i.e. more than 5 days late): Blood deficiency, stasis of Blood or stasis of Cold. • Irregular (sometimes late, sometimes early): stagnation of Liver-Qi, stasis of Liver-Blood, Spleen deficiency or Kidney deficiency. It should be borne in mind that for approximately the first 2 years from menarche, the menstrual cycle may be somewhat irregular: this is quite normal. To have an idea as to how the periods were in the beginning, I therefore always ask how they were about 2 years after menarche. The Golden Mirror of Medicine says: “When periods come early, it is due to Heat, when late, it is due to Blood stasis.”1 Summary Cycle
• Always early (i.e. more than 5 days early): either Qi deficiency or Blood-Heat • Always late (i.e. more than 5 days late) : Blood deficiency, stasis of Blood or stasis of Cold
• Irregular (sometimes late, sometimes early): stagnation of Liver-Qi, stasis of Liver-Blood, Spleen deficiency or Kidney deficiency
Amount The loss of blood during menstruation can vary between 30 and 80 ml. A period is defined as ‘heavy’ if the loss of blood is either profuse or prolonged or both. A heavy loss of blood is due to either Qi deficiency or Blood-Heat (depending on colour; see below). If the period is scanty, it denotes either Blood deficiency, stasis of Blood or Cold in the Uterus. Summary Amount
• The loss of blood during menstruation can vary between 30 and 80 ml • A heavy loss of blood is due to either Qi deficiency or Blood-Heat • If the period is scanty, it denotes either Blood deficiency, stasis of Blood or Cold in the Uterus
Colour The colour of the menstrual blood varies slightly during the period. In general, it is usually dark-red, being lighter at the beginning, deep-red in the middle, and pinkish at the end of the period. The following are the main areas of questioning with regard to colour: • Dark-red or bright-red: Blood-Heat.
• Pale: Blood deficiency. • Blackish, very dark: stasis of Blood. • Purplish: Full-Cold. • Brownish like soya bean sauce and dilute: Empty-Cold. • Scarlet-red: Empty-Heat in Blood. The Golden Mirror of Medicine says: When the colour [of menstrual blood] is pale and amount scanty, it is due to Deficiency, the period is not usually painful; if the colour is dark and the amount heavy and there is pain, it is due to Fullness.2 Summary Colour
• The colour of the menstrual blood is usually dark-red, being lighter at the beginning, deep-red in the middle, and pinkish at the end of the period • Dark-red or bright-red: Blood-Heat • Pale: Blood deficiency • Blackish, very dark: stasis of Blood • Purplish: Full-Cold • Brownish like soya bean sauce and dilute: Empty-Cold • Scarlet-red: Empty-Heat in Blood
Consistency The normal flow does not coagulate and there are no clots; the blood is neither dilute nor thick. The following are the main areas of questioning with regard to the consistency of menstrual blood: • Clotted, with dark, dull clots: stasis of Blood/Cold. • Clotted, with dark but fresh-looking clots: Heat. • Large clots: stasis of Blood. • Small dark clots, but blood not dark: stasis of Cold. • Watery: Blood or Yin deficiency. Summary Consistency
• Clotted, with dark, dull clots: stasis of Blood/Cold • Clotted, with dark but fresh-looking clots: Heat • Large clots: stasis of Blood • Small dark clots, but blood not dark: stasis of Cold • Watery: Blood or Yin deficiency
Pain
Apart from a slight discomfort, normally the period should be almost painless. The main areas of questioning with regard to menstrual pain are as follows: • Pain before the period: stagnation of Qi or stasis of Blood (the latter is typically relieved by the onset of the period and especially by the passing of dark clots). • Pain during the period: Blood stasis or Blood-Heat. • Pain after the period: Blood deficiency. • Severe, stabbing pain: stasis of Blood. • Severe, cramping pain, eased by application of heat (such as a hot-water bottle): stasis of Cold. • Mild pain: either Blood-Heat or deficiency of Blood. • Dragging feeling in the lower abdomen with mild pain: sinking of Qi. • Feeling of heaviness in the lower abdomen with pain: Dampness. • Pain on ovulation: Dampness. Summary Pain
• Pain before the period: stagnation of Qi or stasis of Blood • Pain during the period: Blood stasis or Blood-Heat • Pain after the period: Blood deficiency
• Severe, stabbing pain: stasis of Blood • Severe, cramping pain, eased by application of heat (such as a hot-water bottle): stasis of Cold. • Mild pain: either Blood-Heat or deficiency of Blood • Dragging feeling in the lower abdomen with mild pain: sinking of Qi • Feeling of heaviness in the lower abdomen with pain: Dampness • Pain on ovulation: Dampness
Pre-menstrual symptoms Pre-menstrual tension with irritability, depression, tendency to crying, etc., indicates Liver-Qi stagnation, especially if accompanied by abdominal or breast distension. Nausea or vomiting before the period denotes stagnant Liver-Qi invading the Stomach, while pre-menstrual constipation indicates stagnant Liver-Qi invading the Intestines and Spleen. Headaches before the period indicate Liver-Qi stagnation or LiverYang rising. Distension of the breasts denotes Liver-Qi stagnation, but if the breasts become very swollen and painful, it may denote Phlegm (which, in pre-menstrual problems, usually combines with Qi stagnation). Retention of water with oedema before the period indicates SpleenYang and/or Kidney-Yang deficiency. Pre-menstrual irritability with insomnia and thirst may be due to LiverFire and/or Heart-Fire. ! Please note that not all pre-menstrual symptoms are due to Liver-Qi stagnation.
Summary Pre-menstrual symptoms
• Pre-menstrual tension with irritability, depression, tendency to crying, breast and/or abdominal distension: Liver-Qi stagnation • Nausea or vomiting before the period: stagnant Liver-Qi invading the Stomach • Pre-menstrual constipation: stagnant Liver-Qi invading the Intestines and Spleen • Headaches before the period: Liver-Qi stagnation or Liver-Yang rising • Distension of the breasts: Liver-Qi stagnation • Breast distension, swelling and pain: Qi stagnation with Phlegm • Retention of water with oedema before the period: Spleen-Yang and/or Kidney-Yang deficiency • Pre-menstrual irritability with insomnia and thirst: Liver-Fire and/or Heart-Fire
Other symptoms Headaches that occur during the period are usually due to Liver-Yang rising or Liver-Fire blazing, these occurring against a background of Blood-Heat. Headaches occurring after the period indicate Liver-Blood deficiency. Constipation before the period is due to Liver-Qi stagnation or Cold in the Uterus; during the period, it may be due to Liver-Fire; constipation after the period is due to Blood or Kidney deficiency. Insomnia during the period indicates Blood-Heat, often with Liver-Fire and/or Heart-Fire. Insomnia after the period denotes Blood deficiency. Diarrhoea after the period indicates Spleen-Yang and/or Kidney-Yang
deficiency. Summary Other symptoms
• Headaches during the period: Liver-Yang rising or Liver-Fire blazing • Headaches after the period: Liver-Blood deficiency • Constipation before the period: Liver-Qi stagnation or Cold in the Uterus • Constipation during the period: Liver-Fire • Constipation after the period: Blood or Kidney deficiency • Insomnia during the period: Blood-Heat, often with Liver-Fire and/or HeartFire • Insomnia after the period: Blood deficiency • Diarrhoea after the period: Spleen-Yang and/or Kidney-Yang deficiency
Pain Apart from the pain occurring during the period itself, many women suffer from lower abdominal pain in general. From a Western point of view, it is obviously all-important to distinguish whether the pain is of intestinal or gynecological origin. In Chinese medicine, this distinction is somewhat blurred and, strictly speaking, not that important from the point of view of treatment. What matters most is the correct diagnosis and identification of the pattern according to the basic principles of Heat, Cold, Full, Empty, Pathogenic Factors and internal organs. Thus, a woman who complains of painful periods may well suffer from abdominal pain at other times too, the two types of pain having a common root (e.g. Qi stagnation, Blood stasis, Dampness, etc.). As for the significance of the area of pain, the central area of the lower abdomen below the umbilicus is called xiao fu, i.e. ‘small abdomen’, whereas the lateral sides of the abdomen are called shao fu, i.e. ‘lesser abdomen’ (Fig. 5.3). Pain in the central area of the lower abdomen (the ‘small abdomen’) is usually related to the Kidneys and the Directing Vessel. Pain in the lateral sides of the abdomen (the ‘lesser abdomen’) is usually related to the Liver channel and the Penetrating Vessel.
Figure 5.3 ‘Small abdomen’ and ‘lesser abdomen’. The following are therefore the main areas of interrogation with regard to abdominal pain: • Dull ache: deficiency-type pain. • Severe pain: excess-type pain. • Pain that is relieved by the application of heat: Cold.
• Pain that is relieved by pressure or massage: deficiency-type pain. • Pain that is aggravated by pressure or massage: excess-type pain. • Stabbing pain: stasis of Blood. • Cramping, spastic pain: Cold. • Pain with feeling of heaviness: Dampness. • Ache with a dragging-down feeling: sinking of Qi (of Spleen and/or Kidneys). • Abdominal pain extending to the back: Kidney deficiency. • Lower backache extending to the front: Girdle Vessel pathology (usually deficiency). • Lower abdominal pain radiating to the back: Girdle Vessel pathology (usually excess in the form of Dampness). • Umbilical pain along a line with backache radiating to thighs: Girdle Vessel pathology. • Unilateral abdominal pain with distension and feeling of masses: Yin Stepping Vessel (Yin Qiao Mai) pathology, usually stagnation of Qi and/or Blood; although this type of pain is also related to the Liver channel, it will respond well to treatment of the Yin Stepping Vessel. • Lower abdominal pain with a sense of energy rising towards the chest and a feeling of tightness there: Penetrating Vessel (Chong Mai) pathology (rebellious Qi). Summary
Pain
• Dull ache: deficiency-type pain • Severe pain: excess-type pain • Pain that is relieved by the application of heat: Cold • Pain that is relieved by pressure or massage: deficiency-type pain • Pain that is aggravated by pressure or massage: excess-type pain • Stabbing pain: stasis of Blood • Cramping, spastic pain: Cold • Pain with feeling of heaviness: Dampness • Ache with a dragging-down feeling: sinking of Qi (of Spleen and/or Kidneys) • Abdominal pain extending to the back: Kidney deficiency • Lower backache extending to the front: Girdle Vessel pathology (usually deficiency) • Lower abdominal pain radiating to the back: Girdle Vessel pathology (usually excess in the form of Dampness) • Umbilical pain along a line with backache radiating to thighs: Girdle Vessel pathology • Unilateral abdominal pain with distension and feeling of masses: Yin Stepping Vessel (Yin Qiao Mai) pathology, usually stagnation of Qi and/or Blood • Lower abdominal pain with a sense of energy rising towards the chest and a feeling of tightness there: Penetrating Vessel (Chong Mai) pathology (rebellious Qi)
Vaginal discharge Leucorrhoea must be differentiated according to colour, consistency and smell. An increase in vaginal secretions mid-cycle and during pregnancy is normal. Colour
• White: Cold. Cold can derive from Spleen- or Kidney-Yang deficiency, or from Exterior Cold-Dampness. • Yellow: Heat, usually Damp-Heat in the Lower Burner. • Greenish: Damp-Heat in the Liver channel. • Red and white: Damp-Heat. • Yellow, red with white pus after menopause: Toxic-Heat. Consistency
• Watery: Cold-Dampness and/or deficiency condition. • Thick: Damp-Heat and/or excess condition. Smell
• Fishy: Cold. • Leathery: Heat.
Fertility and pregnancy Infertility can be due to many different deficient or excess conditions. Deficient ones are Blood deficiency or Kidney deficiency. Full ones are stasis of Blood, stasis of Cold or Damp-Phlegm. Vomiting during pregnancy indicates rebellious Qi in the Penetrating Vessel affecting the Stomach channel. This can occur against a background of Stomach deficiency or Stomach-Heat. Oedema during pregnancy indicates Kidney-Yang deficiency. High blood pressure denotes a Kidney deficiency with Liver-Yang rising or LiverWind: this may herald a pre-eclampsia state which is also characterized by headache, dizziness and blurred vision. A full eclampsia state manifests with convulsions which, from a Chinese perspective, indicate the development of Liver-Wind from Liver and Kidney deficiency. Summary Fertility and pregnancy
• Infertility from deficiency: Blood deficiency or Kidney deficiency • Infertility from excess: stasis of Blood, stasis of Cold or Damp-Phlegm • Vomiting during pregnancy: rebellious Qi in the Penetrating Vessel affecting the Stomach channel • Oedema during pregnancy: Kidney-Yang deficiency • High blood pressure: Kidney deficiency with Liver-Yang rising or Liver-Wind
Childbirth The following are the main areas of questioning with regard to the conditions of labour: • Nausea and heavy bleeding after labour: exhaustion of the Penetrating Vessel. • Sweating and fever after labour: exhaustion of Qi and Blood. • Post-natal depression: Liver- and Heart-Blood deficiency. • Post-natal psychosis: stasis of Blood in the Uterus.
Miscarriage and abortion It is important to ask about miscarriages and abortion as they weaken a woman’s body. There is a saying in Chinese gynecology that states: “Miscarriage is more serious than childbirth.” It is easy to understand why this should be so: during a miscarriage there is usually a heavy loss of blood; moreover, from a mental–emotional point of view, it means a great loss to the woman with ensuing sadness and grief, which are often underestimated. Abortion is also weakening but to a lesser degree because there is not the loss of blood that occurs during a spontaneous miscarriage. Therefore, when counting the number of children a woman has had, if she has two children and had two abortions and a miscarriage, that counts as if she had had five children. Miscarriage before 3 months indicates a Kidney deficiency, while miscarriage after 3 months denotes sinking of Spleen-Qi, Liver-Blood stasis or Blood-Heat.
Palpation Diagnosis by palpation includes feeling the pulse and skin and palpating the abdomen.
Pulse All the normal considerations for pulse diagnosis apply in gynecology. There are, however, some peculiar characteristics to pulse diagnosis in women which will be discussed below. Differences between men and women in pulse diagnosis There are some differences between the normal pulse in females and that in males. First of all, a woman’s pulse is naturally weaker than a man’s assuming that they are of equal body size (to which the pulse is related). In women, the right-side pulse should be slightly stronger (some say about 8%) than the left. Chapter 7 of the Pulse Classic says: “The left side [of the pulse] is big in men, the right side is big in women.”3 Also, the Rear pulses should be stronger than the Front ones. Chapter 19 of the Classic of Difficulties says: In men the pulse [is found] above the Middle position, in women below the Middle position. Thus, men’s pulse is usually weak on the Rear position while women’s pulse is strong on the Rear position: this is normal.4 Li Shi Zhen says something similar in his book The Study of the Pulse from the Pin Hu Lake: “There are differences in the Rear position in men and women: in women the Yang [i.e. the Front position] is weak and the Yin [i.e. the Rear position] is strong.”5 Qing dynasty’s Chen Jia Yuan says: Men have less Yin and more Yang, women have less Yang and more Yin. South corresponds to Fire and man, the two Front pulse positions correspond to South and the original Yang, hence they are big and overflowing while the two rear positions are weak and soft. Women correspond to North, and so the two Front pulse positions are fine and weak while the two rear positions are big.6
It is interesting to note that this situation is hardly ever encountered in practice in the West as women’s pulses are, in my experience, more commonly weak on the Rear position, perhaps indicating a decline of hereditary Kidney strength compared with previous generations. In my practice, out of nearly 2500 patients, I have found that 21.5% of women have a very weak pulse on both Rear positions, as opposed to 4.5% of men. Summary Differences between men and women in pulse diagnosis
• A woman’s pulse is normally weaker than a man’s • In women, the right-side pulse should be slightly stronger • Classically, the Rear pulses are stronger than the Front ones but this is rarely encountered in practice in the West
Levels of the pulse If we distinguish three levels of depth in the pulse, the Middle level acquires particular importance in women as it corresponds to Blood (the Superficial level corresponding to Qi/Yang and the Deep level to Yin). Chapter 18 of the Classic of Difficulties identifies these three levels, while in Chapter 5 it differentiates five levels corresponding to the five Yin organs; when it describes the pressure to be applied to feel the different levels, it relates this to the weight of beans (the commentary specifies that they are soya beans). It says: If one feels the pulse applying a pressure equivalent to three beans, this corresponds to the skin and the Lungs. Six beans: it corresponds
to Blood and the Heart. Nine beans: it corresponds to the muscles and the Spleen. Twelve beans: it corresponds to the sinews and the Liver. If one presses the fingers down to the bone and then lifts them slightly, it corresponds to the [bones and] the Kidneys.7 Thus, although the text identifies five levels, the principle is the same insofar as the Blood is felt somewhere in between the superficial level and the deep level. If the pulse feels rather Weak and Soft at the Middle level, it indicates Blood deficiency; although the above passage from the Classic of Difficulties identifies this level with the Heart, in women, it also reflects Liver-Blood. If the pulse feels quite Full and Big at the Blood level, it denotes Blood-Heat and the possibility of menorrhagia. If the pulse feels Wiry or Firm (lao) at this level, it denotes Blood stasis. Summary Levels of the pulse
• If we distinguish three levels of depth in the pulse, the Middle level acquires particular importance in women as it corresponds to Blood • If the pulse feels rather Weak and Soft at the Middle level, it indicates Blood deficiency • If the pulse feels quite Full and Big at the Blood level, it denotes Blood-Heat • If the pulse feels Wiry or Firm it denotes Blood stasis
Rear (Chi) position of the pulse The Rear position of the pulse assumes particular importance in women. It
corresponds to the Kidneys, the Fire of the Gate of Life (Ming Men), the Minister Fire and the Uterus. The two positions as a whole therefore reflect the state of Kidney-Yin, Kidney-Essence and Kidney-Yang. As mentioned above, the Rear positions are very often Weak and Deep in women, indicating a high incidence of Kidney deficiency. Although the left side corresponds to Kidney-Yin and the right to Kidney-Yang, I do not find this distinction always reliable in practice and, in fact, one of the most common pulse findings in practice in women is a pulse that is Weak and Deep on both Kidney positions of left and right. The distinction between Kidney-Yin and Kidney-Yang deficiency can therefore be made only on the basis of tongue and symptoms. A Hollow quality on the Rear pulse in a woman indicates a possible haemorrhage (which may also be urinary) and irregular periods. The Hollow quality may also appear after a serious haemorrhage. According to the Pulse Classic, the right Rear position corresponds to the Uterus and the Triple Burner. In Chapter 7 it says: The right-Rear position corresponds to the Kidney. Since this is interiorly–exteriorly related with the Greater Yang, [the righ Rear pulse] also reflects the Bladder. It also unites with the Triple Burner to the right of Ren-4 Guanyuan. On the left [of Ren-4] is the Kidney, on its right the Uterus.8 Dr J H F Shen, however, feels the Uterus on the left Rear position of the pulse rolling the finger proximally very slightly (Fig. 5.4). While these two different interpretations are not necessarily mutually exclusive, I find Dr Shen’s clinically more relevant. Perhaps the description of the pulse position of the Uterus and Triple Burner by the Pulse Classic is more concerned with the energetic aspect of the Uterus being linked to the Motive Force (Dong Qi), which is where the extraordinary vessels start from, and to the concept of the Triple Burner as the ‘ambassador’ or ‘avenue’ through which the Fire of the Gate of Life emerges. Dr Shen’s interpretation has more to do with the Uterus as an anatomical entity. Seen from this point of view, I find the assignment of the proximal part of the left Rear position to the Uterus verified
clinically.
Figure 5.4 Uterus position on the pulse. An Empty and Weak quality on the proximal end of the left Rear position indicates Blood and/or Kidney deficiency with Emptiness of the Uterus, while a Wiry quality here indicates stasis of Blood in the Uterus. A Tight quality denotes Cold in the Uterus. In a girl of 14, if the Rear pulses (both left and right) are Deep and Hidden, it may indicate amenorrhoea. Summary Rear (Chi ) position of the pulse
• The Rear pulse position is very important in women • It corresponds to the Kidneys, the Fire of the Gate of Life (Ming Men), the Minister Fire and the Uterus • The two positions as a whole therefore reflect the state of Kidney-Yin, Kidney-Essence and Kidney-Yang • A Hollow quality on the Rear pulse in a woman indicates a possible haemorrhage (which may also be urinary) and irregular periods • An Empty and Weak quality on the proximal end of the left Rear position indicates Blood and/or Kidney deficiency with Emptiness of the Uterus, • A Wiry quality in the above position indicates stasis of Blood in the Uterus • A Tight quality denotes Cold in the Uterus
Dr Chen Jia Yuan’s pulses in gynecology Dr Chen Jia Yuan gives various pulse findings that are relevant in gynecology.9 He say that a Deep and Hidden pulse on both Rear positions indicates amenorrhoea; a Slippery quality on the Rear positions may indicate leucorrhoea; a Choppy quality on the Middle positions may indicate early menopause; if the Rear position pulses are Floating and the Front ones Deep, the fetus may die and the mother live; if the Rear position pulses are Choppy and the Front ones Hidden, the mother is in danger and the fetus will live; if the pulse is Slowed-Down after childbirth, it is a good sign and a sign of good Stomach-Qi; if the pulse is Slippery after childbirth, Spleen-Yin has been damaged. Li Shi Zhen’s pulses of the eight Extraordinary Vessels Li Shi Zhen identifies certain pulse qualities with the Extraordinary Vessels. The main ones, relevant to gynecology, are as follows:
• A ball feeling on both Front positions reflects the Directing Vessel (Ren Mai). Clinical manifestations of this position include lower abdominal pain, rebellious Qi attacking the heart, contracture in the chest and inability to take a supine position. The Pulse Classic says: A tight, thready and long pulse of the excess type at cun region extending to guan region is the Ren Channel. Its clinical manifestations include pain around the umbilicus, seven types of hernia in men, and palpable masses in the abdomen in women. • A straight up and down Deep and Firm (lao) pulse at the Front, Middle and Rear positions reflects the Penetrating Vessel (Chong Mai): this pulse may occur on both sides or only on the right. Clinical manifestations include a feeling of tightness of the chest. The Pulse Classic says: A solid pulse at the deep level extending to guan region is due to the Penetrating Vessel. Clinical manifestations include pain on the sides of the lower abdomen, an uncomfortable feeling in the heart, hernia, enuresis, and infertility in women. • A Wiry pulse at the Middle position on both sides reflects the Girdle Vessel (Dai Mai). Its clinical manifestations include lower abdominal pain referring to the Fire of the Gate of Life (Ming Men), amenorrhoea, and infertility in women, contracture of the lower abdomen and seminal emission in men. • A Wiry pulse at the Rear position on both sides reflects the Yin Stepping Vessel (Yin Qiao Mai) and also Yin and Yang Linking Vessels (Yin and Yang Wei Mai). Its clinical manifestations include epilepsy, aversion to cold, fever, lower abdominal pain, lumbar pain, hernia and continuous uterine bleeding.10 Summary
Li Shi Zhen’s pulses of the eight Extraordinary Vessels
• A ball feeling on both Front positions reflects the Directing Vessel • A straight up and down Deep and Firm pulse at the Front, Middle and Rear positions reflects the Penetrating Vessel • A Wiry pulse at the Middle position on both sides reflects the Girdle Vessel • A Wiry pulse at the back position on both sides reflects the Yin Stepping Vessel, Yin and Yang Linking Vessels
Pulses in pregnancy During pregnancy, the pulse becomes Slippery; if it lacks this quality, that is not a good sign. During pregnancy, both the Rear (third) and the left Front (first) positions undergo changes. While the whole pulse becomes Slippery, the Rear position (on both sides) becomes Big and the left Front position Overflowing. Chapter 7 of The Simple Questions says when discussing pulse diagnosis: “If Yin [i.e. the Rear pulse] throbs [strongly] and Yang [i.e. the Front pulse] stands out, this indicates pregnancy.”11 Thus, for the pulse to indicate pregnancy, the relationship between the Rear and Front positions is important. It is only when both undergo the changes described above that pregnancy may be diagnosed. The Qing dynasty’s gynecologist Chen Jia Yuan specifically says that if the Rear position only is Slippery and Big, this could simply indicate retention of Dampness in the Uterus: it is only if the left Front position is Overflowing that pregnancy may be diagnosed.12 He also refers to the relative strength of the Liver and Lung pulses: he says that if the Rear positions are slippery and the Liver pulse is Big and the Lung pulse small, this indicates pregnancy.13 Yet another sign of pregnancy according to Dr Chen is a Slippery quality in the left Front position and a Big quality in the left Rear one; or also a Rapid
quality in the left Rear position and a Minute quality on the left Middle one. The ABC of Acupuncture says: “In examining women, when the pulse of the hand Lesser Yin beats [strongly], it indicates pregnancy.”14 ‘Hand Lesser Yin’ can be interpreted as the Heart pulse on the left Front position, or as the pulse of the cubital artery along the Heart channel: both interpretations are correct. As for diagnosing the sex of the fetus, opinions vary. Some doctors relate it to the relative strength of the Rear position: if the left is stronger it is a boy. Others refer to the relative strength of the left Front position compared with the Rear ones: if the left Front position is stronger, it is a boy. Still others refer to the pulse on the cubital artery on the Heart channel: if this is strong, it is a boy. Of course, the difficulty lies in not knowing the strength of the woman’s pulse before pregnancy, so that, for example, if she normally has a weak Heart pulse, its Overflowing quality from a pregnancy might not be so obvious. In any case, one has a 50% chance of being right! Dr Chen Jia Yuan also gives other indications for diagnosing the sex of the fetus and even multiple pregnancies.15 He says that if the left Front position feels like a belt, the fetus is a boy; if the right Front position feels like a belt, the fetus is a girl. If the left Middle and Rear positions are Big and the Heart pulse ‘flowing’, it indicates male triplets; if the right Middle and Rear positions are Big and the Heart pulse ‘flowing’, it indicates female triplets. If the pulses of both left and right are Slippery, it indicates male twins; if both left and right pulses are Floating, it indicates female twins. Apart from the pulse, Wu Qian, author of the Golden Mirror of Medicine (1742), gives indications for diagnosing the sex of the fetus according to the shape of the mother’s abdomen. He says that if the mother is carrying a girl, the abdomen is small above and large below, like a basket, and the fetus faces the abdomen with her legs and knees below. If she is carrying a boy, the abdomen is high and round in the Middle like an upturned cauldron and the fetus faces the mother’s back, with his back and spine below.16 Pulses that indicate possible problems with the pregnancy are a pulse that is Deep, Fine and Short, or a pulse that is very Deep and Weak on both
Rear positions and is Intermittent. Some doctors say that an Intermittent pulse at 100 days of pregnancy is normal. If the pulse during pregnancy is Wiry, Hard and Rapid, it indicates the possibility of eclampsia. If the pulse has a Leather quality during pregnancy it indicates the likelihood of miscarriage or threatened miscarriage. The Leather pulse feels relatively Wiry and Large on superficial pressure but Empty and Hollow on a deep pressure. The Synopsis of Prescriptions from the Golden Cabinet by Zhang Zhong Jing says: A pulse may be Wiry and Big: Wiry implies a reduced size, while Big implies Hollow. A reduced size means Cold and a Hollow pulse Deficiency: a combination of these two qualities is called Leather pulse. This indicates miscarriage or threatened miscarriage in women.17 A Hollow and Rapid pulse during pregnancy may indicate the danger of miscarriage. Summary Pulses in pregnancy
• During pregnancy, while the whole pulse becomes Slippery, the Rear position (on both sides) becomes Big and the left Front position Overflowing • Pulses that indicate possible problems with the pregnancy are a pulse that is Deep, Fine and Short, or a pulse that is very Deep and Weak on both Rear positions and is Intermittent • A Hollow and Rapid pulse during pregnancy may indicate the danger of miscarriage
Pulses in labour
During labour, the pulses of both chi positions become Tight, Slippery and Rapid. After labour, it is normal for the pulse to be Weak and Soft. If it is very Fine and Irregular, it indicates severe deficiency of Qi and Blood. If it is Floating, Rapid and Full, it indicates Blood-Heat and infection. Pulses during menstruation During menstruation, the pulse is naturally somewhat Slippery, Big and slightly Rapid. Of course, in the absence of the period, such pulse qualities would indicate Damp-Heat or Blood-Heat. The Hollow pulse in gynecology A Hollow pulse in women appears after a profuse loss of blood such as may occur after childbirth, a miscarriage or a very heavy period in a woman suffering from menorrhagia. Conversely, a Hollow and Rapid pulse during pregnancy may indicate the danger of miscarriage. The pulse in menorrhagia Particular attention should be paid to the pulse in chronic menorrhagia: during a heavy period the pulse would be Empty but Big and Wiry, while after the period it would be Hollow. After many years of chronic menorrhagia the pulse should be Fine, Thin or Choppy; if it is instead Floating, Overflowing, Hurried or Rapid, this is not a good sign.
Skin One should check the temperature, moisture and possible swelling of the skin. Limbs Cold arms and legs indicate Spleen- and/or Kidney-Yang deficiency. If only the hands and feet are cold, it indicates stagnation of Liver-Qi (this symptom is called the ‘four rebellious’ and Si Ni San Four Rebellious Powder is the applicable formula). If only the hands are cold, it may indicate Heart-Blood deficiency. If the hands and feet are cold and also dry, it indicates Blood deficiency. If the hands are hot on the dorsum, it denotes Full-Heat (in gynecology this could mean Blood-Heat); if they are hot on the palms, it indicates Empty-Heat. If the feet are hot on the soles, it indicates Kidney-Yin deficiency with Empty-Heat. A swelling of the ankles with pitting oedema indicates deficiency of Kidney-Yang and Spleen-Yang. If the oedema is not pitting, it is due to Qi stagnation. Abdomen The temperature of the abdomen should also be checked as it gives an immediate impression of the state of the Directing and Penetrating Vessels. If the lower abdomen feels cold to the touch, it indicates Cold in the Uterus and in the Directing and Penetrating Vessels. If the abdomen feels dry to the touch, it indicates Blood and/or Yin deficiency. Summary Skin
Limbs
• Cold arms and legs: Spleen- and/or Kidney-Yang deficiency • Cold hands and feet: Liver-Qi stagnation • Cold, dry hands and feet: Blood deficiency • Cold hands alone: Heart-Blood deficiency • Hot dorsum of hands: Full-Heat • Hot palms: Empty-Heat • Hot soles of feet: Kidney-Yin deficiency with Empty-Heat • Swollen, pitted oedematous ankles: Kidney-/Spleen-Yang deficiency; without pitting: Qi stagnation
Abdomen
• The temperature of the abdomen indicates the state of the Directing and Penetrating Vessels • A cold abdomen to the touch indicates Cold in the vessels or Uterus; a dry abdomen indicates Blood/Yin deficiency
Abdomen One should check the lower abdomen in women as this reflects the state of the Kidneys, the Uterus and the Penetrating and Directing Vessels. The abdomen should feel elastic, neither too tight nor too soft. Compare the lower abdomen with the upper abdomen, below the xiphoid process: this latter area should feel softer than the former. If the lower abdomen feels too soft (as it often is in women who have had several children) and the practitioner’s hand sinks in very easily when palpating, it indicates a Kidney deficiency, with exhaustion of the Directing Vessel if in the centre or the Penetrating Vessel if on the lateral sides. If the lower abdomen feels tight and hard, it indicates stasis of Blood, and if it is distended, it indicates stagnation of Qi: in both cases, the Penetrating Vessel might be involved (with rebellious Qi). Palpable masses indicate stasis of Blood if they are hard and unmovable, and Phlegm if they are soft; if they come and go, they are due to Qi stagnation. Abdominal pain that improves on palpation or massage is due to a deficiency (usually a Kidney deficiency). If the abdominal pain is aggravated by pressure or massage it indicates an excess condition, which could be stagnation of Qi, stasis of Blood or Dampness. With regard to abdominal masses and palpation, it should be stressed that the disease-entity of ‘Abdominal Masses’ (Zheng Jia) in Chinese medicine implies the presence of a mass that can be felt on palpation. Obviously, doctors in ancient China did not have recourse to X-rays or scans. Therefore, this raises the question: are small, non-palpable masses to be considered ‘Abdominal Masses’? Does a very small myoma in the uterus that is not palpable from the outside fall into the category of ‘Abdominal Mass’? Or, in other words, is it legitimate to make a Chinese diagnosis of ‘Abdominal Masses’ on the basis of Western tests? Opinions on this question vary: my opinion is that small, non-palpable masses that are detected only by Western tests such as scans are indeed ‘Abdominal Masses. This means that treatment should be focused on softening and dissolving masses.
Clinical Note In my opinion, it is possible to make a Chinese Bian Bing diagnosis (identifying the disease category) on the basis of Western tests. However, there is an important caveat here. Although we can treat a small, non-palpable mass as an ‘Abdominal Mass’, the Chinese identification of patterns is extremely important and our treatment should be guided by it. In other words, just because a patient may have a small mass detected by Western tests, that does not mean that we can go all out in breaking Blood (assuming the mass is from Blood stasis) and dissolving masses with strong herbs. We must always use a proper identification of patterns and, most of all, make a clear assessment of the relative importance of deficiency or excess. In other words, assuming that a woman had a small myoma occurring against a background of Qi and Blood deficiency, a strong Blood-breaking formula such as is used for abdominal masses from Blood stasis would most probably make the patient worse. However, the presence of a myoma is not entirely discounted and one might add some Blood-invigorating herbs to whatever formula one uses. Summary Abdomen
• The lower abdomen reflects the state of the Kidneys, Uterus, Penetrating and Directing Vessels • A very soft lower abdomen indicates Kidney deficiency with exhaustion of the Directing Vessel if in the centre, or the Penetrating Vessel if on the lateral sides • If the lower abdomen feels tight and hard, it indicates stasis of Blood; if it is distended, it indicates stagnation of Qi • Hard and unmovable palpable masses indicate stasis of Blood; soft ones
indicate Phlegm; ones that come and go are due to Qi stagnation. • In my opinion, small, non-palpable masses that are detected only by Western tests such as scans are also ‘Abdominal Masses’
Observation
Complexion All organs obviously influence the complexion, but, whatever the organ, the complexion shows the state of the Mind and Spirit. Yu Chang, in Principles of Medical Practice (1658), calls the complexion the “banner of the Mind and Spirit” and he says: When the Mind and Spirit are flourishing, the complexion is glowing; when the Mind and Spirit are declining, the complexion withers. When the Mind is stable the complexion is florid.18 A healthy Mind and Spirit show most of all in a complexion with shen. This implies an indefinable quality of lustre, glow, glitter and floridity of the complexion, which indicates a good prognosis even if the colour itself is pathological. Shi Pa Nan in Origin of Medicine (1861) says: The shen of the complexion consists in lustre and body. Lustre means that the complexion appears clear and bright from the outside; body means that it is moist and with lustre in the inside.19 If a complexion has such attributes, even if the colour is pathological, it indicates that the Mind and Spirit are stable and unaffected and therefore the prognosis is good. Shen in a woman’s complexion is closely related to Blood: a healthy, glowing complexion with shen indicates a healthy state of Blood, apart from denoting a stable state of the Mind as described above. Conversely, a complexion lacking in shen and looking dull, somewhat dry and without lustre indicates Blood deficiency, which could affect the Heart, Spleen or Liver. The area around the mouth is related to the Liver and the Directing and Penetrating Vessels: if it is dull, pale and without lustre, it indicates LiverBlood deficiency and Emptiness of the Directing Vessel and/or Penetrating Vessel; if greenish, it may indicate Liver-Qi stagnation. Brownish discolourations of the skin on the chin indicate a deficiency of
the Directing Vessel possibly with Blood-Heat. The area between and just above the eyebrows is related to the Heart: if it is pale, dull and dry, it indicates Heart-Blood deficiency. A dark, greenish complexion indicates Blood stasis; from a mental– emotional point of view, this type of complexion often denotes that the cause of the disease is anger, frustration, resentment, hatred or guilt. A bright-red flush over the whole cheek indicates Blood-Heat; a flush that affects only the cheek bones (malar flush), Empty-Heat. The latter is, of course, very common in menopausal hot flushes. However, there are other possible causes of a ‘floating’, flushed, red colour along the cheek bones, so such a flush should not be automatically attributed to Empty-Heat from Yin deficiency. It is, in fact, very common in women of all ages and may be due to Blood deficiency or even Qi deficiency. Both Blood and Qi deficiency can give rise to the ‘Empty-Heat’ although this term is usually applied to Yin deficiency. ! In women, a malar flush (flushed, red cheek bones) is not always due to Empty-Heat from Yin deficiency. A type of ‘Empty-Heat’ in women often arises from Blood deficiency or even Qi deficiency. Furthermore, a red, flushed complexion can sometimes be due to rising rebellious Qi in the Penetrating Vessel: this is merely an imbalance within this vessel and represents neither Full-Heat nor Empty-Heat. This phenomenon has been discussed in the Chapter 3 on pathology. A bright white complexion indicates Yang deficiency and Cold. A yellowish complexion that looks also slightly puffy is a clear sign of Dampness. The more sallow it is, the longer the Dampness’s duration. A dark, brownish complexion indicates longstanding deficiency of Kidney-Yin. Summary
Complexion
• The complexion shows the state of the Mind and Spirit • Shen in a woman’s complexion is closely related to Blood: a healthy, glowing complexion with shen indicates a healthy state of Blood, apart from denoting a stable state of the Mind • Conversely, a complexion lacking in shen and looking dull, somewhat dry and without lustre indicates Blood deficiency, which could affect the Heart, Spleen or Liver • Area around the mouth dull, pale and without lustre: Liver-Blood deficiency and Emptiness of the Directing Vessel and/or Penetrating Vessel • Area around the mouth greenish: Liver-Qi stagnation • Brownish discolouration of the skin on the chin: deficiency of the Directing Vessel possibly with Blood-Heat • The area between and just above the eyebrows pale, dull, and dry: HeartBlood deficiency • A dark, greenish complexion: Blood stasis • A bright red flush over the whole cheek: Blood-Heat • Flushed cheek bones (malar flush): Empty-Heat (from Yin, Blood or Qi deficiency) • Red, flushed complexion can be due to rising rebellious Qi in the Penetrating Vessel • A bright white complexion: Yang deficiency and Cold • A yellowish complexion that looks also slightly puffy: Dampness • A dark, brownish complexion: longstanding deficiency of Kidney-Yin
Lips The lips show the state of the Spleen and Blood. If they are pale, they indicate Spleen deficiency and Emptiness of Blood. If they are dark red, they denote Blood-Heat or Spleen-Heat. If they are bright red, they may indicate Empty Heat (which may also derive from Blood deficiency apart from Yin deficiency). Greenish lips indicate Cold, while purplish lips denote stasis of Blood. Dry lips indicate Spleen-Yin deficiency. Summary Lips
• The lips show the state of the Spleen and Blood • Pale lips: Spleen deficiency and Emptiness of Blood • Dark red lips: Blood-Heat or Spleen-Heat • Bright red lips: Empty-Heat (which may also derive from Blood deficiency apart from Yin deficiency) • Greenish lips: Cold • Purplish lips: stasis of Blood • Dry lips: Spleen-Yin deficiency
Tongue Tongue diagnosis in gynecology in general does not differ from that of general internal medicine and I will summarize the main points chiefly in relation to gynecology.20 The main aspects to discuss are as follows: • Tongue-body colour. • Tongue-body shape. • Tongue coating. Tongue-body colour There are three main colours: Pale, Red (which includes Dark Red) and Purple (which includes Blue). Pale
A Pale tongue is very common in women and it indicates either Yang deficiency (in which case it would be slightly wet) or Blood deficiency (in which case it would be slightly dry and possibly Thin). However, in women it is extremely common for Blood deficiency to cause a Pale tongue that is Swollen (instead of Thin) from the presence of Dampness or Phlegm (see below). A particular type of Pale tongue is one that is also peeled (without coating): this denotes very severe Blood deficiency (normally a peeled tongue is Red). Red or Dark Red
By ‘Red’ is meant too Red when compared with a normal Pale Red colour.
Red always indicates Heat, and whenever one sees a Red tongue one should immediately distinguish whether it is with or without a coating (or with a rootless coating). A Red tongue with coating indicates Full-Heat, while a Red tongue completely or partially without coating (or with a rootless coating) denotes Empty-Heat arising from Yin deficiency. The Red tongue (with or without coating) is frequently seen in menorrhagia from Blood-Heat. The tongue could be Red (or redder) in selected parts, most commonly the tip and the sides. A Red tip indicates Heart-Fire or Heart Empty-Heat depending whether the tongue has a coating or not. This nearly always indicates the presence of emotional problems, not only those affecting the Heart but also those affecting other organs. This is because the Heart houses the Mind (Shen) which alone has the insight to recognize and feel the emotional stimuli. In fact, stagnation of Liver-Qi can often cause the tip to become red. Red sides indicate Liver-Fire or Liver Empty-Heat depending on whether the tongue has a coating or not; they are very common in women. Liver-Fire often causes Blood-Heat (because the Liver stores Blood) and therefore menorrhagia. If the sides are only slightly Red and the rest of the tongue is not Red, this may reflect stagnation of Liver-Qi, typically causing pre-menstrual tension. Please note that, in women, the sides of the tongue reflect the Liver but also the Uterus: thus, a Red colour on the sides may indicate Blood-Heat affecting the Uterus (which, however, we would treat through the Liver channel). If we relate the Red tongue to the theory of the Four Levels elaborated by the Warm Disease School we can distinguish three types of Heat syndrome: 1. Heat at the Qi level: the tongue is Red or slightly Red with a thin, yellow coating. Heat at this level does not cause Blood-Heat. It is treated by the method of ‘clearing Heat’ (Qing Re) with cold and pungent herbs such as Shi Gao Gypsum fibrosum or Zhu Ye Folium Phyllostachys nigrae to push the Heat outwards.
2. Fire at the Qi level: the tongue is Red or Dark Red with a thick, yellow, brown or black coating which is also very dry. Fire is stronger and deeper than Heat, it dries up the Body Fluids more than Heat, it dries up the faeces causing constipation with dry stools, it causes Blood-Heat, it agitates the Mind more than Heat and it may cause bleeding. To treat it, drain Fire (Xie Huo) with cold and bitter herbs such as Huang Qin Radix Scutellariae, Huang Lian Rhizoma Coptidis, Da Huang Radix et Rhizoma Rhei and Long Dan Cao Radix Gentianae, most of which drain Fire downwards by evacuation. It would be a mistake to treat Heat as Fire with one of the above herbs. Fire can cause Blood-Heat and lead to menorrhagia of the Full type. 3. Heat at the Nutritive-Qi or Blood level: the tongue is Red without a coating (completely or partially) because the Heat has dried up the Yin fluids and led to Yin deficiency. Vice versa, it may be that Yin deficiency has given rise to Empty-Heat. In both cases, a Red tongue without coating indicates Heat at the Nutritive-Qi or Blood level. This is treated by nourishing Yin and clearing Empty-Heat. This condition can also lead to menorrhagia or may result from a chronic menorrhagia caused by Fire leading to Yin deficiency. Purple
A Purple tongue always indicates stasis of Blood. Although some authors say that stagnation of Qi can also cause the tongue to become Purple, I do not agree; I feel that the tongue-body colour reflects Blood more than Qi and I therefore interpret a Purple colour as always being due to stasis of Blood. Stasis of Blood can derive from internal Cold obstructing the circulation of Blood, in which case the tongue is Bluish-Purple, or from Heat condensing Blood, in which case it is Reddish-Purple. A Bluish-Purple tongue usually develops from a Pale tongue while a Reddish-Purple tongue normally develops from a Red tongue (Fig. 5.5).
Figure 5.5 Purple tongue. A Purple tongue in a woman is always a poor sign as it indicates longstanding stasis of Blood with the possibility of lumps (benign or malignant), cysts, myomas, endometriosis, etc., because when Blood stagnates for a long time it may form masses. If a woman does have a malignancy, a very purple tongue indicates a poor prognosis. Both a Bluish-Purple and a Reddish-Purple are also seen in chronic dysmenorrhoea. The ‘chest’ area on the tongue acquires particular importance when it is Purple. The chest area is on the sides, between the centre and the tip of the tongue (Fig. 5.6). The chest area reflects pathologies of the lungs, heart or breast, but in a Western medical sense. A change in the chest area may involve a change in colour or body shape. How to differentiate when a change in the chest area indicates a problem of the lungs or heart or of the breasts in women? A change in the chest area indicates a pathology of the breast in women rather that of lungs/heart: • in the absence of an obvious lungs/heart pathology • especially when it is unilateral.
Figure 5.6 Chest area on tongue. Examples of lung pathology manifesting in the chest area are chronic asthma or chronic emphysema (in which case the chest area would be Swollen and possibly Purple). An example of heart pathology is chronic coronary heart disease (in which case the chest area would be Purple). In women, in the absence of obvious lung or heart disease, a purple colour in the chest area indicates Blood stasis in the breasts; if it is unilateral, it indicates Blood stasis in the breast of that side. How do we use this information? If the woman has no diagnosis of breast cancer, the presence of a purple colour alerts us to the fact that there is Blood stasis in the breasts and that we should treat it. Remember that Blood stasis in the breasts may not necessarily indicate carcinoma because it may also be related to fibroadenoma. If a woman has already had breast cancer and comes to us perhaps after she has had a lumpectomy and radiotherapy, we should carefully analyse the breast (or chest) area: if it is not Purple, it is a good sign; if it is
Purple, it is a poor prognostic sign. In such a case, we should therefore actively invigorate Blood and even break Blood as if she still has the cancerous lump. Apart from a Purple colour and a swelling, other possible changes in the chest area are teethmarks that are confined only to the chest area, Red points or a peeling of the chest area. Teethmarks that appear only in the breast area usually indicate a problem in the breast in women (possible carcinoma) occurring against a background of severe Qi deficiency. Red points in the breast area indicate Toxic-Heat in the lungs or, in women only, in the breast. A peeling (absence of coating) in the breast area indicates a possible problem in the breasts in women occurring against a background of Yin deficiency. Bearing in mind that the sides of the tongue reflect the Uterus as well as the Liver, a Purple colour on the sides in women is usually related to Blood stasis in the Uterus. Summary Tongue-body colour
Pale
• A Pale tongue in women indicates either Yang deficiency (slightly wet) or Blood deficiency (slightly dry) • Pale tongue without coating: severe Blood deficiency Red or Dark Red
• Red tongue with coating: Full-Heat
• Red tongue completely or partially without coating: Empty-Heat arising from Yin deficiency • Red tip: Heart-Fire or Heart Empty-Heat • Red sides: Liver-Fire or Liver Empty-Heat • Red sides may also indicate Blood-Heat affecting the Uterus • Red or slightly Red with a thin-yellow coating: Heat at Qi level • Red or Dark Red with a thick, yellow, brown or black coating which is also very dry: Fire at the Qi level • Red without a coating (completely or partially): Heat at Nutritive-Qi or Blood level Purple
• A Purple tongue always indicates stasis of Blood • Bluish-Purple: stasis of Blood from internal Cold • Reddish-Purple: Blood stasis from Heat condensing Blood • In women, in the absence of obvious lung or heart disease, a Purple colour in the chest area indicates Blood stasis in the breasts • Teethmarks confined only to the chest area: a problem in the breast in women (possible carcinoma) occurring against a background of severe Qi deficiency • Red points in the breast area indicate Toxic-Heat in the breast • A peeling in the breast area: possible problem in the breasts in women occurring against a background of Yin deficiency • A Purple colour on the sides in women may indicate Blood stasis in the Uterus
Tongue-body shape
Tongue-body shapes commonly include Swollen, Thin, Toothmarked, Quivering, Long, Short, Stiff, Deviated, Moving, Cracked. Swollen The Swollen tongue is extremely common. Among my patients, nearly 40% have a Swollen tongue, which generally indicates Dampness or Phlegm (more commonly the latter). A common finding in women is a swelling of the edges in the central part of the tongue indicating Spleen deficiency. A thinner swelling all along the sides indicates Liver-Fire and is usually seen on a Red tongue. Figure 5.7 compares a Spleen-type with a Liver-type swelling. A Swollen tip which is usually also Red indicates Heart-Fire and it means that the emotional problems causing this condition are more severe than if the tip were only Red.
Figure 5.7 Spleen deficiency and Liver-Heat.
Thin
A Thin tongue indicates either Blood deficiency or Yin deficiency depending on whether the tongue is Pale or without coating. Although Blood deficiency is common in women, the Thin tongue is not, because Phlegm (which makes the tongue Swollen) is also very common. Toothmarked The tongue with teethmarks is very common indeed: it indicates Spleen-Qi deficiency. Quivering The Quivering tongue trembles with movements of a very small range. It also denotes Spleen-Qi deficiency. Long The Long tongue indicates Heart-Heat. Short The Short tongue indicates Cold from Yang deficiency or extreme Yin deficiency depending on whether the tongue is Pale or without coating. Stiff The Stiff tongue may indicate Liver-Wind, Yin deficiency or stasis of Blood. It is usually seen only in older women. Deviated
The Deviated tongue indicates Liver-Wind: this also is seen only in older women. Moving The Moving tongue moves slowly from side to side with a large and ample movement: it indicates Liver-Wind and is seen only in older women. Cracked A cracked tongue generally indicates Yin deficiency. Scattered small cracks or a wide, midline crack in the central section of the tongue indicate Stomach-Yin deficiency (Fig. 5.8). A deep, midline crack extending from near the root to almost the tip of the tongue indicates the tendency to Heart patterns and mental–emotional problems (Fig. 5.9).
Figure 5.8 Stomach cracks.
Figure 5.9 Heart crack.
Summary Tongue-body shape
Swolle n
• Swollen tongue: Dampness or Phlegm • Swelling of the edges in the central part of the tongue: Spleen deficiency • A thinner swelling all along the sides: Liver-Heat • A Swollen, Red tip: Heart-Heat from emotional problems Thin
• Either Blood deficiency (Pale) or Yin deficiency (without coating) Toothmarke d
• Spleen-Qi deficiency
Q uive ring
• Spleen-Qi deficiency Long
• Heart-Heat Short
• Cold from Yang deficiency (Pale) or extreme Yin deficiency (without coating) Stiff
• Liver-Wind, Yin deficiency or stasis of Blood De viate d
• Liver-Wind Moving
• Liver-Wind Cracke d
• A cracked tongue generally indicates Yin deficiency • Scattered small cracks or a wide, midline crack in the central section of the tongue: Stomach-Yin deficiency • A deep, midline crack extending from near the root to almost the tip of the tongue: tendency to Heart patterns and mental–emotional problems
Tongue coating
While the tongue-body colour reflects the state of the Yin organs, the coating reflects the state of the Yang organs and especially of the Stomach. The coating is formed as a byproduct of the Stomach activity of rotting and ripening. A thin-white coating with root is normal and indicates that StomachQi is healthy. A coating is said to be rootless when it looks as if it has been added to the tongue surface rather than growing out of it. The rootless tongue indicates Stomach-Qi deficiency and is the very first step of a long process leading to a completely peeled tongue. In fact, in the beginning stages of Stomach-Qi deficiency, the coating will be rootless. It will next fall off from the centre, then from the whole surface of the tongue. At the same time, the tongue will tend to become Red. By the time the tongue is Red and completely peeled, it indicates Stomach- and Kidney-Yin deficiency with Empty-Heat. The stages leading to this could be summarized as follows in order of severity: 1. Rootless coating: Stomach-Qi deficiency (beginning stage). 2. Coating missing in the centre, rootless elsewhere: Stomach-Qi deficiency. 3. Coating missing everywhere (tongue peeled), normal body colour: Stomach-Yin deficiency (no Empty-Heat). 4. Tongue peeled, Red in the centre only: Stomach-Yin deficiency with Stomach Empty-Heat. 5. Tongue peeled, Red all over: Stomach- and Kidney-Yin deficiency with Empty-Heat. Thus, the absence of coating indicates Yin deficiency. A thick coating may indicate many different pathogenic factors such as Cold, Heat, Dampness, Phlegm and retention of food. The thickness of the coating reflects the strength of the pathogenic factor very directly: the thicker the coating, the stronger the pathogenic factor. A common type of coating in
women is thick with red spots on the root signifying Damp-Heat in the Lower Burner, which could be in the Bladder, Intestines or gynecological system. The colour of the coating reflects the Hot and Cold nature of the condition: a yellow coating indicates Heat, a white coating Cold. A grey or black coating may indicate severe Heat or severe Cold depending on whether it is dry or wet. Summary Tongue coating
• The coating reflects the state of the Yang organs and especially of the Stomach • A thin-white coating with root is normal and indicates that Stomach-Qi is healthy • The rootless tongue coating indicates Stomach-Qi deficiency • Absence of coating: Yin deficiency • A thick coating: Cold, Heat, Dampness, Phlegm and retention of food • Thick-yellow coating with red spots on the root: Damp-Heat in the Lower Burner, which could be in the Bladder, Intestines or gynecological system • Yellow coating: Heat • White coating: Cold • Grey or black coating: severe Heat (dry) or severe Cold (wet)
Aspects of tongue diagnosis in gynecology
Apart from the above general indication of tongue diagnosis, a few aspects peculiar to gynecological problems must be mentioned. 1. Although with Blood deficiency (a very common condition in gynecology) the tongue should be Thin, it very seldom is. This is because it is very common to have Spleen-Qi deficiency which leads, on the one hand, to deficiency of Blood, but also, on the other hand, to Phlegm which makes the tongue Swollen (Fig. 5.10). For this reason, one should not be surprised to see very many women who have symptoms of Blood deficiency but with a Swollen tongue. 2. The tongue often does not show much indication of stagnation of LiverQi. Only if the condition is longstanding and severe may the tongue have Red sides (Red rather than Purple, as Purple indicates stasis of Blood rather than Qi). It is for this reason that very many women have many symptoms of Liver-Qi stagnation such as pre-menstrual tension, irritability, mood swings, abdominal and breast distension, without any appreciable change in the tongue-body colour. 3. Although in theory the Uterus is reflected on the root of the tongue, conditions such as stasis of Blood in the Uterus often show only on the sides of the tongue as this condition is due to stasis of Liver-Blood. Signs on the root of the tongue such as a thick, sticky, yellow coating with red spots are often related to the other parts of the reproductive organs such as ovaries and tubes. 4. The sides of the tongue in the area between the tip and centre, which normally reflect the chest, in women may reflect the breasts (see Fig. 5.6). If one of these areas is Purple (Bluish or Reddish) or if both are, it indicates stasis of Blood in the breast or breasts. This is an important prognostic sign in breast disease and especially cancer of the breast: the presence of a Purple colour in this area indicates a poor prognosis. Conversely, if this area is not purple in a woman with breast cancer, this indicates a good prognosis.
5. The general appearance of the tongue is also an important prognostic sign in breast cancer. If the tongue is Dark Red, with a thick, sticky, dry, yellow coating (signs of Toxic-Heat), it indicates a poor prognosis, and surgery in such a case may lead to metastasis. 6. A Pale and peeled tongue (i.e. without coating) indicates severe deficiency of Blood with the possibility of amenorrhoea or infertility. 7. The tongue-body colour and coating in women are important diagnostic signs that allow us to differentiate Kidney-Yin from Kidney-Yang deficiency. As mentioned in Chapter 3 on pathology, in women very often Kidney-Yin and Kidney-Yang are both deficient. The pulse may not help very much in differentiating which is predominant because very often both Rear positions are weak. The symptoms may also be confusing and present a mixture of Yin and Yang deficiency. In such cases, the tongue-body colour and presence or absence of coating are crucial and absolutely reliable signs in diagnosing whether Kidney-Yin or Kidney-Yang deficiency predominates. If the tonguebody colour is without coating, deficiency of Kidney-Yin predominates; if it is Pale, deficiency of Kidney-Yang is preponderant. 8. Although the tongue-body colour shows the true condition of the patient, it should be remembered that it does not necessarily show the whole condition. An example will clarify this concept. A woman may suffer from Liver-Blood deficiency leading to Liver-Yang rising, which causes headaches during her periods. Her tongue may be Pale reflecting the Blood deficiency and her pulse Wiry reflecting the rising of Liver-Yang. If she has other symptoms of Liver-Yang rising, such as a slightly Red complexion and a dry throat, we may be baffled by the Pale colour of the tongue: in fact, most books will say that with Liver-Yang rising the tongue (or its sides) will be Red. However, if we understand the principle that the tongue may show only a part of the configuration of patterns, we realize that the tongue is reflecting the deficiency of Liver-Blood and the pulse and symptoms the rising of Liver-Yang (Fig. 5.11).
9. The tongue coating can be very helpful to confirm a diagnosis of candidiasis. In this condition, the tongue coating is usually thin, white and sticky but rootless.
Figure 5.10 Spleen deficiency, Dampness and Blood deficiency.
Figure 5.11 Liver-Blood deficiency and Liver-Yang rising.
Summary Aspects of tongue diagnosis in gynecology
• The tongue rarely appears Thin with Blood deficiency • Liver-Qi stagnation is often not clearly visible on the tongue • Conditions such as stasis of Blood in the Uterus often show only on the sides of the tongue and not on the root • The sides of the tongue in the area between the tip and centre, which
normally reflect the chest, in women may reflect the breasts • The general appearance of the tongue is an important prognostic sign in breast cancer • A Pale and peeled tongue indicates severe deficiency of Blood • The tongue-body colour and coating in women are important diagnostic signs that allow us to differentiate Kidney-Yin from Kidney-Yang deficiency • The tongue coating can be very helpful to confirm a diagnosis of candidiasis
Auscultation Auscultation includes hearing and smelling.
Hearing
Voice A weak voice indicates Qi deficiency. Frequent sighing denotes Liver-Qi or Lung-Qi stagnation; a high-pitched voice indicates an excess condition or Heat.
Smelling
Menstrual blood A strong, foul smell usually indicates Heat. Vaginal discharge A fishy smell indicates Cold-Dampness while a leathery smell indicates Damp-Heat. End notes 1. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian ), People’s Health Publishing House, Beijing, Vol. 3, p. 10. First published in 1742..
2. Ibid., p. 10..
3. Wang Shu He 1988 A Revised Explanation of the ‘Pulse Classic’ (Mai Jing Jiao Shi ), with commentary by the Fuzhou City People’s Hospital, People’s Health Publishing House, Beijing, p. 16. First published in AD 280..
4. Nanjing College of Traditional Chinese Medicine 1979 A Revised Explanation of the Classic of Difficulties (Nan Jing Jiao Shi ), People’s Health Publishing House, Beijing, p. 50. First published c. AD 100..
5. Cheng Bao Shu 1988 An Annotated Translation of the Study of the Pulse of the Pin Hu Lake (Pin Hu Mai Xue Yi Zhu ), Ancient Chinese Medical Texts Publishing House, Beijing, p. 4. The Study of the Pulse of the Pin Hu Lake by Li Shi Zhen was first published in 1564..
6. Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 153. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang )..
7. A Revised Explanation of the Classic of Difficulties, p. 12..
8. A Revised Explanation of the Pulse Classic, p. 79..
9. Eight Secret Books on Gynaecology, p. 82..
10. Wang Luo Zhen 1985 A Compilation of the Study of the Eight Extraordinary Vessels (Qi Jing Ba Mai Kao Jiao Zhu ), Shanghai Science Publishing House, Shanghai, p. 111. The Study of the Eight Extraordinary Vessels (Qi Jing Ba Mai Kao ) by Li Shi Zhen was published in 1578..
11. 1979 The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen ), People’s Health Publishing House, Beijing, p. 56. First published c. 100 BC..
12. Eight Secret Books on Gynaecology, p. 82..
13. Ibid., p. 82..
14. Shandong College of Traditional Chinese Medicine 1980 An Explanation of the ABC of Acupuncture (Zhen Jiu Jia Yi Jing Jiao Shi
), People’s Health Publishing House, Beijing, p. 1469. The ABC of Acupuncture was written by Huang Fu Mi c. AD 259..
15. Eight Secret Books on Gynaecology, p. 82..
16. Golden Mirror of Medicine, Vol. 3, p. 47..
17. He Ren 1981 A New Explanation of the Synopsis of Prescriptions from the Golden Cabinet (Jin Gui Yao Lue Xin Jie ), Zhejiang Science Publishing House, p. 46–47. The Synopsis of Prescriptions from the Golden Cabinet was written by Zhang Zhong Jing c. AD 200..
18. Principles of Medical Practice, cited in Wang Ke Qin 1988 Theory of the Mind in Chinese Medicine (Zhong Yi Shen Zhu Xue Shuo ), Ancient Chinese Medical Texts Publishing House, p. 56..
19. Shi Pa Nan 1861 Origin of Medicine, cited in Theory of the Mind in Chinese Medicine, p. 55..
20. For a detailed discussion of tongue diagnosis, see Maciocia G 1995 Tongue Diagnosis in Chinese Medicine, 2nd edn, Eastland Press, Seattle..
SECTION 3 Methods of Treatment
CHAPTER 6 Principles and Methods of Treatment
INTRODUCTION 121 When to tonify and when to eliminate 122 Combinations of gynecological and systemic manifestations 124 Relationship among patterns, Chinese diseases and Western diseases 125 PATHOLOGY OF THE INTERNAL ORGANS 127 Kidneys 127 Liver 132 Spleen 144 Heart 149 QI AND BLOOD PATHOLOGY 152 Qi rebellious 152 Blood-Cold 154 The famous doctor of the late Ming dynasty, Zhang Jing Yue (1563– 1640) said that “To treat one woman equals treating five men”, which means that treating women is five times more difficult than treating men. The reason for this is presumably that the menstrual function adds complexity to women’s pathology and treatment. I personally find quite the opposite: I would say that treating one man equals treating five women! This is because I think that the menstrual function, rather than adding complexity to women’s pathology, actually clarifies it. In fact, the additional diagnostic signs deriving from the regularity
of the cycle, the amount of bleeding, the colour and consistency of the blood, the pre-menstrual symptoms, the conditions of pregnancy and childbirth, all these factors assist the diagnosis. In many cases, when women are seeking treatment not for gynecological but for other problems, an analysis of the menstrual symptoms is a ‘clinching’ factor. To give a simple example: a woman who presents with Painful Obstruction Syndrome is suffering aches and pain in the joints; if the pain is severe we might suspect stasis of Blood, a diagnosis confirmed if her menstrual blood is dark and clotted. ! According to Dr Zhang Jing Yue, treating a woman is five times more difficult than to treat a man. My experience shows the opposite is true. Another example: suppose a woman presents with lower abdominal pain and we are unsure about the diagnosis which may be Dampness, Qi stagnation, Blood stasis or Cold. If her menstrual blood is dark with large, dark clots, then her abdominal pain is due to Blood stasis. In this example, the menstrual symptom made the diagnosis easier, not more difficult. There are other not-strictly medical reasons why I find treating women easier that treating men. In general, women tend to be more in touch with their bodies than men are; they also tend to be more in touch with their emotions than men are. Some psychotherapists say that men take on average 9 months to reach the point in therapy where women start from. The discussion of principles of treatment will be carried out according to the following topics: • Introduction. • Pathology of the internal organs. • Qi and Blood pathology.
Introduction The steps to a successful treatment are as follows: • Correct identification of the Chinese disease-symptom (bian bing). • Correct identification of the pattern (bian zheng). • Appropriate strategy of treatment: this includes whether to tonify the body’s Qi or clear pathogenic factors or both, and timing of treatment. • Appropriate method of treatment: this includes choosing the proper method for the pattern, the disease, the patient’s condition and other factors. If acupuncture is used, in addition to the above points, a successful treatment depends on these further factors: • A correct and harmonious choice of points, including correct location. • The proper manipulation of the needles according to the methods of reinforcing or reducing (or even). This chapter will discuss the methods of treatment in herbal medicine and acupuncture for each organ. Before doing so, it is appropriate to discuss the choices facing us when deciding whether to tonify the body’s Qi or eliminate pathogenic factors, whether to heat or cool, and how to approach cases with contradictory symptoms and signs. This discussion will be conducted in three parts: 1. When to tonify and when to eliminate. 2. Combinations of gynecological and systemic manifestations. 3. Relationships among patterns, Chinese diseases and Western diseases.
When to tonify and when to eliminate The decision whether to tonify the body’s Qi or to eliminate pathogenic factors is absolutely crucial particularly when using herbal medicine. Obviously one should tonify in cases of deficiency and clear in cases where there are pathogenic factors. In practice, however, the choice is not so simple because in the overwhelming majority of cases a deficiency of the body’s Qi and the presence of pathogenic factors occur simultaneously, i.e. the condition is characterized by both Emptiness and Fullness. There are, of course, formulae that can simultaneously tonify and clear but in my experience it is often preferable to address the Fullness first by clearing pathogenic factors. In gynecology, there are many examples of conditions characterized by both Fullness and Emptiness, e.g. deficiency of the Kidney with Dampness in the genital system (e.g. in ovarian cysts or polycystic ovary syndrome), Liver-Blood deficiency with Liver-Qi stagnation or Liver-Blood stasis (e.g. in pre-menstrual tension), Spleen-Qi deficiency with Dampness (e.g. in postpartum urinary problems), Spleen-Qi deficiency with Qi stagnation (e.g. in abdominal pain), Kidney deficiency with Blood stasis (e.g. in dysmenorrhoea or endometriosis), Blood deficiency with Cold in the Uterus (e.g. in infertility), Yin deficiency with Empty-Heat (e.g. in menopausal problems), etc. If we tonify the body’s Qi (with herbal medicine) before clearing pathogenic factors, there is always the danger of clogging the body and aggravating the obstruction created by the pathogenic factors (because tonic herbs tend to be ‘cloying’). For example, if we tonify Qi and Blood with sweet and warm herbs, these may aggravate any Dampness or Heat that there is. If, on the contrary, we eliminate pathogenic factors first, the terrain is cleared for tonification so that tonic herbs will be more effective. This problem does not usually arise when only acupuncture is used. We should not look upon a clearing treatment as ‘weakening’: if the identification of pattern is correct and a clearing treatment is appropriate, the patient will actually feel better and have more energy. This is easily explained
since eliminating pathogenic factors automatically allows Qi to flow more easily and therefore perform its function better. For example, eliminating Dampness will automatically benefit Qi as this will be able to flow unhampered by the obstruction created by Dampness. In fact, if the approach of clearing pathogenic factors is used when it is indicated, the patient will nearly always feel dramatically better. The decision on whether to tonify the body’s Qi or eliminate pathogenic factors is usually based on the clinical manifestations, tongue and pulse. The pulse is particularly important in assisting this decision: if the pulse is of the Full type in general (e.g. Slippery, Wiry or Tight), then it is appropriate to eliminate pathogenic factors, while if it is of the Empty type in general (e.g. Fine, Weak, Empty, Choppy), it is appropriate to tonify the body’s Qi. Another possible approach to the treatment of complicated Full–Empty conditions in gynecology is related to the four phases of the menstrual cycle, i.e. to concentrate on treating the Full condition (i.e. expelling pathogenic factors) during the pre-menstrual phase and menstrual phase (phases 4 and 1) and to tonify the deficiency during the post-menstrual or inter-menstrual phases (phases 2 and 3). It should be noted here that the above choices in treatment strategy apply more to herbal medicine than to acupuncture as the latter works in a different way from the former. The choice between eliminating pathogenic factors and tonifying the body’s Qi in herbal medicine is clearly mirrored in herbal formulae: some eliminate pathogenic factors without tonifying (e.g. Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction) while others tonify the body’s Qi without eliminating pathogenic factors (e.g. Ba Zhen Tang Eight Precious Decoction). Thus, the choice between eliminating pathogenic factors or tonifying the body’s Qi is very clear-cut. There are, of course, formulae that tonify the body’s Qi and eliminate pathogenic factors simultaneously, but even in those, the emphasis is always on one aspect of these two choices. For example, the formula Liu Jun Zi Tang Six Gentlemen Decoction tonifies Qi and resolves Dampness, but its emphasis is on tonification. Acupuncture works in a different way from herbal medicine by
regulating the function of the channels rather than by introducing foreign substances into the body. Thus, an acupuncture point can have a dual function in tonifying the body’s Qi and eliminating pathogenic factors simultaneously. For example, Ren-12 Zhongwan tonifies the Spleen but also resolves Dampness. Of course, a different needling technique should be used in each case, i.e. reinforcing to tonify the Spleen and reducing to resolve Dampness. Nevertheless, because acupuncture does not introduce any foreign substance into the body, it works by harmonizing and regulating the channel system and therefore, although it is still important to adopt the proper treatment strategy, it has a more ‘neutral’, harmonizing and homoeostatic action than herbal medicine. Two case histories will clarify the important question of treatment principles especially in relation to herbal medicine. Case history A 42-year-old woman had been suffering from painful periods for 5 years. Her periods came usually late (every 5 weeks) and the menstrual blood was dark with small clots. The period pain was intense, of a spastic nature and alleviated by the application of a hot-water bottle. She also suffered from backache, dizziness, tiredness, frequent, pale urination and slight depression. Her tongue was Pale and wet and her pulse was Deep, Weak on both Rear positions, and Tight in general. Diagnosis This is a clear case of Blood stasis from Cold in the Uterus occurring against a background of Kidney-Yang deficiency. Treatment principle Since there is a Full condition (Blood stasis and Cold in the Uterus) and a deficiency one (Kidney-Yang deficiency), the practitioner faces a choice in
deciding what to do first: expel pathogenic factors or tonify Kidney-Yang? The decision depends on the clinical manifestations. In this case, the main presenting problem was severely painful periods. Since these are due to Blood stasis (the Manifestation), it is preferable to concentrate on eliminating pathogenic factors first, i.e. invigorating Blood, eliminating stasis and expelling Cold. Another factor that indicates the need to eliminate pathogenic factors first in this case is the Tight quality of the pulse. Although the pulse is Weak on both Rear positions, the Tight quality indicates the presence of pathogenic factors, so it is preferable to concentrate on eliminating them. Had the pulse been Weak in all positions and the periods only slightly painful, then it might have been preferable to concentrate on tonifying Kidney-Yang. Case history A 36-year-old woman had been trying to conceive for 4 years. Her menstrual cycle was long (34–35 days) and getting longer, the period lasted 5–7 days, it was painful and the menstrual blood was dark with clots. She also experienced abdominal pain before the period. She had been diagnosed as having endometriosis and a cyst on the right ovary. She had undergone two IVF treatments without success. She had also been suffering from night sweating for 5 years, the sweating occurring for 10 days before the period and also during it. On interrogation, it transpired that she also experienced the following symptoms: dizziness, frequent, pale urination, feeling cold, chilblains, floaters, poor memory, tingling of limbs, tiredness and thrush. Her tongue was very sightly Red on the sides and very slightly peeled in the centre, and had a sticky-yellow coating. Her pulse was Slippery on the right side and Empty at the deep level on the left side. Diagnosis This patient presents a complex picture with various patterns, some Empty and some Full in nature. On the Full side, there is Liver-Qi and Liver-Blood
stasis (abdominal pain before the period, Red sides of the tongue, painful period with dark, clotted blood), and Dampness (thrush, sticky-yellow coating, ovarian cyst, Slippery pulse). On the Empty side, there is KidneyYang deficiency (late cycle, frequent, pale urination, tiredness, dizziness, feeling cold, chilblains), Blood deficiency (floaters, poor memory, tingling of limbs) and the very beginning of Yin deficiency (tongue peeled in centre, night sweating and Empty pulse at the deep level). Treatment principle Faced with such a complex condition, treatment could be approached from many different angles but the chief choice to make is whether we want to deal with the Full or the Empty condition first. I usually prefer to start by eliminating pathogenic factors first because encumbrances are thus removed and the terrain is prepared on which tonics work better. If we start by tonifying the body’s Qi, the sweet and sticky nature of tonic herbs may aggravate the Full conditions. In this case, I therefore opted for resolving Dampness and moving Qi first, using a modification of the formula Si Miao San Four Wonderful Powder: • Cang Zhu Rhizoma Atractylodis 6 g • Huang Bo Cortex Phellodendri 4 g • Yi Yi Ren Semen Coicis 9 g • Chuan Niu Xi Radix Cyathulae 4 g • Chen Pi Pericarpium Citri reticulatae 3 g • Fu Ling Poria 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Xiang Fu Rhizoma Cyperi 6 g • Ze Lan Herba Lycopi 4 g
• Dang Gui Radix Angelicae sinensis 6 g • Tu Si Zi Semen Cuscutae 4 g
Explanation
• The first four herbs constitute the formula Si Miao San Four Wonderful Powder which drains Damp-Heat from the Lower Burner. • Chen Pi, Fu Ling and Ban Xia help to resolve Dampness. • Xiang Fu moves Qi and eliminates stagnation. • Ze Lan invigorates Blood and eliminates stasis and it also helps to resolve Dampness. • Dang Gui pacifies the Liver and nourishes Blood. • Tu Si Zi tonifies Kidney-Yang.
Thus, although this prescription contains a Blood and a Kidney tonic, its main impact is to drain Dampness and move Qi. After only 15 days of taking this formula, the patient had a period which came 28 days after the previous one; it was already less painful and less dark; her night sweating lasted only 2 nights rather than 10. I continued with a modification of this prescription for 3 months until most of the symptoms of Dampness and stagnation had gone, and then followed it up with a formula to tonify Kidney-Yang and to nourish Blood.
Combinations of gynecological and systemic manifestations We can distinguish three possible situations: one where the gynecological and systemic signs simply coexist with each other, one where there is a causal interaction between them and another where the gynecological signs contradict each other. Coexistence manifestations
of
contradictory
gynecological
and
systemic
Coexistence of contradictory gynecological and systemic manifestations is very common: for example, a woman may suffer from heavy periods with shortened cycle and dark red menstrual blood clearly indicating Blood-Heat, but also from tiredness, loose stools, chilliness, poor appetite, a Weak pulse and a Pale tongue, indicating Spleen-Yang deficiency. In such a case, the condition of Blood-Heat and the Spleen-Yang deficiency simply coexist with no causal relationship between them. This often arises when two different aetiological factors occur at different stages of life. For example, Blood-Heat may arise early in life through emotional problems leading to Liver-Fire, and Spleen deficiency may arise later in life through overwork. The treatment strategy in a case such as the one above depends on the relative severity of symptoms and on the history. Obviously, if the periods are very heavy to the point that the patient needs to stay at home for 3 or 4 days, then these should be treated first, ignoring the Spleen-Yang deficiency. Vice versa, if the periods are heavy but not to the point of interfering with the patient’s normal life while the symptoms of Spleen deficiency are severe with a pronounced tiredness, then it might be preferable to treat the Spleen deficiency first. The history of the condition is also important in deciding upon a treatment strategy. For example, in the above case, if the patient had been suffering from heavy periods for a very long time, then it might be preferable to treat the Spleen deficiency first. On the other hand, if previously normal
periods had suddenly become heavy, causing great inconvenience, then one should treat the Blood-Heat first. However, the treatment alternatives are not necessarily mutually exclusive; in the above example, one would add one or two herbs to tonify the Spleen in a cooling-Blood prescription, or one or two herbs to cool Blood in a Spleen-tonifying one. Interacting gynecological and systemic manifestations An interaction of gynecological and systemic manifestations is also common in gynecological conditions and it happens when a certain gynecological pathology leads to a systemic pathology or vice versa. For example, if a woman suffers from heavy periods, say from Blood-Heat, for many years, the excessive loss of blood over the years may lead to Blood deficiency and this, in turn, to Qi deficiency. In such cases, one usually needs to treat both pathological conditions because there is a causal relationship between them. Thus, in the above example, one would have to add Qi and Blood tonics to a Blood-cooling prescription. Contradiction among gynecological manifestations Contradiction in gynecological manifestations is also a very common situation. As we discussed in Chapter 5 on diagnosis, the length of the cycle, the amount of menstrual bleeding and the colour of the menstrual blood normally agree. For example, if a woman suffers from Blood-Heat, the cycle is short, the period too heavy and the colour bright red or dark red. Similarly, if a woman suffers from Blood stasis, the cycle is irregular, the bleeding probably heavy, the menstrual blood dark with clots and the period painful. However, in practice, contradictory signs often occur. For example, in the above case, the cycle might be short and the period heavy but the blood dark with clots rather than bright red. This would simply indicate that in addition to Blood-Heat there is also Blood stasis. Another example of contradictory signs could be that of a woman
suffering from a short cycle with bright red blood indicating Blood-Heat but with a scanty flow. The latter could be due to Cold, Blood deficiency or Blood stasis. As the first two conditions may be excluded, it simply follows that in addition to Blood-Heat there is also Blood stasis. Generally speaking, when contradictory gynecological signs appear, the treatment principle should be chosen according to the severity of manifestations and the tongue. Thus, if the period is very heavy and the blood is bright red, Blood-Heat is indicated; the cycle may be long, which contradicts this diagnosis, but we can safely treat the patient for Blood-Heat despite other contradictory signs. Second, the tongue-body colour assists the diagnosis of contradictory conditions greatly. In the above example, if the tongue-body colour were Red, there would be no doubt about Blood-Heat being the main aspect of the contradiction, even if the cycle were long. Similarly, supposing the patient has a short cycle and the period is heavy (indicating Blood-Heat) but also painful (indicating Blood stasis), if the tongue is Purple, we can safely treat Blood stasis first with a Bloodinvigorating prescription modified with the addition of some Blood-cooling herbs.
Relationship among patterns, Chinese diseases and Western diseases In our clinical practice, we can identify three types of clinical interpretation of symptoms and signs: the Western diagnosis with its categorization into a Western disease (e.g. ‘ovarian cysts’ or ‘endometriosis’), the Chinese diagnosis with its categorization into a Chinese ‘disease’ (e.g. Painful Periods or Late Periods) and the Chinese pattern identification (e.g. Liver-Qi stagnation or Kidney-Yang deficiency). Let us analyse first the relationship between the Western diagnosis and the Chinese diagnosis. Western diagnosis and its corresponding categorization of Western disease obviously creates a system of medicine quite different from the Chinese, with an entirely different philosophy of the human body and disease. The two systems, however, are not contradictory but simply different because they move from entirely different paradigms. In fact, the two systems are perfectly complementary because they are so different and, for this reason, we should never discount Western diagnosis as in this field the two systems dovetail perfectly. Chinese medicine can diagnose imbalances of Qi and Blood but not much in the way of actual organic diseases: for example, if a woman suffers from abdominal pain deriving from ovarian cysts that are not palpable, then this problem would fall under the disease category of ‘Abdominal Pain’ in Chinese medicine, but a Chinese doctor would not know that the pain is due to the ovarian cysts. So we should take account of Western diagnosis; in a few cases, it may also signpost a Chinese disease categorization different from the norm. For example, a condition is categorized as ‘Abdominal Masses’ when there are palpable abdominal masses: if there are internal tumours that are not palpable, then an ancient Chinese doctor could not have categorized the condition under this heading. Thus, if a woman is diagnosed as suffering from ovarian cysts, this condition would belong to the category of ‘Abdominal Masses’ even though they are not palpable: this is an example of a case when we should actually rely on a Western diagnosis as well as on a Chinese one.
Treating according to Chinese diagnosis with its categorization into Chinese diseases and patterns is never ‘wrong’, and, in the above example, if we had diagnosed the Chinese disease of ‘Abdominal Pain’ and differentiated it correctly, identifying the patterns of, say, Liver-Blood stasis and Damp-Heat, our treatment would not be wrong and would yield some results. However, if we take the Western diagnosis into account as well, our treatment will be more effective because, knowing that we are dealing with actual tumours, we will add herbs that dissolve lumps and soften masses. In some cases, however, the Western diagnosis may not add any useful information to our diagnosis or treatment strategy. For example, if a patient suffers from abdominal pain, it will not change our diagnosis or treatment whether he or she suffers from irritable bowel syndrome or diverticulitis. However, in many cases the Western diagnosis is important for prognosis: the most striking example of this is in breast lumps because the prognosis is obviously very different according to whether they are benign or malignant. In any case, in many instances, the patient has had no Western diagnosis because no Western disease was found. For example, in my practice, out of a total of 1531 cases, 692, or 45%, had had no Western diagnosis. Finally, the diagnosis of a Chinese disease often clears a difficult case when there is no corresponding Western diagnosis. For example, a complex gynecological case, entirely baffling to Western doctors, may be clearly identified as a Penetrating Vessel disease. As for the relationship between Chinese disease categories (such as ‘Abdominal Pain’ or ‘Painful Periods’) and Chinese patterns (such as LiverQi stagnation), this is of great importance. Pattern identification (bian zheng) is often emphasized to the detriment of (Chinese) disease identification (bian bing), and yet the latter is also important. Identifying the Chinese disease properly makes the treatment according to patterns more focused and ultimately more effective. Treating according to pattern identification only may not be enough: for example, we may correctly identify a pattern of Liver-Yin deficiency in two patients but, if one suffers from Menopausal Problems and the other from Atrophy Syndrome, the treatment will be very different in each case. Clavey
makes this point eloquently: If one’s selection of diagnosis is incorrect the focus of treatment will be skewed, and then even proper identification of the symptom pattern differentiation will only serve to help the patient in a general way.1 Thus both disease and pattern identification are necessary in Chinese medicine; problems may arise when a patient suffers from more than one Chinese disease. For example, it is not unusual for a woman to suffer from Painful Periods, Pre-Menstrual Syndrome and Heavy Periods: in such a case, which Chinese disease should we treat? The answer depends largely on two factors, i.e. the relative severity of each problem and the regularity or irregularity of the menstrual cycle. In the above example of a woman suffering from those three conditions, obviously if her periods are so painful that she is debilitated for 5 days each month, being unable to work, then we should treat Painful Periods as the main disease. Alternatively, should her period be so heavy and flooding that she must be confined to the house for over a week each month because of the flooding rather than the pain, then we should obviously treat Flooding and Trickling as the main disease. The regularity (or irregularity) of the cycle is also very important. Often, but not always, an irregularity of the cycle takes precedence over other conditions. For example, if a woman’s period comes every 6–7 weeks and is scanty, it would be totally wrong to treat this as a case of Scanty Periods; regulating the cycle is more important. Similarly, if a woman has a period every 2–3 weeks and the period is mildly painful, it would also be wrong to treat this as a case of Painful Periods; it is best treated as a case of Early Periods. Very often, regulating the cycle also regulates other aspects of the period, such as any pain or pre-menstrual tension. In any case, if we prescribe herbal medicine we can adapt any formula that regulates the cycle to treat other symptoms such as pain or pre-menstrual tension. However, in some very complicated cases when a woman suffers from many different symptoms and Chinese diseases, it might be sometimes necessary to ignore the various Chinese diseases and simply treat according
to patterns. In conclusion, treating according to Chinese disease identification is important but it should not become a strait-jacket limiting our therapeutic intervention. Finally, there are certain treatment methods that should not be used during the periods. In particular, one should not cause sweating in case of invasions of Wind occurring during the period. Thus one should not use herbs such as Ma Huang Herba Ephedrae, Gui Zhi Ramulus Cinnamomi, Fang Feng Radix Saposhnikoviae or Qiang Huo Rhizoma seu Radix Notopterygii. This is because during the period the blood vessels are ‘open’ and the channels vulnerable; to expel Wind during the periods, it is preferable to adopt the method of harmonizing Nutritive and Defensive Qi with a formula such as Gui Zhi Tang Ramulus Cinnamomi Decoction.
Pathology of the internal organs I shall discuss the various methods of treatment focusing on each of the Yin organs with the exception of the Lungs as they do not have a direct influence on gynecological problems. Lung-Qi deficiency plays an indirect role in excessive bleeding from Qi not holding blood, but this is always associated with, and secondary to, Spleen-Qi deficiency. Thus, the discussion will be conducted according to the following topics: • Kidneys. • Liver. • Spleen. • Heart.
Kidneys Since the Kidneys can only be deficient, the methods of treatment for this organ consist only in tonification. They are: • tonify Kidney-Yang • strongly tonify Kidney-Yang and stoke up the Fire of the Gate of Life • nourish Kidney-Yin • nourish Kidney-Essence • tonify both Kidney-Yang and Kidney-Yin. Tonify Kidney-Yang Tonifying Kidney-Yang is applicable in deficiency of Kidney-Yang which may cause amenorrhoea, infertility, early periods, heavy periods or miscarriage. In pure deficiency of Kidney-Yang there will be chilliness, frequent, pale urination, backache, pale complexion, slight depression, Pale tongue and Deep-Weak pulse. Typical herbs are Rou Gui Cortex Cinnamomi, Ba Ji Tian Radix Morindae officinalis, Yin Yang Huo Herba Epimedii, Tu Si Zi Semen Cuscutae, Suo Yang Herba Cynomorii, Fu Pen Zi Fructus Rubi, Du Zhong Cortex Eucommiae, Xu Duan Radix Dipsaci, etc. Representative formulae are You Gui Wan Restoring the Right [Kidney] Pill, You Gui Yin Restoring the Right [Kidney] Decoction and Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill. Among the Three Treasures formulae, Strengthen the Root tonifies Kidney-Yang. Among the Women’s Treasure formulae, Unicorn Pearl, Warm the Palace and Ease the Journey-Yang tonify Kidney-Yang. The herbs and prescriptions that tonify Kidney-Yang are obviously
warm or hot and care must be taken that there is no Heat anywhere. In fact, it would not be unusual for a patient to suffer from Kidney-Yang deficiency and Damp-Heat in the Bladder: in such a case, the use of one of the above formulae would be contraindicated. There are two methods to tonify Kidney-Yang in gynecology. The first is to tonify Fire from Water, i.e. stoking up Fire by nourishing Water which means obtaining Yang from Yin. As mentioned in Chapter 3 on pathology, Water and Fire are inseparable and mutually nourishing, especially so in women. Thus, in order to tonify Fire it is necessary to nourish Yin as well so that the newly-generated Fire does not consume Water: if we recall the metaphor of the oil lamp (see Figure 3.1), when we increase the flame, the oil is consumed at a speedier rate. In applying the method of obtaining Fire from Water, relatively large amounts of Yang tonics are added to Yin tonics. This method is clearly reflected in Zhang Zhong Jing’s Jin Gui Shen Qi Wan Golden Chest KidneyQi Pill which contains the six herbs forming Liu Wei Di Huang Wan SixIngredient Rehmannia Pill to nourish Kidney-Yin, plus Rou Gui Cortex Cinnamomi (or Gui Zhi Ramulus Cinnamomi) and Fu Zi Radix Aconiti lateralis preparata. You Gui Wan (Yin) Restoring the Right [Kidney] Pill (Decoction) formulated by Zhang Jing Yue according to this same principle is also widely used. The second method of tonifying Yang is that of tonifying Yang by strengthening Qi: this is achieved by adding Yang tonics to Qi-tonifying formulae. By so doing, we tonify both the Spleen and Kidneys for the purpose of restoring Kidney-Yang. This method is applied when there is a deficiency of both Spleen and Kidneys and it is reflected in the formulae Zhen Wu Tang True Warrior Decoction, and Hua Shui Zhong Zi Tang Transforming Water and Planting a Seed Decoction, Jian Gu Tang Strengthening and Consolidating Decoction, Yuan Tu Gu Tai Tang Helping the Earth and Consolidating the Fetus Decoction, and Wen Bao Yin Warming the Uterus Decoction, all in Fu Qing Zhu’s Gynecology (Fu Qing Zhu Nu Ke). This method of treatment is particularly indicated when, in addition to Kidney-Yang deficiency, the Spleen is also deficient and there is
some Dampness, an extremely common occurrence in practice. Acupuncture
The main points to tonify Kidney-Yang are: BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, KI-7 Fuliu, Ren-4 Guanyuan, and KI-13 Qixue with moxa. Although various authors differentiate the action of different Kidney points according to their ability to tonify Kidney-Yin or Kidney-Yang (e.g. KI-7 Fuliu for Kidney-Yang and KI-6 Zhaohai for Kidney-Yin), in my opinion the most important differentiation in tonifying Kidney-Yin or Kidney-Yang is in the use of moxa; in other words, any Kidney point can tonify Kidney-Yang or Kidney-Yin depending on whether one uses moxa or not (obviously moxa is used for Kidney-Yang deficiency).2 Thus, the above-mentioned points should be used with moxa to tonify Kidney-Yang. The moxa could be used on the needle or as moxa cones on the skin. The use of moxa cones on Ren4 Guanyuan is particularly effective, while KI-3 Taixi is very effective when used with a warm needle (i.e. moxa on the needle). The use of BL-23 Shenshu is particularly important as, being on the Yang surface, it does have a tendency to tonify Yang. The use of the BackTransporting points is particularly important in chronic diseases. Summary Tonify Kidney-Yang
Gynecological symptoms
Amenorrhoea, infertility, early periods, heavy periods or miscarriage General manifestations
Chilliness, frequent, pale urination, backache, dizziness, tinnitus, pale complexion, slight depression, Pale tongue and Deep-Weak pulse Herbs
Rou Gui Cortex Cinnamomi, Ba Ji Tian Radix Morindae officinalis, Yin Yang Huo Herba Epimedii, Tu Si Zi Semen Cuscutae, Suo Yang Herba Cynomorii, Fu Pen Zi Fructus Rubi, Du Zhong Cortex Eucommiae, Xu Duan Radix Dipsaci, etc. Formulae
Representative formulae are You Gui Wan Restoring the Right [Kidney] Pill, You Gui Yin Restoring the Right [Kidney] Decoction and Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill Three Treasures or Women’s Treasure formulae
Strengthen the Root, Unicorn Pearl, Warm the Palace and Ease the Journey-Yang tonify Kidney-Yang Acupuncture
BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, KI-7 Fuliu, Ren-4 Guanyuan, and KI-13 Qixue with moxa Strongly tonify Kidney-Yang and stoke up the Fire of the Gate of Life Tonifying Kidney-Yang and stoking up the Fire of the Gate of Life (Ming Men) is used when there is a very pronounced deficiency of Kidney-Yang
and decline of the Fire of the Gate of Life without any signs of Kidney-Yin deficiency. The main manifestations are infertility, amenorrhoea, mental depression, feeling cold, cold limbs, very frequent and pale urination, incontinence of urine, nocturia, backache, a feeling of cold in the back and knees, a very Pale and wet tongue and a Deep, Weak and Slow pulse. In this case, there are very pronounced symptoms and signs of severe Kidney-Yang deficiency and decline of the Fire of the Gate of Life. One therefore adopts the method of tonifying and warming the Fire of the Gate of Life, without nourishing Yin as in the previous case. Obviously, this method should be used only in the complete absence of any Heat signs. The main herbs that stoke up the Fire of the Gate of Life are Rou Gui Cortex Cinnamomi, Lu Rong Cornu Cervi pantotrichum, Xian Mao Rhizoma Curculiginis and Fu Zi Radix Aconiti lateralis preparata. Any of the other Kidney-Yang tonics mentioned above is also applicable. Representative formulae are Zan Yu Dan Aiding Fertility Pill and Tu Si Zi Wan Cuscuta Pill. Among the Women’s Treasure formulae, Unicorn Pearl, Warm the Palace and Ease the Journey-Yang tonify Kidney-Yang and the Minister Fire. Acupuncture
The main points to stoke up the fire of the Gate of Life are basically the same as those that tonify Kidney-Yang: BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, KI-7 Fuliu, Ren-4 Guanyuan, and KI-13 Qixue with moxa. In addition to these, an important point to use is Du-4 Mingmen with moxa: the use of this point with direct moxa (cones) is the closest acupuncture can get to using Rou Gui Cortex Cinnamomi and Fu Zi Radix Aconiti lateralis preparata. Summary Strongly Tonify Kidney-Yang and stoke up the fire of the Gate of Life
Gynecological symptoms
Infertility, amenorrhoea General manifestations
Mental depression, feeling cold, cold limbs, very frequent and pale urination, incontinence of urine, nocturia, backache, a feeling of cold in the back and knees, a very Pale and wet tongue and a Deep, Weak and Slow pulse Herbs
Rou Gui Cortex Cinnamomi, Lu Rong Cornu Cervi pantotrichum, Xian Mao Rhizoma Curculiginis and Fu Zi Radix Aconiti lateralis preparata Formulae
Zan Yu Dan Aiding Fertility Pill and Tu Si Zi Wan Cuscuta Pill Women’s Treasure formulae
Unicorn Pearl, Warm the Palace and Ease the Journey-Yang Acupuncture
BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, KI-7 Fuliu, Ren-4 Guanyuan, and KI-13 Qixue with moxa Nourish Kidney-Yin
Nourishing Kidney-Yin is adopted in cases of deficiency of Yin. There are several variations of this method according to the condition. They are: • mildly nourish Yin • strongly nourish Yin • nourish Yin and clear Empty-Heat • nourish Yin and Blood • nourish Yin and astringe. The main manifestations of Kidney-Yin deficiency are infertility, menorrhagia, habitual miscarriage, menopausal problems, backache, dizziness, tinnitus, a feeling of heat, malar flush, night sweating, a FloatingEmpty or Fine-Rapid pulse and a Red tongue without coating. The main Kidney-Yin tonics used in gynecology are Sheng Di Huang Radix Rehmanniae, Shu Di Huang Radix Rehmanniae preparata (this herb nourishes Blood primarily but it features in many Yin-nourishing formulae), Gou Qi Zi Fructus Lycii, Nu Zhen Zi Fructus Ligustri lucidi, Tian Men Dong Radix Asparagi and Gui Ban Plastrum Testudinis. Herbs that clear Empty-Heat and are especially used in gynecology include Han Lian Cao Herba Ecliptae, Qing Hao Herba Artemisiae annuae, Qin Jiao Radix Gentianae macrophyllae, Di Gu Pi Cortex Lycii, Ze Xie Rhizoma Alismatis, Xuan Shen Radix Scrophulariae, Zhi Mu Radix Anemarrhenae and Mu Dan Pi Cortex Moutan. Herbs that nourish Yin and astringe are Wu Wei Zi Fructus Schisandrae, Shan Zhu Yu Fructus Corni, Suan Zao Ren Semen Ziziphi spinosae, Mu Li Concha Ostreae, Long Gu Fossilia Ossis mastodi and Fu Pen Zi Fructus Rubi. Astringent herbs are added to Yin-nourishing formulae either to stop bleeding or to stop sweating, especially night sweating. This method is often used in night sweats from Yin deficiency during the menopause. Examples of Yin-nourishing formulae for a mild condition are Liang Di
Tang Two ‘Di’ Decoction and Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill. Examples of Yin-nourishing formulae for a severe condition are San Jia Fu Mai Tang Three-Shell Restoring the Pulse Decoction and Zuo Gui Wan (Yin) Restoring the Left [Kidney] Pill (Decoction). Among the Three Treasures formulae, Nourish the Root nourishes Kidney-Yin. Among the Women’s Treasure formulae, Ease the Journey-Yin, Female Treasure and Heavenly Empress nourish Kidney-Yin and clear Empty-Heat while Nourish Yin and Restrain the Flow and Growing Jade nourish Kidney-Yin. Examples of formulae that nourish Yin and clear Empty-Heat are Qing Hao Bie Jia Tang Artemisia-Amyda Decoction, Qing Gu San Clearing the Bones Powder and Qing Jing San Clearing the Menses Powder. Representative formulae that nourish both Yin and Blood are Gui Shao Di Huang Tang Angelica-Paeonia-Rehmannia Decoction, and Yang Jing Zhong Yu Tang Nourishing the Essence and Planting Jade Decoction. Acupuncture
The main points to nourish Kidney-Yin are Ren-4 Guanyuan, KI-6 Zhaohai, KI-3 Taixi, KI-13 Qixue, KI-10 Yingu, KI-9 Zhubin, and SP-6 Sanyinjiao, without moxa. In addition to these, BL-23 Shenshu and BL-52 Zhishi may also be used even though they may tend to tonify Kidney-Yang (as explained above): without moxa, they may be used to tonify Kidney-Yin especially when the patient suffers from backache or from a pronounced physical and mental exhaustion (as these points strengthen the Will-Power, Zhi). I use KI-9 Zhubin for its mental effect in Kidney deficiency: it nourishes the Kidneys and calms the Mind, relieving anxiety. Summary Nourish Kidney-Yin
Gynecological symptoms
Infertility, menorrhagia, habitual miscarriage, menopausal problems General manifestations
Backache, dizziness, tinnitus, a feeling of heat, malar flush, night sweating, a Floating-Empty or Fine-Rapid pulse and a Red tongue without coating Herbs
Sheng Di Huang Radix Rehmanniae, Shu Di Huang Radix Rehmanniae preparata, Gou Qi Zi Fructus Lycii, Nu Zhen Zi Fructus Ligustri lucidi, Tian Men Dong Radix Asparagi and Gui Ban Plastrum Testudinis, Han Lian Cao Herba Ecliptae, Qing Hao Herba Artemisiae annuae, Qin Jiao Radix Gentianae macrophyllae, Di Gu Pi Cortex Lycii, Ze Xie Rhizoma Alismatis, Xuan Shen Radix Scrophulariae, Zhi Mu Radix Anemarrhenae, Mu Dan Pi Cortex Moutan, Wu Wei Zi Fructus Schisandrae, Shan Zhu Yu Fructus Corni, Suan Zao Ren Semen Ziziphi spinosae, Mu Li Concha Ostreae, Long Gu Fossilia Ossis mastodi and Fu Pen Zi Fructus Rubi Formulae
Liang Di Tang Two ‘Di’ Decoction, Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill, San Jia Fu Mai Tang Three-Shell Restoring the Pulse Decoction and Zuo Gui Wan (Yin) Restoring the Left [Kidney] Pill (Decoction), Qing Hao Bie Jia Tang Artemisia-Amyda Decoction, Qing Gu San Clearing the Bones Powder, Qing Jing San Clearing the Menses Powder, Gui Shao Di Huang Tang Angelica-Paeonia-Rehmannia Decoction, and Yang Jing Zhong Yu Tang Nourishing the Essence and Planting Jade Decoction Three Treasures or Women’s Treasure formulae
Nourish the Root, Ease the Journey-Yin, Female Treasure and Heavenly Empress, Nourish Yin and Restrain the Flow and Growing Jade Acupuncture
Ren-4 Guanyuan, KI-6 Zhaohai, KI-3 Taixi, KI-13 Qixue, KI-10 Yingu, KI-9 Zhubin, and SP-6 Sanyinjiao, without moxa Nourish the Kidney-Essence The Kidney-Essence has a Yin and a Yang aspect and its deficiency can therefore manifest with symptoms of either Yin or Yang deficiency. Apart from the manifestations pertaining to a background of Yin or Yang deficiency, the main manifestations of Kidney-Essence deficiency are weak knees, poor memory, weak bones, osteoporosis, loose teeth, falling or prematurely greying hair, infertility and primary amenorrhoea. Herbs that nourish the Essence include Wu Wei Zi Fructus Schisandrae, Tu Si Zi Semen Cuscutae, Huang Jing Rhizoma Polygonati, Lu Rong Cornu Cervi pantotrichum, Gou Qi Zi Fructus Lycii and Zi He Che Placenta hominis. There is no specific category of formulae that nourish the Essence. However, any of the formulae tonifying Kidney-Yang or nourishing KidneyYin can nourish the Essence if it includes one or more of the abovementioned herbs. Acupuncture
There are no points that nourish the Essence specifically and any of the points mentioned above may be used, with or without moxa depending on whether there is a deficiency of Yang or not: Ren-4 Guanyuan, KI-6 Zhaohai, KI-3
Taixi, SP-6 Sanyinjiao, BL-23 Shenshu, BL-52 Zhishi, KI-13 Qixue and KI-7 Fuliu. Of these, the three points that most nourish the Essence would be Ren-4, KI-13 and BL-52. Summary Nourish the Kidney-Essence
Gynecological symptoms
Primary infertility, amenorrhoea General manifestations
Weak knees, poor memory, weak bones, osteoporosis, loose teeth, falling or prematurely greying hair Herbs
Wu Wei Zi Fructus Schisandrae, Tu Si Zi Semen Cuscutae, Huang Jing Rhizoma Polygonati, Lu Rong Cornu Cervi pantotrichum, Gou Qi Zi Fructus Lycii and Zi He Che Placenta hominis Formulae
Any of the formulae tonifying Kidney-Yang or nourishing Kidney-Yin with the addition of herbs that nourish Kidney-Essence Acupuncture
Ren-4 Guanyuan, KI-6 Zhaohai, KI-3 Taixi, SP-6 Sanyinjiao, BL-23
Shenshu, BL-52 Zhishi, KI-13 Qixue and KI-7 Fuliu Tonify both Kidney-Yang and Kidney-Yin As explained in Chapter 3 on pathology, a simultaneous deficiency of both Kidney-Yang and Kidney-Yin is very common in women; however, this is never a 50–50 situation and the deficiency of one will always predominate. When treating this condition, therefore, one must make a clear diagnosis of the condition to decide whether there is a predominance of Kidney-Yang or Kidney-Yin deficiency. In the former case, one selects a formula that tonifies Kidney-Yang and modifies it with the addition of some Yin tonics. Vice versa applies in the case of a predominance of Kidney-Yin deficiency. There is no specific category of formulae to tonify both Kidney-Yang and Kidney-Yin and one would simply add a few Kidney-Yin tonics to a Yang-tonifying prescription or a few Kidney-Yang tonics to a Yin-nourishing prescription. The structure and composition of certain classical formulae, however, are based on the principle of tonifying both Yin and Yang. For example, Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill is based on the formula Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill which nourishes Kidney-Yin, with the addition of two Yang tonics, Fu Zi Radix Aconiti lateralis preparata and Rou Gui Cortex Cinnamomi (or Gui Zhi Ramulus Cinnamomi). The modern formula Er Xian Tang Two Immortals Decoction, used for menopausal problems from a deficiency of both Kidney-Yin and Kidney-Yang, also combines herbs that strongly tonify Kidney-Yang with herbs that nourish Yin and clear Empty-Heat. Among the Women’s Treasure formulae, Ease the Journey-Yin and Ease the Journey-Yang tonify both Yin and Yang when there is a predominance of Kidney-Yin or Kidney-Yang deficiency respectively: they are both used for menopausal problems. Acupuncture
Any of the points mentioned above for Kidney-Yang and Kidney-Yin deficiency may be used: Ren-4 Guanyuan, KI-13 Qixue, KI-3 Taixi, KI-6 Zhaohai, KI-7 Fuliu, KI-10 Yingu, KI-9 Zhubin, BL-23 Shenshu and BL-52 Zhishi. These points should all be used without moxa. In complicated cases of deficiency of both Kidney-Yang and KidneyYin, acupuncture is often better than herbal medicine because it is more ‘neutral’ as, for example, simply using KI-3 Taixi will tonify Kidney-Yang or Kidney-Yin as needed. Summary Tonify both Kidney-Yang and Kidney-Yin
Gynecological symptoms
Infertility, scanty periods, amenorrhoea, irregular periods General manifestations
Dizziness, tinnitus, backache, night sweating, cold feet, frequent, pale urination, Weak pulse on both Rear positions Formulae
Er Xian Tang Two Immortals Decoction Women’s Treasure formulae
Ease the Journey-Yin and Ease the Journey-Yang. Acupuncture
Ren-4 Guanyuan, KI-13 Qixue, KI-3 Taixi, KI-6 Zhaohai, KI-7 Fuliu, KI10 Yingu, KI-9 Zhubin, BL-23 Shenshu, and BL-52 Zhishi
Liver There are six treatment methods related to the Liver: 1. Nourish the Liver. 2. Pacify the Liver and eliminate stagnation of Qi. 3. Pacify the Liver and eliminate stasis of Blood. 4. Clear Liver-Heat by pacifying the Liver. 5. Drain Liver-Fire. 6. Subdue Liver-Yang or extinguish Liver-Wind. The above treatment methods are extremely important in gynecology given the importance of the Liver in all gynecological functions and pathology. Nourish the Liver To nourish the Liver means nourishing Liver-Blood or Liver-Yin. A deficiency of Liver-Blood and/or Liver-Yin may be at the root of amenorrhoea or infertility. Clinical manifestations include poor memory, insomnia, blurred vision, dry eyes, dry hair, tingling of the limbs, a Pale and dry tongue and a Choppy or Fine pulse. The chief herb to nourish Liver-Blood is of course Dang Gui Radix Angelicae sinensis and others include Shu Di Huang Radix Rehmanniae preparata, Gou Qi Zi Fructus Lycii, Sang Ji Sheng Herba Taxilli, Bai Shao Radix Paeoniae alba and Long Yan Rou Arillus Longan. Formulae that nourish Liver-Blood include Si Wu Tang Four Substances Decoction, Ba Zhen Tang Eight Precious Decoction, Dang Gui Shao Yao San Angelica-Paeonia Powder and many others, many of which are based on Si Wu Tang. The formula Si Wu Tang Four Substances
Decoction forms the basis for endless variations which can treat most menstrual problems. For example, the book Essential Methods of Dan Xi (1347) mentions several variations of this formula: For late periods with scanty blood use Si Wu Tang plus Dang Shen and Bai Zhu. If there is Phlegm and leucorrhea add Ban Xia and Chen Pi [to Si Wu Tang]. If there is Blood-Heat and the periods are irregular use Si Wu Tang plus Huang Lian. If there is Blood-Heat and the menstrual blood has clots and is painful use Si Wu Tang plus Xiang Fu and Huang Lian. If there is Blood deficiency and the periods are late use Si Wu Tang plus Huang Qi, Chen Pi and Sheng Ma. If there is backache and abdominal pain during the period with stagnation of Qi and stasis of Blood use Si Wu Tang plus Hong Hua, Tao Ren, E Zhu, Yan Hu Suo, Xiang Fu and Mu Xiang. If there is Heat and the menstrual blood is dark with clots use Si Wu Tang plus Huang Lian and Chai Hu. If the Blood is dried up and there is amenorrhoea use Si Wu Tang plus Tao Ren and Hong Hua. If there is abdominal pain during the period use Si Wu Tang plus Chen Pi, Yan Hu Suo, Mu Dan Pi and Gan Cao. If there is Yin deficiency with scanty urination, body aches and amenorrhoea use Si Wu Tang plus Cang Zhu, Niu Xi, Chen Pi and Gan Cao.3 A formula that nourishes Liver-Yin is Yi Guan Jian One Linking Decoction. Nearly all the formulae that nourish Kidney-Yin also nourish Liver-Yin. Among the Three Treasures formulae, several nourish LiverBlood when this occurs in combination with other pathologies: Brocade Sinews (with Wind-Dampness in the joints), Brighten the Eyes (with eye problems), Glorious Sea (with skin problems), Bend Bamboo (with LiverYang rising), Freeing the Moon (with Liver-Qi stagnation) and Root the Spirit (with insomnia). Of the Women’s Treasure formulae, Precious Sea, Warm the Palace, Free-Flowing Sea and Planting Seeds nourish LiverBlood (some of these also tonify the Kidneys). Acupuncture
The main points to nourish Liver-Blood are: LIV-8 Ququan, Ren-4 Guanyuan, SP-6 Sanyinjiao, BL-18 Ganshu, BL-17 Geshu and ST-36 Zusanli. BL-17 Geshu nourishes when used with direct moxa and in conjunction with BL-18 Ganshu. Summary Nourish the Liver
Gynecological symptoms
Amenorrhoea, scanty periods or infertility General manifestations
Insomnia, blurred vision, dry eyes, dry hair, tingling of limbs, a Pale and dry tongue and a Choppy or Fine pulse Herbs
Dang Gui Radix Angelicae sinensis, Shu Di Huang Radix Rehmanniae preparata, Gou Qi Zi Fructus Lycii, Sang Ji Sheng Herba Taxilli, Bai Shao Radix Paeoniae alba and Long Yan Rou Arillus Longan Formulae
Si Wu Tang Four Substances Decoction, Ba Zhen Tang Eight Precious Decoction, Dang Gui Shao Yao San Angelica-Paeonia Powder, Yi Guan Jian One Linking Decoction Three Treasures or Women’s Treasure formulae
Brocade Sinews (with Wind-Dampness in the joints), Brighten the Eyes (with eye problems), Glorious Sea (with skin problems), Bend Bamboo (with Liver-Yang rising), Freeing the Moon (with Liver-Qi stagnation), Root the Spirit (with insomnia), Precious Sea, Warm the Palace, Free-Flowing Sea and Planting Seeds Acupuncture
LIV-8 Ququan, Ren-4 Guanyuan, SP-6 Sanyinjiao, BL-18 Ganshu, BL-17 Geshu, and ST-36 Zusanli Pacify the Liver and eliminate stagnation of Qi This is one of the most important methods of treatment in gynecology as stagnation of Qi is such a pervasive pathology in this field. Stagnation of Qi is a major and frequent cause of pre-menstrual tension and dysmenorrhoea. The main clinical manifestations are sighing, a feeling of distension of the epigastrium, abdomen or breasts, moodiness, depression, irritability and a Wiry pulse. It is important in practice to make a fundamental distinction between stagnation of Liver-Qi arising by itself (usually from emotional strain) and that secondary to a deficiency of Liver-Blood. The former is nearly always caused by emotional strain over a long period of time; the latter arises from a deficiency of Liver-Blood and can therefore be caused by overwork and not necessarily emotional problems. The pathological mechanism in the latter case is due to Liver-Blood (the Yin of the Liver) not rooting or anchoring Liver-Qi (the Yang of the Liver) which consequently stagnates. The most important distinguishing features between these two types of stagnation are the pulse and the tongue. When stagnation of Liver-Qi is primary and arises independently, the pulse will be all Wiry and the tongue slightly Red on the sides; when it is secondary and stemming from Liver-Blood deficiency, the
pulse will be generally Choppy and Fine and only very slightly Wiry, perhaps on one side only, and the tongue will be Pale. Herbs that move Liver-Qi are plentiful: Qing Pi Pericarpium Citri reticulatae viride, Xiang Fu Rhizoma Cyperi, Mu Xiang Radix Aucklandiae, Wu Yao Radix Linderae, Zhi Ke Fructus Aurantii, Zhi Shi Fructus Aurantii immaturus, Da Fu Pi Pericarpium Arecae, Fo Shou Fructus Citri sarcodactylis, etc. Most of the herbs that move Liver-Qi are warm and pungent and their prolonged use may tend to injure Yin, but there are a few that move Liver-Qi without damaging Yin: Chuan Lian Zi Fructus Toosendan, Mei Gui Hua Flos Rosae rugosae and Wu Mei Fructus Mume. As for moving-Qi formulae, one must distinguish between those that pacify the Liver and move Qi in primary stagnation of Liver-Qi and those that pacify the Liver by nourishing Liver-Blood. Among the former is Yue Ju Wan Gardenia-Ligusticum Pill, Ban Xia Hou Po Tang Pinellia-Magnolia Decoction and Jin Ling Zi San Melia Powder. Of the formulae that pacify the Liver by nourishing Liver-Blood, by far the most important in gynecology is of course Xiao Yao San Free and Easy Wanderer Powder. Others include Si Ni San Four Rebellious Powder and Si Qi Tang Four Seven Decoction. If Liver-Qi stagnation is associated with Phlegm, one can use Cang Fu Dao Tan Wan Atractylodes-Cyperus Conducting Phlegm Pill. Among the Three Treasures formulae, Break into a Smile pacifies the Liver and eliminates stagnation (especially for pain), Release Constraint pacifies the Liver and eliminates stagnation (especially for emotional stagnation). Of the Women’s Treasure formulae, Freeing the Moon pacifies the Liver, moves Qi and nourishes Liver-Blood, and Free Flow and Freeing Constraint pacify the Liver, move Qi and eliminate stagnation. Acupuncture
The main points to pacify the Liver and eliminate stagnation are: LIV-3 Taichong (this is the principal one), G.B.-34 Yanglingquan, LIV-14 Qimen,
LIV-13 Zhangmen, G.B.-26 Daimai, LIV-5 Ligou, T.B.-6 Zhigou and P-6 Neiguan. These points should be needled with reducing or even method. LIV-3 is the main point to move Liver-Qi and it has an influence on the whole length of the Liver channel as well as a very good mental–emotional effect. G.B.-34 Yanglingquan has a similar but less strong effect and relieves stagnation especially in the epigastrium and hypochondrium. LIV-14 Qimen moves Liver-Qi and harmonizes Liver and Stomach, while LIV-13 harmonizes Liver and Spleen. G.B.-26 Daimai is the beginning point of the Girdle Vessel and it harmonizes this Extraordinary Vessel and also resolves Damp-Heat. LIV-5 Ligou eliminates stagnation in the Liver channel mostly when it affects the Bladder or the genitals. T.B.-6 Zhigou pacifies the Liver and eliminates stagnation especially on the sides of the body. P-6 Neiguan indirectly pacifies the Liver and eliminates stagnation on the strength of its connection with the Liver channel within the Terminal Yin (Jue Yin): it is particularly effective when there are pronounced emotional problems. Summary Pacify the Liver and eliminate stagnation of Qi
Gynecological symptoms
Pre-menstrual tension and dysmenorrhoea General manifestations
Sighing, a feeling of distension of the epigastrium, abdomen or breasts, moodiness, depression, irritability and a Wiry pulse Herbs
Qing Pi Pericarpium Citri reticulatae viride, Xiang Fu Rhizoma Cyperi, Mu Xiang Radix Aucklandiae, Wu Yao Radix Linderae, Zhi Ke Fructus Aurantii, Zhi Shi Fructus Aurantii immaturus, Da Fu Pi Pericarpium Arecae, Fo Shou Fructus Citri sarcodactylis, Chuan Lian Zi Fructus Toosendan, Mei Gui Hua Flos Rosae rugosae and Wu Mei Fructus Mume Formulae
Yue Ju Wan Gardenia-Ligusticum Pill, Ban Xia Hou Po Tang PinelliaMagnolia Decoction, Jin Ling Zi San Melia Powder, Xiao Yao San Free and Easy Wanderer Powder, Si Ni San Four Rebellious Powder, Si Qi Tang Four Seven Decoction, Cang Fu Dao Tan Wan AtractylodesCyperus Conducting Phlegm Pill Three Treasures or Women’s Treasure formulae
Break into a Smile, Release Constraint, Freeing the Moon, Free Flow and Freeing Constraint Acupuncture
LIV-3 Taichong, G.B.-34 Yanglingquan, LIV-14 Qimen, LIV-13 Zhangmen, G.B.-26 Daimai, LIV-5 Ligou, T.B.-6 Zhigou and P-6 Neiguan Pacify the Liver and eliminate stasis of Blood Stasis of Blood is usually the consequence of stagnation of Qi over a long period of time and the two conditions often occur together in gynecological problems. If one were to compare and contrast stagnation of Qi with stasis of Blood, one could say in a nutshell that distension is the symptom of the former and pain the symptom of the latter. Other clinical manifestations of stasis of Blood, with particular reference to gynecological problems, are
painful periods, dark menstrual blood with clots, abdominal masses, a dark complexion, abdominal pain, a Wiry, Firm or Choppy pulse and a Purple tongue. Invigorating Blood is such an important method of treatment in gynecology and other disorders that Tang Zhong Hai, author of the Discussion on Blood Syndromes (1884), said: “In Blood syndromes one must always eliminate stasis of Blood.”4 There are many herbs that eliminate stasis of Blood such as Hong Hua Flos Carthami, Tao Ren Semen Persicae, Yi Mu Cao Herba Leonuri, Wu Ling Zhi Faeces Trogopterori, E Zhu Rhizoma Curcumae, Yu Jin Radix Curcumae, Ze Lan Herba Lycopi, San Leng Rhizoma Sparganii, Pu Huang Pollen Typhae, Chi Shao Radix Paeoniae rubra, Mu Dan Pi Cortex Moutan, Chuan Xiong Rhizoma Chuanxiong, Dan Shen Radix Salviae miltiorrhizae, Yan Hu Suo Rhizoma Corydalis, Ji Xue Teng Caulis Spatholobi, San Qi Radix Notoginseng, Si Gua Luo Retinervus Luffae fructus, Mo Yao Myrrha, Ru Xiang Olibanum, Chuan Niu Xi Radix Cyathulae, Wang Bu Liu Xing Semen Vaccariae, Lu Lu Tong Fructus Liquidambaris, Chuan Shan Jia Squama Manitis, Di Bie Chong (also called Tu Bie Chong) Eupolyphaga and Su Mu Lignum Sappan. The overwhelming majority of the above obviously belong to the category of herbs that invigorate Blood; there are, however, herbs in other categories which also invigorate Blood, such as Pu Huang Pollen Typhae, San Qi Radix Notoginseng and Qian Cao Gen Radix Rubiae (all in the Stopping-Bleeding category), and Chi Shao Radix Paeoniae rubra and Mu Dan Pi Cortex Moutan (both in the Cooling-Blood category). The Blood-invigorating effect of these herbs can be enhanced by steaming the herb in a mixture of water and wine. Wine, in fact, raises Yang, warms and penetrates the blood vessels, and invigorates Blood: these actions enhance the Blood-invigorating effect of a herb. Practically all Blood-invigorating herbs are contraindicated in pregnancy: unless absolutely necessary, it is strongly recommended that they are not given to a pregnant patient. The only Blood-invigorating herbs that might be relatively safe to use in pregnancy are Chi Shao Radix Paeoniae
rubra, Si Gua Luo Retinervus Luffae fructus, Ji Xue Teng Radix Spatholobi and Dan Shen Radix Salviae miltiorrhizae. Since there are so many Blood-invigorating herbs and given that they play an extremely important role in gynecology, to classify them in a rational way makes their use easier. However, classification is fraught with difficulties as different Chinese books use different terminologies for the same herb. A three-fold classification around which there is some consensus is between herbs that invigorate Blood, herbs that invigorate Blood and eliminate stasis and herbs that break up Blood and eliminate stasis, in ascending order of strength.5 A list of herbs according to this three-fold classification is as follows: 1. Herbs that invigorate Blood: Chuan Xiong Rhizoma Chuanxiong, Yan Hu Suo Rhizoma Corydalis, Yu Jin Radix Curcumae, Ru Xiang Olibanum, Mo Yao Myrrha, Wang Bu Liu Xing Semen Vaccariae. 2. Herbs that invigorate Blood and eliminate stasis: Dan Shen Radix Salviae miltiorrhizae, Yi Mu Cao Herba Leonuri, Tao Ren Semen Persicae, Hong Hua Flos Carthami, Chuan Niu Xi Radix Cyathulae, Ze Lan Herba Lycopi, Su Mu Lignum Sappan. 3. Herbs that break up Blood and eliminate stasis: E Zhu Rhizoma Curcumae, San Leng Rhizoma Sparganii, Shui Zhi Hirudo, Meng Chong Tabanus, Di Bie Chong Eupolyphaga, listed here in ascending order of strength. These herbs are particularly strong and are said to ‘break up’ (rather than ‘invigorate’) Blood. Herbs that break up Blood are suitable to dissolve masses from stasis of Blood and should be used with great care and sparingly. Also, a standing recommendation is that they be used in a small dose, no more than 6 g per day. Di Bie Chong is toxic and I personally confine its use to cases of carcinoma. A different classification of the Blood-invigorating herbs differentiates four groups, listed here in ascending order or strength: 1. Herbs that invigorate and nourish Blood: Dan Shen Radix Salviae
miltiorrhizae and Ji Xue Teng Radix Spatholobi. 2. Herbs that invigorate Blood and promote healing of tissues: Ru Xiang Olibanum, Mo Yao Myrrha, Di Bie Chong Eupolyphaga. 3. Herbs that dispel stasis and scatter Blood: San Leng Rhizoma Sparganii, E Zhu Rhizoma Curcumae. 4. Herbs that break-up Blood: Shui Zhi Hirudo, Meng Chong Tabanus, Di Bie Chong Eupolyphaga. Apart from these two classifications (the first of which is clinically more significant), the Blood-invigorating herbs can be classified according to various other criteria as follows: According to nature (hot or cold)
• Hot: Chuan Xiong Rhizoma Chuanxiong, Ji Xue Teng Radix Spatholobi, Yan Hu Suo Rhizoma Corydalis, Ze Lan Herba Lycopi, Hong Hua Flos Carthami, E Zhu Rhizoma Curcumae, Ru Xiang Olibanum, Wu Ling Zhi Faeces Trogopterori. • Cold: Dan Shen Radix Salviae miltiorrhizae, Yu Jin Radix Curcumae, Yi Mu Cao Herba Leonuri, Chi Shao Radix Paeoniae rubra, Mu Dan Pi Cortex Moutan, Chuan Shan Jia Squama Manitis, Di Bie Chong Eupolyphaga. Herbs that invigorate Blood and stop bleeding
• Pu Huang Pollen Typhae. • San Qi Radix Notoginseng.
• Qian Cao Gen Radix Rubiae. • Su Mu Lignum Sappan. • Wu Ling Zhi Faeces Trogopterori. The first three herbs listed pertain to the Stopping-Bleeding category but they also invigorate Blood. All the herbs listed above are obviously extremely useful in menorrhagia and metrorrhagia because not only do they stop bleeding, but they also invigorate Blood: since one should always invigorate Blood when stopping bleeding to prevent excessive cloying, herbs that combine both functions are particularly welcome. Herbs that invigorate and cool Blood
• Mu Dan Pi Cortex Moutan. • Chi Shao Radix Paeoniae rubra. These two herbs are very widely used in gynecology to cool and invigorate Blood simultaneously. Blood-invigorating herbs that particularly influence menstruation
• Yan Hu Suo Rhizoma Corydalis, Yi Mu Cao Herba Leonuri, Ze Lan Herba Lycopi, Chi Shao Radix Paeoniae rubra, Tao Ren Semen Persicae, Hong Hua Flos Carthami, San Leng Rhizoma Sparganii, Wang Bu Liu Xing Semen Vaccariae, Su Mu Lignum Sappan, Wu Ling Zhi Faeces Trogopterori, Chuan Shan Jia Squama Manitis. Yan Hu Suo and Wu Ling Zhi are particularly indicated for menstrual pain. Blood-invigorating herbs that affect the breasts and the Connecting (Luo) Channels
Some Blood-invigorating herbs are also said to ‘penetrate the Connecting (Luo) Channels’: this means that they move Qi and Blood and remove obstructions from the Connecting Channels. They can be used for channel problems, but in gynecology they can also be used for breast problems. These herbs are: Si Gua Luo Retinervus Luffae fructus, Chuan Shan Jia Squama Manitis and Lu Lu Tong Fructus Liquidambaris. Blood-invigorating herbs that invigorate the lower back and knees
• Chuan Niu Xi Radix Cyathulae and Ji Xue Teng Radix Spatholobi. Chuan Niu Xi is particularly important because, besides invigorating the lower back and knees, it has a descending movement and is often used for upwards bleeding (such as epistaxis, haematemesis or haemoptysis) deriving from stasis of Blood. Herbs that invigorate Blood and calm the Mind Dan Shen Radix Salviae miltiorrhizae invigorates Blood and calms the Mind. It is such an important Blood-invigorating herb that some doctors say that using Dan Shen in the proper dosage is like using the formula Si Wu Tang Four Substances Decoction: this is because, in small dosages, Dan Shen can also nourish Blood. According to modern research, this herb also has an anti-allergic effect.6 Yu Jin Radix Curcumae also calms the Mind and opens the Mind’s orifices in cases when this is obfuscated by stasis of Blood or Phlegm. It is especially indicated in depression. It may be useful to list the principal secondary actions (relevant to gynecology and apart from menstruation) of some of the Blood-invigorating herbs to differentiate them more easily: • Chuan Xiong Rhizoma Chuanxiong: expels Wind from the head, for
headache. • Dan Shen Radix Salviae miltiorrhizae: calms the Mind. • Ji Xue Teng Radix Spatholobi: invigorates the lower back and knees. • Yu Jin Radix Curcumae: opens the Mind’s orifices, for mental depression. • Ze Lan Herba Lycopi: promotes urination, for post-partum oedema or post-partum urinary difficulty. • Si Gua Luo Retinervus Luffae fructus: benefits the breasts, ‘penetrates’ the Connecting (Luo) Channels, for swollen breasts, insufficient lactation. • Chi Shao Radix Paeoniae rubra: cools the Blood, widely used for Hot and stagnant Blood in gynecological problems. • Mu Dan Pi Cortex Moutan: cools the Blood, clears Liver-Heat. This herb actually pertains to the Cooling-Blood category but it does also invigorate Blood. • Ru Xiang Olibanum: invigorates Blood in the channels, for chronic Painful Obstruction Syndrome with stasis of Blood. • Chuan Niu Xi Radix Cyathulae: invigorates the lower back and knees. • Wang Bu Liu Xing Semen Vaccariae: reduces breast swelling. • Su Mu Lignum Sappan: stops bleeding, for post-partum bleeding. • Wu Ling Zhi Faeces Trogopterori: stops bleeding, for uterine bleeding. • Tao Ren Semen Persicae: moistens the intestines and promotes bowel movement, for post-partum constipation. It may be useful to classify the Blood-invigorating herbs according to
their target area/organ (Fig. 6.1): • Mind: Dan Shen. • Head: Chuan Xiong. • Breasts: Wang Bu Liu Xing, Mo Yao, Chuan Shan Jia, Si Gua Luo, Hong Hua. • Chest: Yu Jin, Dan Shen. • Lower back and knees: Ji Xue Teng, Chuan Niu Xi. • Epigastrium: Yan Hu Suo, Yu Jin, Lu Lu Tong, Wu Ling Zhi. • Uterus: Yan Hu Suo, Yi Mu Cao, Ze Lan, Chi Shao, Hong Hua, Tao Ren, San Leng, Su Mu, Wu Ling Zhi, Di Bie Chong. • Lower abdomen: Yan Hu Suo, Tao Ren, San Leng, Di Bie Chong. • Bladder: Yi Mu Cao, Ze Lan.
Figure 6.1 Target areas/organs of Blood-invigorating herbs. Finally, something should be said about the complex pharmacology of the Blood-invigorating herbs which makes them some of the most useful herbs in the Chinese pharmacopoeia. The pharmacological actions of these
herbs may be summarized as follows: • They improve the dynamics of blood flow and dilate the peripheral, coronary, cerebral, renal and mesenteric arteries. • They improve microcirculation. Disturbance of microcirculation causes many diseases such as coronary heart disease, angiitis, endometriosis, chronic hepatitis, hepatic cirrhosis and scleroderma. • They improve concentration, coagulation and accumulation of blood and prevent thrombosis by inhibiting accumulation of platelets. • They influence connective tissues and can treat diseases of these tissues such as skin warts, burn scars and adhesions. • They readjust cellular and humoral immunity. • They have an analgesic effect. • They increase uterine contractions • They combat inflammation and bacterial infection. The method of invigorating Blood is often combined with other methods of treatment according to the condition. The main treatment methods combined with invigorating Blood are: • move Qi • tonify Qi • nourish Blood • warm the menses and scatter Cold • clear Heat
• move downwards • transform Water and resolve Phlegm • open the orifices. These combinations will now be discussed in detail. Move Qi The treatment method that combines moving Qi with invigorating Blood is extremely common and is based on the well-known principle that “Qi is the commander of Blood: if Qi moves, Blood moves”. It is for this reason that very many Blood-invigorating prescriptions contain herbs that move Qi. For example, Dan Shen Yin Salvia Decoction contains Tan Xiang Lignum Santali albi and Sha Ren Fructus Amomi to move Qi; Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction contains Xiang Fu Rhizoma Cyperi, Zhi Ke Fructus Aurantii and Wu Yao Radix Linderae. Very many other examples could be given. Another reason for using Qi-moving herbs when invigorating Blood is that most of the Qi-moving herbs enter the Liver and stagnation of Qi of this organ is often at the basis of stagnation of Qi in many areas and other organs. That is why it is said that “No matter which channel is affected in stagnation, the treatment cannot ignore the Liver”. Bearing in mind that, as mentioned above, the movement of Blood depends on the movement of Qi, Qi-moving herbs are also used to set the other herbs in motion by regulating the ascending and descending of Qi. Two pairs of herbs that are often used for this purpose are Zhi Ke Fructus Aurantii with Jie Geng Radix Platycodi and Chai Hu Radix Bupleuri with Niu Xi Radix Achyranthis bidentatae seu Cyathulae: Zhi Ke makes Qi descend while Jie Geng directs herbs upwards, and Chai Hu makes Qi ascend while Niu Xi directs herbs downwards. Both pairs of herbs are found in Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction. In the context of moving Qi in order to invigorate Blood, Chuan Xiong
Radix Chuanxiong is a particularly significant herb because it is said to enter the “Qi within Blood”. Tonify Qi Stasis of Blood may arise from many different conditions, among which is Qi deficiency. When Qi is deficient it does not circulate as it should and it therefore fails to invigorate Blood properly. Thus, when there is stasis of Blood against a background of Qi deficiency, one should add one or two Qi tonics to the formula. The formula Bu Yang Huan Wu Tang Tonifying Yang and Restoring Five-Tenths Decoction is an example of a prescription for Blood stasis occurring against a background of Qi deficiency, for which the formula uses a very large dose of Huang Qi Radix Astragali membranacei. Nourish Blood It is often necessary to nourish Blood when invigorating it either because Blood deficiency may be at the root of Blood stasis or because the latter may cause the former. This happens because stagnant Blood obstructs the channels and blood vessels and prevents new Blood from taking its rightful place. Yet another reason for nourishing Blood when invigorating it is that many Blood-invigorating herbs are pungent and may therefore injure Blood and Yin. Thus, some Blood tonics may be added to Blood-invigorating formulae whether there are signs of Blood deficiency or not. The combination of nourishing and invigorating Blood means that Blood tonics will not cause cloying and Blood-invigorating herbs will not injure Blood or Yin. Examples of Blood-invigorating formulae that also nourish Blood are Si Wu Tang Four Substances Decoction (which can be classified as a Bloodinvigorating formula) and Wen Jing Tang Warming the Menses Decoction. Warm the menses and scatter Cold
The method of warming the menses and scattering Cold is used when there is Blood stasis deriving from Cold obstructing the Uterus. This condition may cause dysmenorrhoea, infertility or abdominal masses. Examples of herbs that warm the menses and scatter Cold are Gui Zhi Ramulus Cinnamomi, Xiao Hui Xiang Fructus Foeniculi, Wu Zhu Yu Fructus Evodiae, Gan Jiang Rhizoma Zingiberis, Fu Zi Radix Aconiti lateralis preparata, Ai Ye Folium Artemisiae argyi and Rou Gui Cortex Cinnamomi. The use of herbs that warm the menses greatly helps to invigorate Blood when stasis of Blood derives from Cold in the Uterus. A good example of this method of treatment is mirrored in the use of Gui Zhi Ramulus Cinnamomi and Wu Zhu Yu Fructus Evodiae within Wen Jing Tang Warming the Menses Decoction. The use of Pao Jiang Rhizoma Zingiberis preparatum (fried) within Sheng Hua Tang Generating and Resolving Decoction and that of Gan Jiang Rhizoma Zingiberis, Rou Gui Cortex Cinnamomi and Xiao Hui Xiang Fructus Foeniculi within Shao Fu Zhu Yu Tang Lower Abdomen Eliminating Stasis Decoction are other examples of this method. Warming herbs may be used even when stagnant Blood is combined with Heat, because, being pungent and penetrating, they can be used as messenger herbs. The formula Tao He Cheng Qi Tang Persica Conducting Qi Decoction is a good case in point. This formula, based on Da Huang Radix et Rhizoma Rhei and Tao Ren Semen Persicae, is for stasis of Blood in the Lower Burner following childbirth and affecting the Mind: it invigorates Blood and it clears Heat by moving downwards. However, it also contains Gui Zhi Ramulus Cinnamomi which is warm and pungent. Gui Zhi is used in this formula for two reasons: first because it penetrates the blood vessels and therefore assists the other herbs in invigorating Blood, and second because the cold and bitter herbs used to clear Heat may congeal Blood, and Gui Zhi, being warm and penetrating the blood vessels, prevents this from happening. Thus, the use of a warm and pungent herb within the formula allows us to clear Heat without congealing Blood, and to warm without increasing the Heat. Tang Zhong Hai (1862–1918) says this about the formula:
The formula is pungent and scattering [with Gui Zhi]: together with Cang Xiao, Da Huang and Tao Ren it enters the Lower Burner and breaks up accumulation of Blood so that stasis is eliminated in no other way than via the two excretions, with Da Huang and Cang Xiao via defecation and with Gui Zhi via urination.7 This passage clearly highlights the role and the importance of Gui Zhi, a warm and pungent herb, within a formula to invigorate Blood and eliminate stasis. Clear Heat Heat is another pathogenic factor that may lead to stasis of Blood: it does so by condensing Blood and therefore slowing down its circulation. Wang Qing Ren said in his book Corrections of Errors in Medicine (Yi Lin Gai Cuo, 1830): “When the Blood has Heat it is evaporated and forms lumps.”8 On the other hand, long-term stasis of Blood may also give rise to Heat by itself. Thus, when Blood stasis is caused by Heat, one must usually either clear Heat and resolve Toxic-Heat or clear Heat and cool Blood, adding a few herbs to invigorate Blood and eliminate stasis. If stasis of Blood derives from Heat, clearing Heat may resolve the Blood stasis by itself. If, on the other hand, Heat results from long-term Blood stasis, the treatment should emphasize invigorating Blood and eliminating stasis, and only secondarily aim at clearing Heat and cooling Blood: eliminating stasis of Blood will in itself mean Heat will go. An example of the latter method of treatment is the formula Da Huang Bie Chong Wan Rheum-Eupolyphaga Decoction which is for long-term stasis of Blood leading to Heat. In this formula, there are several strong breaking up substances (insects) plus Huang Qin Radix Scutellariae and Sheng Di Huang Radix Rehmanniae to clear Heat and cool Blood. The formula Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction is another case in point. This formula is for stasis of Blood in the Upper Burner with Heart-Heat deriving from stasis. Accordingly, the main
emphasis of the prescription is on invigorating Blood and eliminating stasis and only secondarily on clearing Heat with Sheng Di Huang Radix Rehmanniae and Chi Shao Radix Paeoniae rubra. Whether long-term Blood stasis leads to Heat or whether Heat condenses the Blood and induces Blood stasis, herbs that simultaneously invigorate and cool Blood are always applicable: Mu Dan Pi Cortex Moutan, Chi Shao Radix Paeoniae rubra and Dan Shen Radix Salviae miltiorrhizae. Move downwards The method of moving downwards (i.e. eliminating pathogenic factors through defecation) is frequently used in conjunction with that of invigorating Blood and eliminating stasis in the treatment of stasis of Blood in the Middle or Lower Burner (though not Upper Burner). Tao He Cheng Qi Tang Persica Conducting Qi Decoction is a good example of this principle: it eliminates stasis of Blood (for which it uses Tao Ren Semen Persicae coordinated with Gui Zhi Ramulus Cinnamomi to invigorate Blood for the reasons explained above) by moving downwards with Da Huang Radix et Rhizoma Rhei and Mang Xiao Sulfas Natrii. If Da Huang is cooked for a long time (or for the same time as the other herbs), its Blood-invigorating effect is enhanced, and even more so if it is treated with wine. An example of this principle is the formula Fu Yuan Huo Xue Tang Restoring the Source and Invigorating Blood Decoction which invigorates Blood and eliminates stasis, particularly for traumatic injuries: it contains wine-treated Da Huang, decocted with the other herbs to move downwards and eliminate stasis. Transform Water and resolve Phlegm There is an interrelationship between stasis of Blood and Phlegm, especially in chronic conditions. When Blood stagnates over many years, the stagnant Blood obstructs the proper movement of Qi and functioning of the internal organs and impairs the transformation of Body Fluids, leading to the
formation of Phlegm. This situation is so common that some doctors say that one may nearly always treat old people suffering from a chronic, complicated illness for stasis of Blood and Phlegm. Tang Zong Hai in fact says: “When Blood stagnates for a long time it gives rise to Phlegm.”9 On the other hand, long-term retention of Phlegm may also cause stasis of Blood simply because the obstructing Phlegm impairs the circulation of Blood in the channels and blood vessels. An example of the principle of combining eliminating stasis of Blood with resolving Phlegm is the formula Gui Zhi Fu Ling Wan Ramulus Cinnamomi-Poria Pill which is for abdominal masses from stasis of Blood. This formula contains Fu Ling Poria to resolve Phlegm in combination with Gui Zhi Ramulus Cinnamomi which, being warm and pungent, helps to resolve Phlegm by moving Yang. Another example of this treatment method is the formula Da Huang Mu Dan Tang Rheum-Moutan Decoction which is for abdominal pain from Heat and stasis of Blood and contains Dong Gua Ren Semen Benincasae to resolve Dampness and Phlegm in the Intestines and expel pus. Yet another example is the formula Ou Jing Tang Lotus Stem Decoction which is for Lung-Heat and Phlegm with stasis of Blood: it contains Dong Gua Ren Semen Benincasae and Yi Yi Ren Semen Coicis to resolve Phlegm. There are also some Blood-invigorating herbs that transform Water and resolve Phlegm such as Ze Lan Herba Lycopi and Yi Mu Cao Herba Leonuri; conversely there are some Water-transforming herbs that also invigorate Blood such as Mu Tong Caulis Mutong and Dong Kui Zi Fructus Malvae. Open the orifices The orifices of the Heart may be clouded not only by Phlegm but also by stagnant Blood. Obstruction of the Heart’s orifices may occur with various degrees of severity and in serious cases it causes total loss of insight giving rise to psychotic episodes. Stagnant Blood affects the Heart’s orifices because this organ houses the Mind and governs Blood, and in conditions of
not only Heart-Blood deficiency but also of Blood stasis, the Mind therefore suffers. A good example of obstruction of the Mind (the Heart’s orifices) by stagnant Blood is the post-natal psychosis occurring as a result of stasis of Blood after childbirth: the formula Tao He Cheng Qi Tang Persica Conducting Qi Decoction, mentioned above, is precisely for such a clinical situation. In gynecology, stagnant Blood obstructing the Mind is often the result of Blood stasis in the Uterus first: due to the connection between this and the Heart via the Uterus Vessel, stagnant Blood in the Uterus may obfuscate the Mind. For stagnant Blood clouding the Heart’s orifices, herbs that have an ascending movement are often added to a Blood-invigorating formula to direct it to the Upper Burner and head. For example, the formula Tong Qiao Huo Xue Tang Opening the Orifices and Invigorating Blood Decoction for stasis of Blood in the head contains Cong Bai Bulbus Allii fistulosi which acts as a messenger herb to direct the formula to the head. Another example is the formula Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction for stasis of Blood in the Upper Burner, which contains Chai Hu Radix Bupleuri, Jie Geng Radix Platycodi and Chuan Xiong Rhizoma Chuanxiong, all of which direct the herbs to the Upper Burner. Of the Three Treasures formulae, Red Stirring invigorates HeartBlood. Of the Women’s Treasure formulae, Stir the Field of Elixir invigorates Liver-Blood and eliminates stasis from the Uterus and Invigorate Blood and Stem the Flow invigorates Blood and stops bleeding. Acupuncture
The main points to pacify the Liver and eliminate stasis of Blood are the same as those that eliminate stagnation of Liver-Qi, i.e. LIV-3 Taichong (this is the main one), G.B.-34 Yanglingquan, LIV-14 Qimen, LIV-13 Zhangmen, G.B.-26 Daimai, and LIV-5 Ligou. These points should be needled with reducing or even method. In addition, two points which specifically invigorate Blood are BL-17 Geshu (with needle, no moxa) and SP-10 Xuehai.
In gynecological diseases, Blood is invigorated also with the use of the Penetrating Vessel (Chong Mai), i.e. SP-4 on the right and P-6 on the left together with KI-14 Siman and LIV-3 Taichong. Summary Pacify the Liver and eliminate stasis of Blood
Gynecological symptoms
Painful periods, dark menstrual blood with large, dark clots, myoma, irregular periods, endometriosis General manifestations
Abdominal pain, dark complexion, mental restlessness, Purple tongue, Wiry, Firm or Choppy pulse Herbs
Hong Hua Flos Carthami, Tao Ren Semen Persicae, Yi Mu Cao Herba Leonuri, Wu Ling Zhi Faeces Trogopterori, E Zhu Rhizoma Curcumae, Yu Jin Radix Curcumae, Ze Lan Herba Lycopi, San Leng Rhizoma Sparganii, Pu Huang Pollen Typhae, Chi Shao Radix Paeoniae rubra, Mu Dan Pi Cortex Moutan, Chuan Xiong Rhizoma Chuanxiong, Dan Shen Radix Salviae miltiorrhizae, Yan Hu Suo Rhizoma Corydalis, Ji Xue Teng Caulis Spatholobi, San Qi Radix Notoginseng, Si Gua Luo Retinervus Luffae fructus, Mo Yao Myrrha, Ru Xiang Olibanum, Chuan Niu Xi Radix Cyathulae, Wang Bu Liu Xing Semen Vaccariae, Lu Lu Tong Fructus Liquidambaris, Chuan Shan Jia Squama Manitis, Di Bie Chong (also called Tu Bie Chong) Eupolyphaga, Su Mu Lignum Sappan
Formulae
• Move Qi and invigorate Blood: Dan Shen Yin Salvia Decoction, Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction • Tonify Qi and invigorate Blood: Bu Yang Huan Wu Tang Tonifying Yang and Restoring Five-Tenths Decoction • Nourish Blood and invigorate Blood: Si Wu Tang Four Substances Decoction and Wen Jing Tang Warming the Menses Decoction • Warm the menses and scatter Cold: Wen Jing Tang Warming the Menses Decoction, Sheng Hua Tang Generating and Resolving Decoction, Shao Fu Zhu Yu Tang Lower Abdomen Eliminating Stasis Decoction • Clear Heat and invigorate Blood: Da Huang Bie Chong Wan RheumEupolyphaga Decoction, Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction • Move downwards and invigorate Blood: Tao He Cheng Qi Tang Persica Conducting Qi Decoction, Fu Yuan Huo Xue Tang Restoring the Source and Invigorating Blood Decoction • Transform Water and resolve Phlegm: Gui Zhi Fu Ling Wan Ramulus Cinnamomi-Poria Pill, Da Huang Mu Dan Tang Rheum-Moutan Decoction, Ou Jing Tang Lotus Stem Decoction • Open the orifices: Tao He Cheng Qi Tang Persica Conducting Qi Decoction, Tong Qiao Huo Xue Tang Opening the Orifices and Invigorating Blood Decoction, Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction Three Treasures or Women’s Treasure formulae
Red Stirring, Stir the Field of Elixir, Invigorate Blood and Stem the Flow, Harmonizing the Moon Acupuncture
LIV-3 Taichong, G.B.-34 Yanglingquan, LIV-14 Qimen, LIV-13 Zhangmen, G.B.-26 Daimai, and LIV-5 Ligou, BL-17 Geshu and SP-10 Xuehai Clear Liver-Heat by pacifying the Liver When Qi stagnates for a long time it tends to give rise to Heat. The method of treatment for Heat deriving from stagnant Qi is quite different from that for other types of Heat such as that deriving from a febrile disease or from dietary causes. Heat deriving from stagnant Qi is treated by pacifying the Liver and eliminating stagnation and using only a few herbs that lightly clear Heat. Examples of herbs that lightly clear Heat are Dan Dou Chi Semen Sojae preparatum, Shan Zhi Zi Fructus Gardeniae, Zhu Ye Folium Phyllostachys nigrae, Lu Gen Rhizoma Phragmitis, etc. The clinical manifestations of Heat deriving from stagnant Liver-Qi are the same as those of stagnation of Liver-Qi plus a feeling of heat, a dry throat, a red face, red sides of the tongue and a slightly Rapid (and Wiry) pulse. Thus, Heat arising from stagnant Liver-Qi is treated by pacifying the Liver, eliminating stagnation and lightly clearing Heat with one or two herbs only. Any of the formulae for moving Qi and pacifying the Liver can be adapted to clearing Heat that stems from stagnant Qi. Indeed, the classical variation to the formula Xiao Yao San, Dan Zhi Xiao Yao San (also called Jia Wei Xiao Yao San) Moutan-Gardenia Free and Easy Wanderer Powder (Augmented Free and Easy Wanderer Powder) is formulated precisely to pacify the Liver and clear Heat deriving from stagnant Liver-Qi. This prescription is used very frequently in gynecological problems. Another example of a prescription that could be used for this purpose is Yue Ju Wan Gardenia-Ligusticum Pill. Of the Three Treasures formulae, Release Constraint (a variation of Yue Ju Wan mentioned above) can be used to clear Liver-Heat deriving from Liver-Qi stagnation. Of the Women’s Treasure formulae, Freeing Constraint can also be used to clear Liver-Heat deriving from stagnation of
Qi. Acupuncture
To clear Heat by pacifying the Liver, the same points that pacify the Liver and eliminate stagnation may be used, i.e. LIV-3 Taichong (this is the main one), G.B.-34 Yanglingquan, LIV-14 Qimen, LIV-13 Zhangmen, G.B.-26 Daimai and LIV-5 Ligou. These points should be needled with reducing or even method. In addition, to strengthen the Heat-clearing effect, one may add LIV-2 Xingjian or L.I.-11 Quchi. Summary Clear Liver-Heat by pacifying the Liver
Gynecological symptoms
Pre-menstrual symptoms, painful periods General manifestations
Sighing, a feeling of distension of the epigastrium, abdomen or breasts, moodiness, depression, irritability, feeling of heat, a dry throat, a red face, red sides of the tongue and a slightly Rapid (and Wiry) pulse Herbs
Same as Qi-moving herbs Formulae
Dan Zhi Xiao Yao San Moutan-Gardenia Free and Easy Wanderer Powder, Yue Ju Wan Gardenia-Ligusticum Pill Three Treasures or Women’s Treasure formulae
Release Constraint, Freeing Constraint Acupuncture
LIV-3 Taichong, G.B.-34 Yanglingquan, LIV-14 Qimen, LIV-13 Zhangmen, G.B.-26 Daimai, and LIV-5 Ligou, LIV-2 Xingjian, L.I.-11 Quchi Drain Liver-Fire ‘Liver-Fire’ is quite different from Liver-Heat deriving from stagnant LiverQi: the former is a more substantial pathogenic factor while the latter is often the result of stagnant Qi.10 Liver-Fire is a more substantial type of Heat occupying a deeper energetic layer than Heat. It is hotter, it dries up the fluids more, it affects the Mind more and it tends to cause haemorrhages (because Fire may invade the Blood). These characteristics explain the clinical manifestations of Fire as opposed to Heat: because it is hotter, there is a very red face, a pronounced feeling of heat; because it dries up fluids more, there is intense thirst, scanty, dark urine and constipation with dry stools; because it affects the Mind more, there is intense irritability, agitation and insomnia; and because it may tend to enter the Blood, there may be epistaxis, vomiting of blood, blood in the stools, blood in the urine or menorrhagia/metrorrhagia. Table 6.1 illustrates the differences between Heat and Fire. Table 6.1 Comparison between Heat and Fire
Heat
Feeling Mild of Heat Thirst Mild Face Red
Fire
Pronounced Intense Very red
Mind
Mild irritability
Urine Yellow Stools Normal Bleeding None Red or only sides Tongue Red Not Rapid or only Pulse slightly Rapid, Overflowing
Severe irritability, agitation, insomnia, slight manic behaviour Dark and scanty Dry, constipation There may be bleeding Dark Red, dry Rapid, Deep, Full
The treatment methods for these two types of Heat (one of which I call ‘Fire’) are quite different: in the case of Heat stemming from stagnant Qi, one needs to pacify the Liver and lightly clear Heat with cool and bland herbs, while in the case of Liver-Fire, one uses bitter and cold herbs to drain Fire. ‘Draining Fire’ by bitter and cold herbs also implies draining Fire by moving downwards, i.e. via the bowels (because Fire occupies a deeper energetic layer), while ‘clearing Heat’ by cool and bland, pungent or sweet herbs gets rid of the Heat by pushing it outwards towards the surface. Examples of lightly Heat-clearing herbs have been given above. Examples of bitter and cold herbs that drain Fire by moving downwards are Da Huang Radix et Rhizoma Rhei, Huang Qin Radix Scutellariae, Huang Lian Rhizoma Coptidis, Huang Bo Cortex Phellodendri, Long Dan Cao Radix Gentianae, Xia Ku Cao Spica Prunellae, etc. The main formula that drains Liver-Fire is Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction. Of the Three Treasures range, Drain Fire and Settling the Soul drain Liver-Fire.
Acupuncture
The main point to drain Liver-Fire is LIV-2 Xingjian, obviously with reducing method and without moxa. Other points include L.I.-11 Quchi, T.B.-5 Waiguan and L.I.-4 Hegu. Summary Drain Liver-Fire
Gynecological symptoms
Pre-menstrual tension, irregular periods, infertility, menorrhagia General manifestations
Irritability, propensity to outbursts of anger, thirst, red face, blood-shot eyes, dry stools, dark urine, headaches, Red tongue with redder sides and with thick-yellow coating, Wiry-Rapid pulse Herbs
Da Huang Radix et Rhizoma Rhei, Huang Qin Radix Scutellariae, Huang Lian Rhizoma Coptidis, Huang Bo Cortex Phellodendri, Long Dan Cao Radix Gentianae, Xia Ku Cao Spica Prunellae Formulae
Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction Three Treasures formulae
Drain Fire and Settling the Soul Acupuncture
LIV-2 Xingjian, L.I.-11 Quchi, T.B.-5 Waiguan and L.I.-4 Hegu Subdue Liver-Yang or extinguish Liver-Wind Liver-Yang or Liver-Wind may rise from a variety of causes: from KidneyYin deficiency, a simultaneous Kidney-Yin and Kidney-Yang deficiency, Liver-Yin deficiency or Liver-Blood deficiency. Whatever the cause, LiverYang or Liver-Wind rising are often at the root of gynecological problems such as headaches related to the menstrual cycle, eclampsia or menopausal problems. The clinical manifestations of Liver-Yang rising include headaches of a throbbing character, irritability, a red face and a Wiry pulse. Liver-Wind manifests with tics, tremors or convulsions (as in eclampsia). From a Western medical perspective, the symptoms of a pre-eclampsia state broadly correspond to those of Liver-Yang rising (hypertension, headache, blurred vision) while the symptoms and signs of a full eclampsia state are typical of Liver-Wind (i.e. convulsions). The herbs that subdue Liver-Yang tend to be the same as those which extinguish Liver-Wind, such as Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus Uncariae cum Uncis, Ju Hua Flos Chrysanthemi, Zhen Zhu Mu Concha Margaritiferae usta, Bai Ji Li Fructus Tribuli, etc. Representative prescriptions to subdue Liver-Yang are Tian Ma Gou Teng Yin Gastrodia-Uncaria Decoction and Zi Shui Qing Gan Yin Nourishing Water and Clearing the Liver Decoction. Formulae that extinguish Liver-Wind include Zhen Gan Xi Feng Tang Pacifying the Liver and Subduing Wind Decoction and Ling Jiao Gou Teng Yin Cornu Antelopis-Uncaria Decoction.
Of the Three Treasures formulae, Bend Bamboo subdues Liver-Yang and Liver-Wind. Of the Women’s Treasure formulae, Female Treasure nourishes Liver- and Kidney-Yin and subdues Liver-Yang. Acupuncture
The main points to subdue Liver-Yang or extinguish Liver-Wind are LIV-3 Taichong, G.B.-20 Fengchi, T.B.-5 Waiguan, L.I.-4 Hegu and Du-16 Fengfu. Summary Subdue Liver-Yang or extinguish Liver-Wind
Gynecological symptoms
Headaches related to the menstrual cycle, pre-eclampsia or eclampsia, or menopausal problems General manifestations
Headaches of a throbbing character, irritability, a red face, and a Wiry pulse. Liver-Wind manifests with tics, tremors or convulsions (as in eclampsia) Herbs
Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus Uncariae cum Uncis, Ju Hua Flos Chrysanthemi, Zhen Zhu Mu Concha Margaritiferae usta, Bai Ji Li Fructus Tribuli Formulae
For Liver-Yang rising: Tian Ma Gou Teng Yin Gastrodia-Uncaria Decoction and Zi Shui Qing Gan Yin Nourishing Water and Clearing the Liver Decoction. Formulae that extinguish Liver-Wind include Zhen Gan Xi Feng Tang Pacifying the Liver and Subduing Wind Decoction and Ling Jiao Gou Teng Yin Cornu Antelopis-Uncaria Decoction Three Treasures or Women’s Treasure formulae
Bend Bamboo, Female Treasure Acupuncture
LIV-3 Taichong, G.B.-20 Fengchi, T.B.-5 Waiguan, L.I.-4 Hegu and Du-16 Fengfu
Spleen The treatment methods applicable to the Spleen are: • tonify Spleen-Qi and Spleen-Blood • tonify Spleen-Yang • tonify and raise Spleen-Qi • tonify the Spleen to hold Blood • harmonize the Spleen and Liver • tonify the Spleen and resolve Dampness. Tonify Spleen-Qi and Spleen-Blood The Spleen, together with the Stomach, is the source of Post-Natal Qi and Blood. The Food-Qi (Gu Qi) of the Spleen is transformed into Gathering Qi (Zong Qi) which, in turn, is transformed into Blood. As we have seen, the Kidneys play the most important role in the formation of menstrual blood, being the source of the Tian Gui, but the Spleen and the Post-Natal Qi play an important function in supplementing Blood. Thus, whenever there is a deficiency of Blood in women, three organs should usually be tonified: the Liver because it stores Blood, the Spleen because it makes Blood and the Kidneys because they are the source of the Tian Gui. By far the most common symptom of deficiency of Spleen-Qi and Spleen-Blood is tiredness; in addition, there may be amenorrhoea or scanty periods. Examples of sweet herbs that tonify Spleen-Qi include Huang Qi Radix Astragali, Bai Zhu Rhizoma Atractylodis macrocephalae, Ren Shen Radix Ginseng, Dang Shen Radix Codonopsis and Shan Yao Rhizoma
Dioscoreae. Herbs that nourish Spleen-Blood are Dang Gui Radix Angelicae sinensis and Bai Shao Radix Paeoniae alba. The best example of the treatment principle of tonifying Qi and nourishing Blood is of course the formula Ba Zhen Tang Eight Precious Decoction which tonifies Spleen-Qi (because it contains the Si Jun Zi Tang Four Gentlemen Decoction), Spleen-Blood and Liver-Blood. The formula Gui Pi Tang Tonifying the Spleen Decoction also tonifies Spleen-Qi and Spleen-Blood and its emphasis is on the Spleen rather than the Liver: it is widely used to stop bleeding (such as excessive menstrual bleeding) from Spleen-Qi deficiency. Among the Three Treasures formulae, Calm the Shen tonifies SpleenQi, Spleen-Blood, Heart-Qi and Heart-Blood. Precious Sea is a variation of Ba Zhen Tang. Acupuncture
The main points to use to tonify Spleen-Qi are: ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu and BL-21 Weishu. These points should be reinforced and moxa is applicable. In fact, the use of the combination ST-36 Zusanli and SP-6 Sanyinjiao with moxa on the needle is a very simple and very effective way to tonify Spleen-Qi or Spleen-Yang. This combination is particularly good for women as the point SP-6 also tonifies Liver and Kidneys and therefore the Uterus. Summary Tonify Spleen-Qi and Spleen-Blood
Gynecological symptoms
Amenorrhoea or scanty periods
General manifestations
Tiredness, poor appetite, loose stools, slight abdominal distension, Pale tongue, Weak pulse Herbs
Huang Qi Radix Astragali, Bai Zhu Rhizoma Atractylodis macrocephalae, Ren Shen Radix Ginseng, Dang Shen Radix Codonopsis, Shan Yao Rhizoma Dioscoreae, Dang Gui Radix Angelicae sinensis, Bai Shao Radix Paeoniae alba Formulae
Ba Zhen Tang Eight Precious Decoction, Gui Pi Tang Tonifying the Spleen Decoction Three Treasures formulae
Calm the Shen, Precious Sea Acupuncture
ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu and BL21 Weishu Tonify Spleen-Yang Spleen-Yang deficiency is a more serious stage of Spleen-Qi deficiency: the clinical manifestations are essentially the same with the addition of a pronounced feeling of cold, cold arms and legs, very loose stools, slight
abdominal pain, a very Pale and wet tongue and a Deep, Weak and possibly Slow pulse. In gynecology, Spleen-Yang deficiency may cause scanty periods, dysmenorrhoea or leucorrhoea. It is frequently associated with Kidney-Yang deficiency. Herbs that tonify Spleen-Yang are all sweet herbs that tonify Spleen-Qi as detailed above. The main formula to tonify Spleen-Yang is Li Zhong Wan Regulating the Centre Pill. If there is pronounced deficiency of SpleenYang with Dampness, the formula Li Zhong Wan can be combined with the formula Quan Sheng Bai Zhu San Whole Generating Atractylodes Powder. Acupuncture
The points to tonify and warm Spleen-Yang are the same as those indicated for Spleen-Qi deficiency, except that moxa should definitely be used. Summary Tonify Spleen-Yang
Gynecological symptoms
Amenorrhoea, scanty periods, infertility General manifestations
Tiredness, poor appetite, loose stools, slight abdominal distension, a pronounced feeling of cold, cold arms and legs, Pale and wet tongue, DeepWeak pulse Herbs
Huang Qi Radix Astragali, Bai Zhu Rhizoma Atractylodis macrocephalae, Ren Shen Radix Ginseng, Dang Shen Radix Codonopsis, Shan Yao Rhizoma Dioscoreae Formulae
Li Zhong Wan Regulating the Centre Pill. If there is pronounced deficiency of Spleen-Yang with Dampness, the formula Li Zhong Wan can be combined with the formula Quan Sheng Bai Zhu San Whole Generating Atractylodes Powder Acupuncture
ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, and BL21 Weishu. Moxa Tonify and raise Spleen-Qi The method of tonifying and raising Spleen-Qi is used when Spleen-Qi is sinking: this is a type of Spleen-Qi deficiency characterized by prolapses, a dragging-down or bearing-down feeling, chronic, longstanding vaginal discharges, or frequency and slight incontinence of urination. Without an actual prolapse, this condition is fairly common and it is seen in chronic vaginal discharge, chronic menorrhagia and chronic interstitial cystitis. However, please note that, in women, all the above three conditions also involve sinking of Kidney-Qi. Sinking of Spleen-Qi has also a mental–emotional aspect: just as the sinking of Spleen-Qi causes Qi to descend and organs to sag, on a mental– emotional level it causes depression and low moods. Thus, the method of tonifying and raising Spleen-Qi may also be used purely for mental depression and low spirits (when this occurs against a background of Spleen
deficiency), in the absence of actual Qi sinking on a physical level. The relevant herbs to tonify Spleen-Qi have been mentioned above. The most apt prescription to tonify and raise Spleen-Qi is Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction which raises Spleen-Qi both on a physical and a mental level. Among the Three Treasures formulae, Tonify Qi and Ease the Muscles tonifies and raises Spleen-Qi. Acupuncture
The points to tonify and raise Spleen-Qi are the same as those mentioned above, i.e. ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu and BL-21 Weishu. In addition, Du-20 Baihui should be needled with reinforcing method or with direct moxa cones. In case of prolapse of the uterus, the point Ren-6 Qihai should also be needled with reinforcing method. Summary Tonify and raise Spleen-Qi
Gynecological symptoms
Prolapse of uterus, menorrhagia, metrorrhagia, chronic urinary symptoms, chronic vaginal discharge General manifestations
Prolapses, a dragging-down or bearing-down feeling, chronic, longstanding vaginal discharges, or frequency and slight incontinence of urination, Pale tongue, Weak pulse
Herbs
Huang Qi Radix Astragali, Bai Zhu Rhizoma Atractylodis macrocephalae, Ren Shen Radix Ginseng, Dang Shen Radix Codonopsis, Shan Yao Rhizoma Dioscoreae Formulae
Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction Three Treasures formulae
Tonify Qi and Ease the Muscles, Breaking Clouds Acupuncture
ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, BL-21 Weishu, Du-20 Baihui Tonify the Spleen to hold Blood One of the functions of the Spleen is to hold Blood in the vessels; to a certain extent this also depends on Spleen-Qi rising (and not sinking). When SpleenQi is weak and fails to hold Blood in the vessels, there may be haemorrhages: this is a major cause of bleeding which is frequently seen in gynecology such as in excessive periods and flooding (beng lou). For such cases, the method of treatment indicated consists in tonifying the Spleen to reinforce its function of holding Blood. The key herb is Huang Qi Radix Astragali and the representative formulae are Gui Pi Tang Tonifying the Spleen Decoction and Bu Qi Gu Jing Wan Tonifying Qi and Consolidating the Menses Pill. Of the Women’s Treasure formulae,
Restrain the Flow tonifies Qi to hold Blood and stop bleeding. Calm the Shen from the Three Treasures formulae can also be used to tonify SpleenQi to hold Blood and stop bleeding. Acupuncture
The points to tonify Spleen-Qi to hold Blood are the same as those mentioned above for the previous two methods of treatment. More specifically, Du-20 Baihui is important to raise Qi and stop bleeding downwards such as with excessive periods. SP-1 Yinbai with direct moxa cones is an empirical point to stop bleeding from the Uterus, even if the bleeding is from Blood-Heat. It also stops other forms of bleeding such as vomiting of blood, bleeding from the nose, blood in the urine and blood in the stools. Summary Tonify the Spleen to hold Blood
Gynecological symptoms
Heavy periods, menorrhagia, metrorrhagia (beng lou) General manifestations
Tiredness, poor appetite, loose stools, Pale tongue, Weak pulse Herbs
Huang Qi Radix Astragali
Formulae
Gui Pi Tang Tonifying the Spleen Decoction, Bu Qi Gu Jing Wan Tonifying Qi and Consolidating the Menses Pill Three Treasures or Women’s Treasure formulae
Restrain the Flow, Calm the Shen Acupuncture
ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, BL-21 Weishu, Du-20 Baihui, SP-1 Yinbai Harmonize Spleen and Liver This method is used when there is a disharmony between Spleen and Liver: this occurs when the Spleen is deficient and Liver-Qi stagnant. Its most common symptoms are abdominal pain and distension and loose stools. In the gynecological sphere, it is a very common pattern in pre-menstrual tension causing irritability, tiredness, epigastric and abdominal distension and swelling of the breasts. The chief formula to harmonize Liver and Spleen is of course Xiao Yao San Free and Easy Wanderer Powder. Of the Women’s Treasure formulae, Freeing the Moon and Free Flow harmonize the Spleen and Liver. Acupuncture
The main points to harmonize Liver and Spleen are: LIV-13 Zhangmen, Ren12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, G.B.-34-Yanglingquan, LIV-
3 Taichong, BL-20 Pishu and BL-18 Ganshu. The points to tonify the Spleen (Ren-12, ST-36, SP-6 and BL-20) should be reinforced while the others should be needled with reducing or even method. Summary Harmonize Spleen and Liver
Gynecological symptoms
Pre-menstrual tension General manifestations
Abdominal pain and distension, loose stools, irritability, tiredness, distension of the breasts Formulae
Xiao Yao San Free and Easy Wanderer Powder Women’s Treasure formulae
Freeing the Moon and Free Flow Acupuncture
LIV-13 Zhangmen, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, G.B.-34-Yanglingquan, LIV-3 Taichong, BL-20 Pishu and BL-18 Ganshu Tonify the Spleen and resolve Dampness
Spleen deficiency with Dampness is one of the most common patterns encountered in practice. Deficient Spleen-Qi fails to transform and transport food essences and fluids which accumulate into Dampness. Since dietary causes of disease are extremely common in our society, this clinical situation is very frequent indeed. The clinical manifestations of Spleen deficiency with Dampness vary according to whether Spleen-Qi deficiency predominates and there is little Dampness, or Dampness is very obvious and dominant. By far the most common and pervasive symptom of Spleen-Qi deficiency is tiredness: a very high proportion of patients present with this as their main complaint. Other symptoms and signs include poor appetite, loose stools, slight abdominal distension and an excessive vaginal discharge. If there is Dampness, the symptoms and signs might include a feeling of fullness and heaviness, a sticky taste, a profuse vaginal discharge, poor digestion with a feeling of fullness, mucus in the stools, a thick, sticky tongue coating and a Slippery pulse. In gynecology, Dampness is an extremely frequent pathogenic factor at the root of many women’s problems. It may, for example, be involved in excessive vaginal discharges, dysmenorrhoea, mid-cycle pain, ovarian cysts, cervical cancer (beginning stages) and infertility. Dampness obstructs the Lower Burner and the Directing, Penetrating and Girdle Vessels (Ren, Chong and Dai Mai), in particular the last of these. In fact, one of the major pathologies of Full conditions of the Girdle Vessel is Dampness infusing downwards causing profuse vaginal discharge and a pronounced feeling of heaviness in the lower abdomen. The treatment principle varies according to the relative importance of Spleen deficiency or Dampness: this ranges from dealing with the Root only by purely tonifying Spleen-Qi, to dealing with the Manifestation only by purely resolving Dampness. Between these two extremes lies a third method which consists in treating both the Root and the Manifestation by tonifying Spleen-Qi and resolving Dampness simultaneously. According to the treatment principle, the relevant herbs are therefore ones that tonify Spleen-Qi as mentioned above; sweet, bland herbs Fu Ling
Poria and Yi Yi Ren Semen Coicis which resolve Dampness; and warm, pungent and aromatic herbs Cang Zhu Rhizoma Atractylodis and Sha Ren Fructus Amomi which aromatically resolve Dampness; however, prolonged use may damage Yin. The representative formula purely to tonify Spleen-Qi is Si Jun Zi Tang Four Gentlemen Decoction. If Spleen-Yang is deficient, Li Zhong Wan Regulating the Centre Pill is used instead. There are very many formulae that resolve Dampness with varying emphasis. There are three basic methods to resolve Dampness: draining Dampness via urination, fragrantly resolving Dampness and drying Dampness. These three methods are frequently combined within one formula, such as Huo Po Xia Ling Tang AgastacheMagnolia-Pinellia-Poria Decoction. A formula that resolves Damp-Heat and is frequently used in gynecology is Er Miao San (or San Miao San or Si Miao San) Two Wonderful Powder (or Three Wonderful Powder or Four Wonderful Powder). If the method of tonifying the Spleen and resolving Dampness simultaneously is adopted, the representative prescription is Shen Ling Bai Zhu San Ginseng-Poria-Atractylodes Powder. If there is Dampness and Spleen-Yang, rather than Spleen-Qi, deficiency, the representative formulae are Quan Sheng Bai Zhu San Whole Generating Atractylodes Powder used together with Li Zhong Wan Regulating the Centre Pill, and the formula Wan Dai Tang Ending Vaginal Discharge Decoction. In chronic cases, Spleen-Yin may also become deficient: this pattern is not often mentioned, but does exist and it always encompasses Spleen-Qi deficiency. The clinical manifestations of Spleen-Yin deficiency include all those of Spleen-Qi deficiency plus: dry lips, dry mouth with desire to drink in small sips, pale, dull face but with a ‘floating’ red hue, dry stools, a feeling of heat in the face although the hands and feet may be cold (from Spleen-Qi deficiency), and a tongue that has transversal cracks on the sides (Fig. 6.2). Spleen-Yin deficiency is more common in women and, in gynecology, it may cause amenorrhoea or scanty periods.
Figure 6.2 Transversal cracks on the tongue from Spleen-Yin deficiency. The representative prescription for Spleen-Yin deficiency is Shen Ling Bai Zhu San Ginseng-Poria-Atractylodes Powder with the addition of Bei Sha Shen Radix Glehniae, Mai Men Dong Radix Ophiopogonis and Shi Hu Herba Dendrobii; the removal of Sha Ren Fructus Amomi; and the substitution of Xi Yang Shen Radix Panacis quinquefolii or Tai Zi Shen Radix Pseudostellariae for Ren Shen Radix Ginseng. Spleen disharmonies are often accompanied by Stomach disharmonies, chiefly that of rebellious Stomach-Qi, i.e. Stomach-Qi ascending instead of descending. In the context of gynecology, this often causes morning sickness during pregnancy and also nausea and vomiting during the periods. If the case is one of upward rebellion of Stomach-Qi, the treatment method is obviously to subdue Stomach-Qi. The representative prescription to achieve this is Xiao Ban Xia Tang Small Pinellia Decoction in combination with Ju Pi Zhu Ru Tang Tangerine Peel-Bambusa Decoction to send rebellious Qi downward and harmonize the stomach. Of the Three Treasures formulae, Soothe the Centre tonifies SpleenQi and resolves Dampness and Central Mansion tonifies Spleen-Qi, Stomach-Qi and Stomach-Yin and resolves Dampness. Acupuncture
The main points to tonify Spleen-Qi are: ST-36 Zusanli, SP-6 Sanyinjiao,
Ren-12 Zhongwan, BL-20 Pishu, and BL-21 Weishu, to be needled with reinforcing method. Those to resolve Dampness are: SP-9 Yinlingquan, BL22 Sanjiaoshu, Ren-9 Shuifen, and ST-28 Shuidao, with reducing or even method. Summary Tonify the Spleen and resolve Dampness
Gynecological symptoms
Chronic vaginal discharge, dysmenorrhoea, mid-cycle pain, cervical dysplasia, cervical cancer, chronic urinary symptoms, ovarian cysts, infertility General manifestations
Tiredness, poor appetite, loose stools, slight abdominal distension, a feeling of fullness and heaviness, a sticky taste, a profuse vaginal discharge, mucus in the stools, a thick-sticky tongue coating and a Slippery pulse Herbs
Huang Qi Radix Astragali, Bai Zhu Rhizoma Atractylodis macrocephalae, Ren Shen Radix Ginseng, Dang Shen Radix Codonopsis, Shan Yao Rhizoma Dioscoreae, Fu Ling Poria, Cang Zhu Rhizoma Atractylodis, Sha Ren Fructus Amomi, Yi Yi Ren Semen Coicis Formulae
• Tonify Qi: Si Jun Zi Tang Four Gentlemen Decoction, Li Zhong Wan Regulating the Centre Pill
• Resolve Dampness: Huo Po Xia Ling Tang Agastache-Magnolia-PinelliaPoria Decoction, Er Miao San Two Wonderful Powder • Tonify Qi and resolve Dampness: Shen Ling Bai Zhu San Ginseng-PoriaAtractylodes Powder, Quan Sheng Bai Zhu San Whole Generating Atractylodes Powder used together with Li Zhong Wan Regulating the Centre Pill, Wan Dai Tang Ending Vaginal Discharge Decoction • Spleen-Yin deficiency with Dampness: Shen Ling Bai Zhu San GinsengPoria-Atractylodes Powder with the addition of Bei Sha Shen Radix Glehniae, Mai Men Dong Radix Ophiopogonis, and Shi Hu Herba Dendrobii; the removal of Sha Ren Fructus Amomi; and the substitution of Xi Yang Shen Radix Panacis quinquefolii or Tai Zi Shen Radix Pseudostellariae for Ren Shen Radix Ginseng • Stomach disharmonies, rebellious Stomach-Qi: Xiao Ban Xia Tang Small Pinellia Decoction in combination with Ju Pi Zhu Ru Tang Tangerine PeelBambusa Decoction Three Treasures formulae
Soothe the Centre, Central Mansion Acupuncture
To tonify Spleen-Qi: ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu and BL-21 Weishu To resolve Dampness: SP-9 Yinlingquan, BL-22 Sanjiaoshu, Ren-9 Shuifen and ST-28 Shuidao
Heart The Heart governs Blood and, together with the Kidneys, plays a role in the formation of menstrual Blood (see Ch. 2 on physiology). It influences the menstrual function also through its connection with the Uterus via the Uterus Vessel. In pathological conditions, the menstrual function may be affected by Heart-Blood deficiency, Heart-Blood Heat and Heart-Blood stasis. These may lead to scanty periods, heavy periods or painful periods respectively. In addition, some menstrual irregularities are due to Heart-Qi and Heart-Blood not descending to the Uterus at the right time (i.e. during bleeding and during ovulation). The five patterns discussed will be: 1. Heart-Blood deficiency 2. Heart-Yin deficiency 3. Heart-Blood stasis 4. Heart-Fire 5. Heart-Blood Heat. Heart-Blood deficiency In the context of gynecology, Heart-Blood deficiency may play a role in causing scanty periods, amenorrhoea, infertility and post-natal depression. The treatment principle consists in nourishing Heart-Blood and the representative formulae are Gui Pi Tang Tonifying the Spleen Decoction, Bai Zi Yang Xin Wan Biota Nourishing the Heart Pill, Yang Xin Tang Nourishing the Heart Decoction and Yang Rong Tang Nourishing and Flourishing Decoction. The method of nourishing Heart-Blood is frequently combined with
tonification of the Kidneys to re-establish communication between Heart and Kidneys. Only when the Heart is quiet can the balance of Yin and Yang with the Kidneys be maintained. Harmony between the Heart and Kidney enables the extraordinary vessels such as the Directing and Penetrating Vessels (Ren and Chong Mai) to keep a relative balance of Yin and Yang in the body: thus, a harmonious interrelationship between Heart and Kidneys is very important for a healthy gynecological function. Dang Gui Radix Angelicae sinensis is the main herb to nourish HeartBlood. Also important are the sweet neutral herbs Bai Zi Ren Semen Platycladi and Suan Zao Ren Semen Ziziphi spinosae that nourish Blood and calm the Shen. The formula Bai Zi Ren Wan from the Complete Works of Jing Yue (Jing Yue Quan Shu, 1624) has precisely this function by tonifying the Kidney, soothing the Heart and regulating the Extraordinary Vessels. The book Gynecology in Chinese Medicine reports a Ming dynasty’s classic statement on this subject: To tonify the Heart, the Kidneys should be strengthened so that their Water can ascend; to tonify the Kidneys, the Heart should be calmed down, so that its Fire can descend.11 Of the Three Treasures formulae, Calm the Shen nourishes HeartBlood and calms the Mind. Acupuncture
The main points to nourish Heart-Blood are: HE-7 Shenmen, BL-15 Xinshu, Ren-15 Jiuwei, Ren-14 Juque, ST-36 Zusanli, SP-6 Sanyinjiao and BL-17 Geshu (this last point with direct moxa cones): all with reinforcing method. ST-36 and SP-6 are used to nourish Blood in general, which is always necessary to do when nourishing Heart-Blood. BL-17 with moxa also nourishes Blood.
Summary Heart-Blood deficiency
Gynecological symptoms
Amenorrhoea, scanty periods, infertility, post-natal depression General manifestations
Tiredness, palpitations, poor memory, insomnia, Pale tongue, Choppy pulse Herbs
Dang Gui Radix Angelicae sinensis, Bai Zi Ren Semen Platycladi, Suan Zao Ren Semen Ziziphi spinosae Formulae
Gui Pi Tang Tonifying the Spleen Decoction, Bai Zi Yang Xin Wan Biota Nourishing the Heart Pill, Yang Xin Tang Nourishing the Heart Decoction and Yang Rong Tang Nourishing and Flourishing Decoction, Bai Zi Ren Wan from the Complete Works of Jing Yue (Jing Yue Quan Shu, 1624) Three Treasures formulae
Calm the Shen Acupuncture
HE-7 Shenmen, BL-15 Xinshu, Ren-15 Jiuwei, Ren-14 Juque, ST-36 Zusanli, SP-6 Sanyinjiao, and BL-17 Geshu (this last point with direct moxa cones) Heart-Yin deficiency Heart-Yin deficiency may play a role in causing scanty periods, amenorrhoea, infertility, post-natal depression, post-natal sweating and menopausal problems. The treatment principle consists in nourishing HeartYin and clearing Empty-Heat and the most effective herbs are Mai Men Dong Radix Ophiopogonis and Tian Men Dong Radix Asparagi. The representative formula is Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill which is often used in menopausal problems. Of the Women’s Treasure formulae, Heavenly Empress nourishes Kidney- and Heart-Yin, clears Heart Empty-Heat and calms the Mind. Acupuncture
The main points to nourish Heart-Yin are: HE-7 Shenmen, HE-6 Jinxi, Ren14 Juque, Ren-15 Jiuwei, SP-6 Sanyinjiao, KI-6 Zhaohai, all with reinforcing method and no moxa. SP-6 and KI-6 are used to nourish Yin in general and in particular Kidney-Yin which is often at the root of Heart-Yin deficiency. Summary Heart-Yin deficiency
Gynecological symptoms
Scanty periods, amenorrhoea, infertility, post-natal depression, menopausal problems General manifestations
Palpitations, poor memory, mental restlessness, insomnia, night sweating, malar flush, feeling of heat in the evening, tongue without coating, pulse Floating-Empty Herbs
Mai Men Dong Radix Ophiopogonis, Tian Men Dong Radix Asparagi Formulae
Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill Women’s Treasure formulae
Heavenly Empress Acupuncture
HE-7 Shenmen, HE-6 Jinxi, Ren-14 Juque, Ren-15 Jiuwei, SP-6 Sanyinjiao, KI-6 Zhaohai Heart-Blood stasis Since the Heart governs Blood and is connected to the Uterus, stasis of Blood of the Heart may influence menstruation contributing to dysmenorrhoea, retention of placenta, retention of lochiae, etc. In such cases,
the treatment method focuses on relieving Heart-Blood stasis by conducting Blood downwards. An excellent herb for this is Dan Shen Radix Salviae miltiorrhizae and the formula Bai Zi Ren Wan Biota Pill has precisely this function; note that I am here citing the formula from Effective Prescriptions for Women (Fu Ren Liang Fang, 1237); there is another formula of the same name in the book Complete Works of Jing Yue (Jing Yue Quan Shu, 1624), as mentioned above. Among the Three Treasures formulae, Red Stirring invigorates HeartBlood. Acupuncture
The main points to invigorate Heart-Blood are: P-6 Neiguan, P-4 Ximen, HE-7 Shenmen, Ren-17 Shanzhong, BL-14 Jueyinshu, BL-17 Geshu, SP10 Xuehai and KI-25 Shencang, with reducing or even method. BL-17 and SP-10 invigorate Blood in general, while KI-25 invigorates Blood in the chest. Summary Heart-Blood stasis
Gynecological symptoms
Dysmenorrhoea, retention of placenta, retention of lochiae General manifestations
Palpitations, mental restlessness, chest pain, Purple tongue, Wiry, Firm or Choppy pulse
Herbs
Dan Shen Radix Salviae miltiorrhizae Formulae
Bai Zi Ren Wan Biota Pill from Effective Prescriptions for Women (Fu Ren Liang Fang, 1237) Three Treasures formulae
Red Stirring Acupuncture
P-6 Neiguan, P-4 Ximen, HE-7 Shenmen, Ren-17 Shanzhong, BL-14 Jueyinshu, BL-17 Geshu, SP-10 Xuehai, and KI-25 Shencang, with reducing or even method Heart-Fire
Women are prone to stagnation of Qi and this often turns into Fire which affects the Heart; Fire harasses downwards and disturbs the Directing and Penetrating Vessels, the Sea of Blood becomes reckless and this may result in Heavy Periods, Flooding and Trickling or excessive vaginal discharge. The key herbs to clear Heart-Fire belong to different categories and as such clear Fire in several different ways. Zhu Ye Folium Phylostachys nigrae clears Heat and purges Fire; Deng Xin Cao Medulla Junci resolves Dampness and clears the Fire by promoting urination. Bitter and cold Lian Zi Xin Plumula Nelumbinis is an astringent which clears the Heat from the Heart; and Huang Qin Radix Scutellariae and Huang Lian Rhizoma
Coptidis are bitter and cold herbs which clear Heat and also dry Dampness. The representative formulae to drain Heart-Fire are Huan Lian Jie Du Tang Coptis Expelling Toxin Decoction and Xie Xin Tang Draining the Heart Decoction. Of the Three Treasures formulae, Drain Fire drains both Liver- and Heart-Fire. Acupuncture
The main points to drain Heart-Fire are P-7 Daling, HE-3 Shaohai, Ren-14 Juque, BL-15 Xinshu. Reducing method, no moxa. Summary Heart-Fire
Gynecological symptoms
Heavy periods, Flooding and Trickling (beng lou), pre-menstrual syndrome, excessive vaginal discharge General manifestations
Palpitations, mental restlessness, insomnia, thirst, red face, feeling of heat, Red tongue with yellow coating and a redder tip, Full-Rapid or Overflowing pulse Herbs
Zhu Ye Folium Phylostachys nigrae, Deng Xin Cao Medulla Junci, Lian Zi Xin Plumula Nelumbinis, Huang Qin Radix Scutellariae, Huang Lian Rhizoma Coptidis
Formulae
Huan Lian Jie Du Tang Coptis Expelling Toxin Decoction, Xie Xin Tang Draining the Heart Decoction Three Treasures formulae
Drain Fire Acupuncture
P-7 Daling, HE-3 Shaohai, Ren-14 Juque, BL-15 Xinshu Heart-Blood Heat Heart-Blood Heat, which may derive from dietary or emotional aetiological factors, heats the Blood in the Uterus through the connection of the Uterus Vessel. Heart-Blood Heat may cause similar gynecological symptoms to those caused by Liver-Blood Heat, i.e. heavy periods, infertility or miscarriage. During pregnancy, Heart-Blood Heat may cause a variety of problems. After conception, Blood is deviated to the nourishment of the fetus, Fire easily rises, this disturbs the Heart and causes mental restlessness during pregnancy. Heart-Blood Heat may be a cause of difficult birth. Herbs which clear Heat and cool Blood are Mu Dan Pi Cortex Moutan and Chi Shao Radix Paeoniae rubra. The representative prescription for Heart-Blood Heat is Dao Chi San Eliminating Redness Powder. Acupuncture
The main points to cool Heart-Blood are P-7 Daling, HE-3 Shaohai, Ren-14 Juque, BL-15 Xinshu, L.I.-11 Quchi, SP-10 Xuehai. Reducing method, no moxa. Summary Heart-Blood Heat
Gynecological symptoms
Heavy periods, menorrhagia, metrorrhagia, infertility or miscarriage General manifestations
Palpitations, mental restlessness, insomnia, thirst, red face, feeling of heat, Red tongue with yellow coating and a redder tip, Full-Rapid or Overflowing pulse Herbs
Mu Dan Pi Cortex Moutan, Chi Shao Radix Paeoniae rubra Formulae
Dao Chi San Eliminating Redness Powder Acupuncture
P-7 Daling, HE-3 Shaohai, Ren-14 Juque, BL-15 Xinshu, L.I.-11 Quchi, SP-10 Xuehai
Qi and blood pathology In addition to Yin organ disharmony, a discussion of Qi and Blood pathology follows below. The possible pathological states of Qi and Blood are: • Qi stagnation • Qi sinking • Qi rebellious • Blood deficiency • Blood-Heat • Blood stasis • Blood-Cold. Apart from Qi rebellious and Blood-Cold, these have all been discussed under the relevant pathology of the internal organs. Thus, Qi stagnation, Blood deficiency, Blood-Heat and Blood stasis have been discussed under the Liver, while Qi sinking was discussed under the Spleen. It therefore remains for us to discuss only Qi rebellious and Blood-Cold.
Qi rebellious Qi becomes ‘rebellious’ when it flows in a counter-direction to its normal one. Although sinking of Qi is also a form of counter-flow of Qi, the term ‘rebellious Qi’ usually applies to Qi that flows upwards instead of downwards. The Qi of the Lungs and Stomach should normally flow downwards and the most common forms of rebellious Qi are those related to these two organs, manifesting with breathlessness in case of the Lungs, and nausea, hiccup, belching and vomiting in case of the Stomach. The Qi of other organs too can rebel upwards and notably that of the Liver and Heart. Liver-Yang rising, Liver-Fire blazing and Liver-Wind are all forms of rebellious Qi. Heart-Qi also should normally descend and when it rebels upwards it causes anxiety, insomnia, breathlessness and nausea. This last symptom is usually related to the Stomach but rebellious Heart-Qi may also cause it: this probably explains the use of P-6 Neiguan as an important point for nausea and vomiting. In gynecology, rebellious Stomach-Qi, Liver-Qi and Heart-Qi are the most significant. Stomach-Qi flowing upwards in gynecological problems is usually related to the Qi of the Penetrating Vessel (Chong Mai) rebelling upwards: this will be discussed in detail under the section on the Extraordinary Vessels (Ch. 7). Rebellious Stomach-Qi causes nausea and vomiting in pregnancy or in connection with the menstrual period (before or during it). Herbs that make Qi descend include Zhi Shi Fructus Aurantii immaturus, Shi Di Calyx Khaki, Da Fu Pi Pericarpium Arecae, Chen Xiang Lignum Aquilariae resinatum, Zi Su Ye Folium Perillae, Ban Xia Rhizoma Pinelliae preparatum, Lu Gen Rhizoma Phragmitis, Wu Zhu Yu Fructus Evodiae and Zi Su Geng Caulis Perillae for rebellious StomachQi. For rebellious Lung-Qi, most of the herbs that stop cough and wheezing make Lung-Qi descend but the main ones are Su Zi Fructus Perillae, Xuan Fu Hua Flos Inulae, Qian Hu Radix Peucedani and Zhu Ru Caulis Bambusae in Taeniam. The representative formula for rebellious StomachQi is Xuan Fu Dai Zhe Tang Inula-Haematitum Decoction. The main symptoms of rebellious Liver-Qi vary according to the other
pathogenic factors with which it associates, i.e. Liver-Yang rising, Liver-Fire blazing and Liver-Wind. In case of Liver-Yang rising, the main symptoms include headache, dizziness and irritability often seen in pre-menstrual tension or during the menopause; in case of Liver-Fire, the main manifestations are headache, dizziness, severe irritability, thirst, bitter taste, often seen also in pre-menstrual tension or menorrhagia; with Liver-Wind, the main manifestations are tics, headache, severe vertigo, often seen in migraine associated with the menstrual cycle or during a pre-eclamptic state. Rebellious Liver-Qi associated with Liver-Fire is particularly significant in gynecology because it may cause bleeding upwards: since Qi is the commander of Blood, if Qi rebels upwards it may push the Blood upwards too causing epistaxis, coughing of blood or vomiting of blood. Some of these symptoms are seen in gynecology during the menstrual cycle in endometriosis. The main herbs that subdue rebellious Liver-Qi are the same as those that subdue Liver-Yang or Liver-Wind, i.e. Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus Uncariae cum Uncis, Shi Jue Ming Concha Haliotidis, Long Gu Fossilia Ossis mastodi, Long Chi Fossilia Dentis mastodi, Zhen Zhu Mu Concha Margaritiferae usta, Ju Hua Flos Chrysanthemi, etc. The representative formulae to subdue rebellious LiverQi are Yi Gan He Wei Yin Restraining the Liver and Harmonizing the Stomach Decoction, Tian Ma Gou Teng Yin Gastrodia-Uncaria Decoction, Zhen Gan Xi Feng Tang Pacifying the Liver and Subduing Wind Decoction and Ling Jiao Gou Teng Tang Cornu Antelopis-Uncaria Decoction. Rebellious Heart-Qi may cause pre-menstrual tension and menstrual irregularities. As bleeding and ovulation rely on the descending of Heart-Qi to the Uterus, premature or late descending of Heart-Qi causes menstrual irregularities. If rebellious Qi carries blood with it causing bleeding from the nose or the vomiting or coughing of blood, representative formulae include Ze Lan Tang Lycopus Decoction and Dao Jing Tang Reversing the Menses Decoction. Of the Women’s Treasure formulae, Penetrating Vessel is specific to
subdue rebellious Qi in the Penetrating Vessel. Acupuncture
The points to subdue rebellious Qi can be classified according to the organ involved, i.e. Stomach, Lungs, Liver or Heart. The main points to subdue rebellious Stomach-Qi are: Ren-13 Shangwan, Ren-10 Xiawan, ST-19 Burong and ST-20 Chengman. Ren-13 is the main one and is indicated for belching, hiccup, nausea and vomiting. Ren10 sends Stomach-Qi down: this is not exactly the same as subduing rebellious Stomach-Qi as it promotes the descending of Stomach-Qi rather than forcing rebellious Stomach-Qi downwards. Because of this, Ren-10 can be used in conjunction with Ren-13. For rebellious Lung-Qi, the main points are: LU-7 Lieque, LU-1 Zhongfu, LU-5 Chize and LU-6 Kongzui. The main points to subdue Liver-Yang rising are: LIV-3 Taichong, G.B.-20 Fengchi and T.B.-5 Waiguan. The main points to make Heart-Qi descend are HE-5 Tongli, Ren-15 Jiuwei in combination with Ren-4 Guanyuan and KI-16 Huangshu. Summary Qi rebellious
Gynecological symptoms
Pre-menstrual symptoms, painful periods, menopausal problems General manifestations
• Heart-Qi: anxiety, insomnia, breathlessness, chest distension and nausea • Stomach-Qi: nausea and vomiting in pregnancy or in connection with the menstrual period • Lung-Qi: breathlessness, chest oppression, sighing. • Liver-Yang rising: include headache, dizziness and irritability • Liver-Fire: headache, dizziness, severe irritability, thirst, bitter taste • Liver-Wind: tics, headache, severe vertigo Herbs
• Heart-Qi: Huang Lian Rhizoma Coptidis, Lian Zi Xin Plumula Nelumbinis • Stomach-Qi: Zhi Shi Fructus Aurantii immaturus, Shi Di Calyx Khaki, Da Fu Pi Pericarpium Arecae, Chen Xiang Lignum Aquilariae resinatum, Zi Su Ye Folium Perillae, Ban Xia Rhizoma Pinelliae preparatum, Lu Gen Rhizoma Phragmitis, Wu Zhu Yu Fructus Evodiae and Zi Su Geng Caulis Perillae • Lung-Qi: Su Zi Fructus Perillae, Xuan Fu Hua Flos Inulae, Qian Hu Radix Peucedani and Zhu Ru Caulis Bambusae in Taeniam • Liver-Yang or Liver-Wind: Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus Uncariae cum Uncis, Shi Jue Ming Concha Haliotidis, Long Gu Fossilia Ossis mastodi, Long Chi Fossilia Dentis mastodi, Zhen Zhu Mu Concha margaritiferae usta, Ju Hua Flos Chrysanthemi Formulae
Xuan Fu Dai Zhe Tang Inula-Haematitum Decoction, Yi Gan He Wei Yin Restraining the Liver and Harmonizing the Stomach Decoction, Tian Ma Gou Teng Yin Gastrodia-Uncaria Decoction, Zhen Gan Xi Feng Tang Pacifying the Liver and Subduing Wind Decoction and Ling Jiao Gou Teng Tang Cornu Antelopis-Uncaria Decoction
Women’s Treasure formulae
Penetrating Vessel Acupuncture
• Stomach-Qi: Ren-13 Shangwan, Ren-10 Xiawan, ST-19 Burong and ST-20 Chengman • Lung-Qi: LU-7 Lieque, LU-1 Zhongfu, LU-5 Chize and LU-6 Kongzui • Liver-Yang rising: LIV-3 Taichong, G.B.-20 Fengchi and T.B.-5 Waiguan • Heart-Qi: HE-5 Tongli, Ren-15 Jiuwei in combination with Ren-4 Guanyuan and KI-16 Huangshu
Blood-Cold Blood-Cold is a common pathological condition in gynecology: it may be caused either by invasion of external Cold (in which case it is Full-Cold) or by deficiency of Yang leading to Empty-Cold. Whether it is Full or Empty, Blood-Cold affects the Uterus by obstructing it with Cold. This may cause several gynecological problems such as dysmenorrhoea, infertility or abdominal masses. Cold in the Uterus usually manifests with small dark clots in the menstrual blood while the menstrual blood itself may be bright red. The main herbs that warm the Uterus are Rou Gui Cortex Cinnamomi, Gui Zhi Ramulus Cinnamomi, Ai Ye Folium Artemisiae argyi, Fu Zi Radix Aconiti lateralis preparata and Ding Xiang Flos Caryophylli. A representative formula for Empty-Cold in the Uterus is Ai Fu Nuan Gong Wan Artemisia-Cyperus Warming the Uterus Pill or Wen Jing Tang Warming the Menses Decoction and for Full-Cold Shao Fu Zhu Yu Tang Lower Abdomen Eliminating Stasis Decoction. Of the Women’s Treasure formulae, Warm the Palace, Warm the Menses and Warm the Mansion warm the Uterus. Acupuncture
The points that expel Cold from the Lower Burner and warm the Uterus are situated mainly on the Directing and Penetrating Vessels (Ren and Chong Mai): Ren-4 Guanyuan, KI-13 Qixue, Ren-3 Zhongji and Qimen extra point (3 cun lateral to Ren-4 Guanyuan). Obviously all points should be used with moxa, either on the needle or direct moxa cones. Summary Blood-Cold
Gynecological symptoms
Dysmenorrhoea, infertility, abdominal masses, endometriosis, bright menstrual blood with small, dark, stringy clots General manifestations
Abdominal pain, feeling cold, cold limbs, feeling cold or colder during the period, Pale tongue, Tight pulse Herbs
Rou Gui Cortex Cinnamomi, Gui Zhi Ramulus Cinnamomi, Ai Ye Folium Artemisiae argyi, Fu Zi Radix Aconiti lateralis preparata, Ding Xiang Flos Caryophylli Formulae
Ai Fu Nuan Gong Wan Artemisia-Cyperus Warming the Uterus Pill, Wen Jing Tang Warming the Menses Decoction, Shao Fu Zhu Yu Tang Lower Abdomen Eliminating Stasis Decoction Women’s Treasure formulae
Warm the Palace, Warm the Menses and Warm the Mansion Acupuncture
Ren-4 Guanyuan, KI-13 Qixue, Ren-3 Zhongji and Qimen extra point (3 cun lateral to Ren-4 Guanyuan). Moxa When treating disharmonies of Qi and Blood in gynecology, it is important to remember Blood while Qi is treated and Qi while Blood is
treated. For example, when there is bleeding upwards (such as vomiting of blood), it is important to use herbs that subdue rebellious Qi as well; likewise if there is bleeding downwards (such as in menorrhagia), one should use herbs that raise Qi. Moreover, it is not advisable to use very sticky herbs or herbs that have a strong action of elimination, as the former may cause stagnation of Qi and Blood, while the latter may damage Qi and Blood. Harmonizing Qi and Blood is also adapted according to the various phases of the menstrual cycle: for example, to move Qi and Blood and eliminate stasis, the patient needs to take the decoction only in the 2 weeks before the periods; to nourish Blood, only in the 2 weeks after the end of the period (although, of course, this rule should not be interpreted too strictly, as obviously it is quite reasonable to take a Blood tonic throughout the menstrual cycle). End notes 1. Clavey S 1995 Fluid Physiology and Pathology in Traditional Chinese Medicine, Churchill Livingstone, Edinburgh, p. 121, note 23. Clavey goes on by reporting the apt story of a beautiful and powerful, if unruly, horse being taken to market. To someone who called out that he was galloping in the wrong direction, the rider replied: “I know, but just look at the speed!”.
2. For example, a controversy ‘rages’ in continental Europe as to whether KI-7 Fuliu tonifies Kidney-Yin or Kidney-Yang. Most traditional Chinese medicine-based colleges teach that this point tonifies Kidney-Yang, whereas French and Italian acupuncture colleges all teach that KI-7 tonifies Kidney-Yin. As mentioned, I personally think that this controversy is fruitless as this point could tonify both Kidney-Yang or Kidney-Yin depending on whether moxa is used or not. Of course, there are certain points which have a definite tendency to tonify Yin more than Yang or vice versa: for example, it is obvious from most literature that KI-6 Zhaohai nourishes Kidney-Yin..
3. Zhu Dan Xi 1347 Essential Methods of Dan Xi (Dan Xi Xin Fa) cited in Zhang Qi Wen 1995 Menstrual Diseases (Yue Jing Bing Zheng
), People’s Hygiene Publishing House, Beijing, p. 42..
4. Cited in Li Fei 1987 Discussion about Formulae to Invigorate Blood and Eliminate Stasis, Journal of the Nanjing College of Traditional Chinese Medicine (Nanjing Zhong Yi Xue Yuan Xue Bao
) 1: 44..
5. There are actually several terms used to say ‘eliminate stasis’: qu yu, hua yu and zhu yu. Qu yu means to ‘eliminate’ or ‘dispel’ stasis, hua yu means to ‘resolve’ stasis and zhu yu means to ‘drive out’ or ‘expel’ stasis. The first and the third are the same except for a difference of degree, the latter being stronger. The second, hua yu, ‘resolving stasis’, indicates a different way of eliminating stasis..
6. Journal of Chinese Medicine (Zhong Yi Za Zhi
) 32(12): 4..
7. Cited in Discussion about Formulae to Invigorate Blood and Eliminate Stasis, p. 43..
8. Ibid., p. 43..
9. Ibid., p. 44..
10. Of course, not all forms of Heat derive from stagnant Qi. Heat can also arise independently from Exterior Heat, from dietary irregularities or from emotional strain. Thus, one can distinguish three types of Heat: one deriving from stagnant Qi, a second arising independently and a third, Fire, which is a particularly intense form of Heat..
11. Nanjing College of Traditional Chinese Medicine 1962 Gynaecology in Chinese Medicine(Zhong Yi Fu Ke Xue
), p. 23..
CHAPTER 7 Treatment of the Extraordinary Vessels
INTRODUCTION 157 PENETRATING VESSEL (CHONG MAI) 162 DIRECTING VESSEL (REN MAI) 171 GOVERNING VESSEL (DU MAI) 181 GIRDLE VESSEL (DAI MAI) 185 YIN STEPPING VESSEL (YIN QIAO MAI) 188 YIN LINKING VESSEL (YIN WEI MAI) 189 GYNECOLOGICAL EXTRA POINTS 189 HERBAL TREATMENT OF THE EXTRAORDINARY VESSELS 191 THE FOUR PATHOLOGIES OF THE EXTRAORDINARY VESSELS AND HERBAL TREATMENT 193 Disharmony of Yin and Yang 193 Deficiency 193 Excess 193 Rebellious or sinking Qi 193 FORMULAE FOR THE DIRECTING AND PENETRATING VESSELS 193
Introduction Regulating and tonifying the Extraordinary Vessels is extremely important in gynecology because these vessels influence menstruation, ovulation, conception, pregnancy and childbirth. Some doctors say no specific treatment is necessary to affect the Extraordinary Vessels because they are closely linked to the channel system (as lakes to rivers) and the internal organs. They say that treating the Liver and Kidney automatically implies treating the Directing and Penetrating Vessels (Ren and Chong Mai), and that regulating Yin and Yang necessarily leads to regulation of the Extraordinary Vessels. For example, when harmonizing Yin and Yang in women, to nourish Blood is often important as doing so strengthens the Penetrating Vessel which is the Sea of Blood. However, many doctors, both modern and old (and including myself), would disagree with this view, maintaining that there are specific herbal strategies and acupuncture methods of treatment which affect the Extraordinary Vessels. The formula Yang Jing Zhong Yu Tang Nourishing the Essence and Planting Jade Decoction is an example of such a principle of treatment as it combines tonification of the Kidneys and of the Extraordinary Vessels with nourishing Blood. Second, regulating and tonifying of Yin, Yang, Qi and Blood should be combined with removing obstructions: the combination of these methods in gynecology also activates the Extraordinary Vessels. For example, tonifying the Kidneys is often combined with moving Blood and eliminating stasis in endometriosis; nourishing Kidney-Yin and eliminating stasis during the midcycle phase tonifies and regulates the Extraordinary Vessels, promotes ovulation and regularizes the periods. The formula Yi Shen Tong Jing Tang Nourishing the Kidneys and Penetrating the Menses Decoction is an example of such a treatment method. With acupuncture, of course, the problem does not arise because it can affect the Extraordinary Vessels directly. For this reason, acupuncture is extremely effective in treating gynecological problems: there is nothing more direct than using points such as Ren-4 Guanyuan to affect the Directing
Vessel (Ren Mai) or KI-13 Qixue to affect the Penetrating Vessel (Chong Mai). There are several ways of using the points of the Extraordinary Vessels, including their ‘opening’ points and points on their trajectory. The eight Extraordinary Vessels and their opening points are: 1. Directing Vessel (Ren Mai) LU-7 Lieque. 2. Governing Vessel (Du Mai) SI-3 Houxi. 3. Penetrating Vessel (Chong Mai) SP-4 Gongsun. 4. Girdle Vessel (Dai Mai) G.B.-41 Zulinqi. 5. Yin Linking Vessel (Yin Wei Mai) P-6 Neiguan. 6. Yang Linking Vessel (Yang Wei Mai) TB-5 Waiguan. 7. Yin Stepping Vessel (Yin Qiao Mai) KI-6 Zhaohai. 8. Yang Stepping Vessel (Yang Qiao Mai) BL-62 Shenmai. They can be grouped in four pairs of the same polarity (both Yin or both Yang) sharing similar pathways, and in pairs in which the opening point of one is the associated point of the other and vice versa, i.e.: 1. Penetrating Vessel and Yin Linking Vessel, SP-4 Gongsun and P-6 Neiguan. 2. Governing Vessel and Yang Stepping Vessel, SI-3 Houxi and BL-62 Shenmai. 3. Girdle Vessel and Yang Linking Vessel, GB-41 Zulinqi and TB-5 Waiguan. 4. Directing Vessel and Yin Stepping Vessel, LU-7 Lieque and KI-6
Zhaohai. By grouping the vessels in four pairs we get four pairs of points: I shall call the point related to each vessel its ‘opening’ point and the point related to the vessel with which it is paired its ‘associated’ point (which, itself, is the opening point of the paired vessel). For example, the opening point of the Directing Vessel is LU-7 Lieque and its associated point is KI-6 Zhaohai: this latter point is the opening point of the Yin Stepping Vessel with which the Directing Vessel is paired. Thus, if we needle LU-7 Lieque first followed by KI-6 Zhaohai, we open the Directing Vessel: if we needle KI-6 first followed by LU-7, we open the Yin Stepping Vessel. These points have always been mentioned as pairs in the classics, sometimes even without mentioning the Extraordinary Vessels, and the Extraordinary Vessels were given family members’ names highlighting their use as pairs to achieve harmony: 1. SP-4 Gongsun, Penetrating Vessel: father. 2. P-6 Neiguan, Yin Linking Vessel: mother. 3. S.I.-3 Houxi, Governing Vessel: husband. 4. BL-62 Shenmai, Yang Stepping Vessel: wife. 5. T.B.-5 Waiguan, Yang Linking Vessel: son. 6. G.B.-41 Zulinqi, Girdle Vessel: daughter. 7. LU-7 Lieque, Directing Vessel: host. 8. KI-6 Zhaohai, Yin Stepping Vessel: guest.1 Because of this arrangement in pairs, the opening point of one vessel is usually used in conjunction with the opening point of the paired vessel. This technique, called ‘host–guest’, was indicated for the very first time in the Guide to Acupuncture Channels (Zhen Jiu Jing Zhi Nan 1295) and later expanded in the Great Compendium of Acupuncture (Zhen Jiu Da Cheng
1601).2 For example, when using the Directing Vessel, one would needle LU-7 Lieque and KI-6 Zhaohai in this order, the former being its opening point and the latter its associated point (and opening point of its paired vessel, Yin Stepping Vessel). There are two possible ways of proceeding: 1. Using the Extraordinary Vessel’s opening point (with or without its associated point). 2. Using a point on the vessel. Using the opening points achieves two results. First, it reaches the area governed by that vessel (e.g. the Directing Vessel, LU-7 Lieque and KI-6 Zhaohai to reach the mouth and gums). Second, it brings into play the Extraordinary Vessels’ role as reservoirs of Qi, i.e. to absorb and regulate excesses and stagnation. This is particularly necessary when the pulse has the same quality in different positions (see below). The effect of using a point on the vessel depends on the vessel in question and cannot be generalized. To understand this, we need to distinguish the categories of Extraordinary Vessels: The Governing and Directing Vessels These are quite different than the other six because they have their own points. They are at once Extraordinary Vessels and ordinary channels (hence the reference sometimes to the 14 channels). Therefore using a point on these two vessels has a powerful effect on them even without using the opening points. A point on one of these two vessels can tonify, activate or move Qi in that particular vessel. For example, using Ren-4 Guanyuan brings into play the energy of the Directing Vessel and it can tonify its Blood and Essence. Of course, very often we use the opening points and a point on the channel as well. For example, it is very common to needle LU-7 Lieque on the right and KI-6 Zhaohai on the left to open the Directing Vessel, together with Ren-4
Guanyuan to strengthen the vessel and the Kidneys. To give another example, using Ren-6 Qihai moves Qi in the Lower Burner, even without the Directing Vessel’s opening points. The Penetrating Vessel (Chong Mai) Although this vessel does not have its own points in the same way as the Governing and Directing Vessels do, one could say that it almost does. In fact, the Penetrating Vessel is closely associated with the Kidney channel flowing as it does through all the Kidney points between KI-11 Henggu and KI-21 Youmen. Therefore, if we tonify KI-13 Qixue, we have a profound tonifying effect on the Penetrating Vessel (nourishing Blood and Essence). If we needle KI-14 Siman, we strongly invigorate Blood in the Uterus. We achieve these effects also without using the Penetrating Vessel’s opening points. The other five vessels The other five vessels do not have their own points and they meander from one channel to the other. The Yang Stepping Vessel (Yang Qiao Mai) is a good example of this as it meanders through nearly all Yang channels from the ankle to the eyes. In the case of the other five channels, using a point on the vessel without its opening points will not have any influence on that vessel. For example, if we needle S.I.-10 Naoshu (on the Yang Stepping Vessel) without its opening points, we would not influence this vessel in any meaningful way. On the contrary, using BL-62 Shenmai and S.I.-3 Houxi would open the Yang Stepping Vessel to perform its function of absorbing excess of Yang energy in the upper part of the body, whereas using S.I.-10 Naoshu only would have no such effect. Although several practitioners use the opening and associated point as a couple, not all doctors use the points in this way and the classics sometimes discuss the points as pairs and sometimes not. Thus, some doctors would use
only LU-7 Lieque to open the Directing Vessel. The three different ways of using the opening points of the Extraordinary Vessels can be summarized as follows: Above–Below Unilaterally This consists in using the opening point of the main vessel and its associated point on the same side. Example: S.I.-3 Houxi on the left, BL-62 Shenmai on the left. This method is suitable for unilateral problems of the back and limbs, or unilateral backache, sprains, Painful Obstruction Syndrome or sequelae of Wind-stroke. When using this method, one needles only the affected side. Left–Right Crossing This consists in using the opening point of the main vessel on one side and its associated point on the other. Example: S.I.-3 Houxi on the left, BL-62 Shenmai on the right. This method is suitable for problems of the head and face and internal organs. The technique is especially suitable for children, old people and patients whose body condition is weak or who suffer from anxiety. One should not use too many other needles or the needles on one limb cannot move Qi well (especially if there are scars or boils with pus). Above–Below Bilaterally This consists in using the opening points of the main vessel bilaterally and its associated points also bilaterally. Example: S.I.-3 Houxi and BL-62 Shenmai both bilaterally. This method has a very wide application and can basically be used for both types of problems indicated above. In my practice I use the second method, i.e. using the opening point of the main vessel unilaterally and its associated point on the opposite side. In deciding on which side to use the opening point of the main vessel, I go by the patient’s sex, i.e. the opening point of the vessel being treated is needled
on the left side for a man and the right side for a woman, and its associated point (which is the opening point of the paired vessel) on the opposite side. For example, if using the Directing Vessel in a male patient, I needle LU-7 Lieque on the left and KI-6 Zhaohai on the right, inserting the needles in this order, and would withdraw them in the reverse order; in a female patient, I would needle LU-7 Lieque on the right and KI-6 Zhaohai on the left, in this order, and again would withdraw them in the reverse order. Although this method of needling according to sex and laterality is not mentioned in the Great Compendium of Acupuncture, that book does suggest needling first the opening point of the chosen vessel and then that of its associated vessel (e.g. LU-7 Lieque and KI-6 Zhaohai for the Directing Vessel).3 When I use the opening points of an Extraordinary Vessel, I do not use any particular technique: I just obtain deqi and leave the needles in for approximately 20–25 minutes. When used in such pairs, the Extraordinary Vessels’ points also harmonize Above and Below as the paired points are always one from the arm and one from the leg. By using these points as pairs, one transcends the action of the individual points and brings into play the energy of the Extraordinary Vessels: it is as if one needed two keys to open a door. That is why I prefer to use the points of the Extraordinary Vessels in pairs. Some doctors in China studied whether the Extraordinary Vessels work better by using the opening point on its own or with its associated point: they report a case of a woman suffering from mental illness for whom they used S.I.-3 Houxi without good results; when this point was associated with BL-62 Shenmai, results improved.4 When paired in this way according to opening and associated points, the Extraordinary Vessels within a pair have a common range of action in terms of body areas: • Directing Vessel and Yin Stepping Vessel: abdomen, chest, lungs, throat, face.
• Governing Vessel and Yang Stepping Vessel: back of legs, back, spine, neck, head, eyes, brain. • Penetrating Vessel and Yin Linking Vessel: inner aspect of leg, abdomen, chest, heart, stomach. • Girdle Vessel and Yang Linking Vessel: outer aspects of leg, sides of body, shoulders, side of neck (Table 7.1). Table 7.1 Areas of influence of Extraordinary Vessel pairs
Some doctors go so far as saying that there are 360 points in the body with 66 most important ones (the Transporting Shu points); but the eight confluent points of the Extraordinary Vessels control all the 66 Shu points. What guidelines can be given for choosing to use the Extraordinary Vessels in practice? There are basically three depending on the nature of the imbalance.
1 Problems of internal organs Use the internal organs identification of patterns. If the clinical condition reflects very clearly the disharmony of one or more organs and manifests with clear-cut internal organ patterns, then it makes sense to treat it according to the internal organs identification of patterns, without using an Extraordinary Vessel. For example, if a patient has clear-cut symptoms and signs of LiverQi stagnation, one can simply treat according to the pattern of Liver-Qi stagnation using the relevant points and disregard the Extraordinary Vessels. 2 Problems of head–limbs–Exterior Use the main channel identification of patterns. This means that a channel problem, distributed clearly along a main channel, is treated according to channel patterns. For example, if a patient suffers from a painful shoulder, with pain radiating clearly along the Large Intestine channel, then it is sufficient to treat this problem mainly according to this channel and not use an Extraordinary Vessel. 3 Problems of several channels simultaneously, complicated conditions, involvement of an internal organ with a different channel, confusing situations of Heat–Cold and deficiency–excess, some mental problems, some neurological problems, the pulse having the same quality in several positions Use the Extraordinary Vessels. As can be seen from the above list, the therapeutic range of the Extraordinary Vessels is very broad indeed. I shall discuss the above points one by one. Problems of several channels simultaneously The Extraordinary Vessels are ideally placed to treat problems involving
several channels for two reasons. First and foremost, this is because they absorb excesses and stagnation from several main channels (just as several streams may flow into one lake); for example, the Yang Stepping Vessel absorbs excesses from all Yang channels. Second, the Extraordinary Vessels do not have their own points (with the exception of Governing and Directing Vessels, of course) and their pathways cross several different main channels. For example, the Yang Linking Vessel crosses the Small Intestine, Gall Bladder, Bladder, Stomach and Governing Vessel. To give another example, the Yang Stepping Vessel gives good results in sciatica when the pain seems to be in between the Bladder and Gall Bladder channels. Complicated conditions The Extraordinary Vessels are often implicated in complex pathological conditions due to their influencing so many different channels and so many different organs. For example, the Penetrating Vessel affects Blood, the Kidneys, the Kidney-Essence, the Heart, the Sea of Blood, all the channels in the abdomen, the facial hair, rebellious Qi in the abdomen and chest, the inner aspect of the leg and big toe, etc. Therefore, a pathology of the Penetrating Vessel could involve all these different aspects and the clinical manifestations would be very difficult to unravel if we referred only to the internal organ patterns. In fact, very often clinical manifestations that appear extremely complicated when analysed according to internal organ patterns are readily disentangled when seen from the point of view of an Extraordinary Vessel’s pathology. Involvement of an organ and a different channel For the same reasons explained above, the Extraordinary Vessels can give rise to symptoms of one organ and a different channel. For example, the Penetrating Vessel arises from in between the Kidneys and can therefore cause symptoms of Kidney deficiency together with symptoms of rebellious Qi in the Stomach.
Confusing situations of Heat and Cold or of deficiency and excess The pathology of the Penetrating Vessel is largely responsible for conditions characterized by confusing symptoms of Heat and Cold as explained in Chapter 3 on pathology. When the Qi of the Penetrating Vessel rebels upwards, it may cause a feeling of heat in the face and, because of a deficiency of Qi in the descending branch of this vessel, cold feet. The Penetrating Vessel is similarly involved in confusing situations of deficiency and excess: for example, a Kidney deficiency may not only cause the Penetrating Vessel to be Empty in the Lower Burner but also cause Qi to rebel upwards with symptoms of Fullness (stagnation of Qi) in the chest. Some mental problems The Extraordinary Vessels are often used for mental–emotional problems, especially the Governing Vessel, the Yang Stepping Vessel, the Penetrating Vessel and the Yin Linking Vessel, as explained in Chapter 3 on pathology. Some neurological problems Some of the Extraordinary Vessels may be used to treat neurological problems such as neuritis and multiple sclerosis. This applies in particular to the Governing Vessel and the Girdle Vessel. Conditions in which the pulse acquires the same quality in different positions This means that the pulse has exactly the same quality, for example, on both Front positions, or on both Guan positions, or on all positions of one side. The Study of the Eight Extraordinary Vessels by Li Shi Zhen describes in detail certain pulse qualities related to these vessels.5 The main pulse findings are detailed below:
1. A ball feeling of both Front positions when the pulse is also Tight, Fine and Long is linked to the Directing Vessel. This is often related to abdominal pain and abdominal masses in women. 2. A straight up-and-down Floating pulse at all three positions, especially on the left, is linked to the Governing Vessel. This is often related to stiffness of the back and mental–emotional problems. 3.A straight up-and-down Deep and Firm pulse at all three positions, especially on the right, is linked to the Penetrating Vessel. This is often related to abdominal fullness and a feeling of oppression of the chest. 4. A Wiry pulse at the Front position on both sides is linked to the Yang Stepping Vessel. This may be related to mental agitation. 5. A Wiry pulse at the Middle position on both sides is linked to the Girdle Vessel. This may be related to amenorrhoea or infertility. 6. A Wiry pulse at the Rear positions on both sides is linked to the Yin Stepping Vessel and also to the Yin and Yang Linking Vessels. This may be related to abdominal pain and menorrhagia. Why should a pulse that displays exactly the same quality in more than one position and usually in corresponding ones (such as both Front positions) be linked to the Extraordinary Vessels’ function of reservoirs of Qi? If the main channels are like rivers (each one reflected in individual pulse positions) and the Extraordinary Vessels like lakes which absorb overflowing energy, it is natural that the state of these vessels would be reflected in more than one position, much as an overflowing river loses its shape and floods a whole area of land. The Extraordinary Vessels are also related to the Four Seas: • Sea of Marrow (Brain): Governing Vessel and Yin and Yang Stepping Vessels. The points are Du-20 Baihui and Du-16 Fengfu (both on the Governing Vessel).
• Sea of Qi (chest): Directing Vessel. The points are ST-9 Renying and Ren-17 Shanzhong (a point of the Directing Vessel). • Sea of Food (Stomach): Penetrating Vessel. The points are ST-30 Qichong (a point of the Penetrating Vessel) and ST-36 Zusanli. • Sea of Blood: Penetrating Vessel. The points are BL-11 Dashu, ST-37 Shangjuxu and ST-39 Xiajuxu. The Sea of Blood is of great significance in gynecology: any menstrual pathology is a pathology of the Sea of Blood and, in consequence, also of the Penetrating Vessel.
Penetrating vessel (chong mai) The Penetrating Vessel is probably the most important of the Extraordinary Vessels and, in relation to gynecology, it has a deep influence on the menstrual function as it is the Sea of Blood. It is therefore related to the Blood in the Uterus and controls menstruation in all its aspects. If the Penetrating Vessel is Empty there may be amenorrhoea, scanty periods or late periods. If Qi and/or Blood are stagnant in the Penetrating Vessel there may be dysmenorrhoea. The Penetrating Vessel also controls the breasts in several ways. The pathway of this vessel runs from the lower abdomen along the Kidney channel and then fans out over the breasts and chest on its way to the throat and eyes. The major arteries that feed the breast, i.e. the axillary artery supplying the outer half and the internal mammary arteries the inner half of the breast, are controlled by the Penetrating Vessel in two ways: because this vessel is the Sea of Blood and controls all blood vessels, and because this vessel spreads over the breasts in women. For this reason, the Penetrating Vessel exerts an important influence on pre-menstrual breast distension, breastfeeding and breast lumps. Because the Penetrating Vessel is the Sea of Blood and breast milk is a transformation of Blood, this vessel influences the supply of breast milk in two ways: if the Penetrating Vessel is Empty, the Sea of Blood is depleted and there may not be enough milk. If the Qi of the Penetrating Vessel is stagnant, the breast Connecting (Luo) channels will be blocked and the milk may not flow even though it is abundant. Figure 7.1 illustrates the pathway of the Penetrating Vessel in relation to the arteries feeding the breast.
Figure 7.1 The Penetrating Vessel and breast arteries. To open the Penetrating Vessel in a woman, I needle SP-4 Gongsun first on the right followed by P-6 Neiguan on the opposite side: the needles are retained for about 20–25 minutes and withdrawn in the reverse order. Apart from obtaining the needling sensation (deqi), it is not necessary to perform any other needling manipulation. Since the subject is gynecology, I shall assume from now on that the opening point is inserted on the right side and the associated one on the left (Fig. 7.2).
Figure 7.2 Order of insertion of opening points for Extraordinary Vessels. Using SP-4 Gongsun on the right and P-6 Neiguan on the left (in a woman) ‘opens’ and regulates the Penetrating Vessel: this means that the vessel is opened to perform its function of absorbing excesses or stagnation of Qi and also that these two points will affect the area influenced by the
Penetrating Vessel, i.e. abdomen, chest, heart and throat. As indicated in Chapter 3, rebellious Qi is a frequent pathology that affects the Penetrating Vessel. Indeed, the word chong in Chinese is also used as a verb to indicate the pathological rising of Qi towards the top. For example, when the Qi of the fetus rebels upwards and disturbs the mother, it is called tai qi chong yu shang, i.e. the “Qi of the fetus rebels (chong) upwards”. The main symptoms and signs indicating such a syndrome are abdominal pain and distension, a feeling of oppression of the chest and throat, palpitations, a suffocating sensation, a feeling of heat in the head, cold feet, anxiety and a pulse that is Firm on all three positions of the left side. Not all these symptoms need be present to use this vessel, but it is usually necessary to have three or four of these symptoms at different levels of the trunk to diagnose this syndrome. Interestingly, the aetiology of this syndrome is attributed to fear and shock, both of which injure the Kidneys. In practice, this syndrome, and its corresponding rebelling of Qi in the Penetrating Vessel, may be either of the Full type stemming from stagnation of Liver-Qi or of the Empty type stemming from a Kidney deficiency. This latter type is particularly common in women: the deficient Kidney within the Penetrating Vessel in the Lower Burner fails to root and anchor Qi so that this rebels upwards affecting both Kidney and Liver channels and causing a sensation of upsurge towards the chest and throat. Thus, the syndrome is a complex one, characterized by a deficiency of the Kidney and stagnation of the Liver with rebellious Qi in the Penetrating Vessel; in terms of areas, deficiency below (the lower abdomen) and excess above (the chest, throat and face). The upsurge of rebellious Qi causes a feeling of heat in the face, while a deficiency of Qi in the descending branch of the Penetrating Vessel causes cold feet: this accounts for contradictory symptoms of Heat and Cold in this syndrome. In gynecology, this syndrome is very common in women over 40, in menopausal problems, or in dysmenorrhoea. The opening and associated points of the Penetrating Vessel (SP-4 Gongsun on the right and P-6 Neiguan on the left) are excellent to treat this condition. However, these points are usually associated with points along the
Penetrating Vessel, such as ST-30 Qichong, KI-13 Qixue, KI-14 Siman, KI-16 Huangshu, KI-18 Shiguan, KI-19 Yindu, KI-20 Futonggu and KI-21 Youmen. The following is an example of point combinations to open the Penetrating Vessel for the Empty type of syndrome of rebellious Qi, i.e. one that derives from a Kidney deficiency: SP-4 Gongsun on the right (inserted first), P-6 Neiguan on the left (inserted second), L.I.-4 Hegu on the right, LIV-3 Taichong on the left, KI-13 Qixue, KI-16 Huangshu, KI-21 Youmen, the last three all bilateral (Fig. 7.3). In this combination, SP-4 and P-6 regulate Qi of the Penetrating Vessel; L.I.-4 and LIV-3 help to regulate the ascending and descending of Qi; KI-13 tonifies the Kidneys and the Penetrating Vessel; KI-16 harmonizes Kidneys and Heart and helps to subdue rebellious Qi; KI-21 helps to subdue rebellious Qi.
Figure 7.3 Point combination for rebellious Qi of the Penetrating Vessel of the Empty type.
An example of point combination for the Full type of Rebellious Qi of the Penetrating Vessel is as follows: SP-4 on the right, followed by P-6 on
the left, L.I.-4 Hegu on the right, LIV-3 Taichong on the left, KI-14 Siman, KI-16 Huangshu, KI-21 Youmen, the last three all bilateral (Fig. 7.4).
Figure 7.4 Point combination for rebellious Qi of the Penetrating Vessel of the Full type.
I shall now discuss the actions and indications of the most important Penetrating Vessel points on the abdomen and chest with particular emphasis on gynecological problems intended in a broad sense: that is, I shall include symptoms that, whilst not strictly ‘gynecological’, are frequently associated with gynecological symptoms and that are very common in women, such as urinary problems, oedema, abdominal pain, etc. ST-30 Qichong (Rushing Qi) ST-30 is an extremely important point of the Penetrating Vessel because it is here that the vessel emerges from the Interior, descending from the space between the kidneys and the uterus. The chong within the name of this point can be translated as ‘rushing’ or ‘penetrating’ and is the same character as that for chong mai, i.e. Penetrating Vessel; thus, its name clearly indicates its relationship with this vessel and, at the same time, it suggests the energetic movement as the Qi of this vessel rushes outwards towards the surface from this point. The word chong can also be translated as ‘infuse’ and, in this sense, it indicates that this point is the place where the three Yang channels (of the leg) infuse outwards, and the three Yin Essences (of the Yin channels of the leg) infuse inwards. The fact that the crossing of the Yang and Yin Essences on their way out and in is on a large artery (femoral) contributes to the name of ‘Infusing Qi’. This point is also frequently called Qijie which means ‘Avenues of Qi’: this is a clear reference to the Penetrating Vessel’s control of all the channels of the abdomen (hence its name of ‘Sea of the 12 Channels’). In fact, at this point, the Stomach channel goes in, the Gall Bladder channel goes out, the Penetrating Vessel emerges; the Liver and Spleen channels also go through this point; it is thus a real crossroads of channels on their way to or from the abdomen and inwards or outwards. All the old books describe this point as being on a ‘big artery’ (the femoral artery) where a strong beat can be felt.
Its location on a major artery is not a matter of chance as the Penetrating Vessel, which emerges from this point, is also the Sea of Blood and controls all channels and blood vessels. The actions of this point are very wide-ranging. It: • pacifies the Liver • benefits the Kidneys • regulates the menses • promotes fertility • regulates Stomach-Qi • regulates the Penetrating Vessel • promotes the Essence • tonifies the Sea of Food • invigorates Blood. As can be seen, apart from its action on Stomach-Qi, all its other actions are of great relevance in gynecology. The indications are very many indeed and I shall list only those relevant to the Penetrating Vessel’s pathology and gynecology: infertility, abdominal pain and distension, Qi of the fetus surging upwards to harass the Heart (of the mother), swelling and pain of external genitalia, irregular periods, retention of placenta and dysmenorrhoea. ST-30 Qichong is an important and powerful point of the Penetrating Vessel. The main thrust of its action is related to its being the point from which the Qi of the Penetrating Vessel emerges from the Interior, hence its dynamic nature. Furthermore, since ST-30 is a point of the Sea of Food of the Stomach, it represents an important connection between the Stomach and the Penetrating Vessel, i.e. between the Post-Natal and Pre-Natal Qi,
and it can be used to strengthen both the Pre-Natal and Post-Natal Qi. Looking at the actions and indications, we can deduce that this point can be used in Empty conditions to tonify Qi, Blood and Essence, and in Full conditions to subdue rebellious Qi and Blood in the Penetrating Vessel and to invigorate Blood. In its former function, it can treat infertility; in its latter function, it can treat dysmenorrhoea, abdominal pain and irregular periods. The point ST-30 Qichong is frequently combined with the opening points of the Penetrating Vessel, i.e. SP-4 Gongsun and P-6 Neiguan, for both Empty and Full conditions as described above. It may also be combined with ST-39 Xiajuxu and LIV-3 Taichong for numbness and cold feet, due to deficiency of Qi and Blood in the descending branch of the Penetrating Vessel. KI-11 Henggu (Horizontal Bone) ‘Horizontal Bone’ indicates the pubic bone, over which this point lies. This point: • benefits the Kidneys • tonifies Yang • clears Heat • treats Painful-Urination Syndrome. Like the previous point, ST-30 Qichong, and like many of the Penetrating Vessel’s points on the abdomen, this point can be used to tonify in Empty conditions and to clear in Full conditions, hence the apparent paradox that it can both tonify Yang and clear Heat. ‘Tonify Yang’ means that it can tonify Kidney-Yang when used with direct moxa cones. ‘Clear Heat’ means that it can clear Heat or Damp-Heat of the Bladder in PainfulUrination Syndrome. Thus this point is used for urinary problems in women more often than for menstrual problems.
Its indications, with particular reference to gynecology, include genital pain, lower abdominal pain, urinary difficulty and Painful-Urination Syndrome. The point KI-11 Henggu can be combined with ST-27 Daju and LIV14 Qimen for fullness of the lower abdomen, urinary difficulty and prolapse of the vagina; with SP-2 Dadu for backache with inability to straighten up from Qi stagnation; and with KI-16 Huangshu for chronic Painful-Urination Syndrome. KI-12 Dahe (Great Flourishing) Other names include Yinwei (‘Linking Yin’) and Yinguan (‘Gate of Yin’). The word he means ‘flourishing, luminous, awe-inspiring’: the point is so called because Yin Qi flourishes here and the Essence accumulates, and also because after conception the uterus enlargement starts at this place. The actions of KI-12 are as follows. It: • benefits the Kidneys • consolidates the Essence • regulates the menses • promotes conception. As explained above, this point too can treat either Empty or Full conditions although it is particularly indicated for Empty ones. In fact, its indications, with particular reference to gynecology, include genital pain, vaginal discharge, prolapse of the uterus, irregular periods, dysmenorrhoea and infertility. This point is frequently encountered in modern prescriptions to promote ovulation. It can be combined with KI-2 Rangu for contraction of the genitals. KI-13 Qixue (Qi Hole)
Other names include Baomen (‘Door to the Uterus’) and Zihu (‘Door of the Baby’). There are three explanations for the meaning of this name: the point is situated near the opening of the bladder, hence ‘hole’; the Kidneys control the grasping of Qi and this point is the ‘hole’ into which Qi is anchored; and the Essence accumulates in this ‘hole’. The actions of this point are as follows. It: • benefits the Directing and Penetrating Vessels • regulates the two Yin (orifices) • tonifies the Kidneys and the Essence. The indications specific to gynecology include: irregular periods, white vaginal discharge, Uterus Empty and Cold, and Directing and Penetrating Vessels Empty. Like the other points on the Penetrating Vessel, KI-13 also has a dual function: it can both supplement a deficiency and clear a Fullness. In Empty conditions, it is probably the most important tonifying point on the Penetrating Vessel: it tonifies the Kidneys (Yin or Yang), nourishes the Essence, strengthens the Original Qi (Yuan Qi) and fills the Directing and Penetrating Vessels. It also strengthens the Kidney’s grasping of Qi and is an important point in treating allergic asthma from Kidney deficiency or nourishing KidneyYin in menopausal problems. In Full conditions, KI-13 Qixue is used for rebellious Qi of the Penetrating Vessel causing an upsurge of energy from the lower abdomen to the chest and throat. It should be noted, however, that in such conditions it need not necessarily be reduced: if the condition of rebellious Qi is secondary to a Kidney deficiency and an Emptiness in the Lower Burner as described above, then this point should be tonified. The Great Dictionary of Chinese Acupuncture compares this point with the keys of a wind musical instrument. It says that it moves Blood through Qi (Qi being compared with the air in a wind instrument and the Kidney points on the abdomen presumably corresponding to its keys), and that it treats the running piglet surging
upwards and the beng lou (Flooding and Trickling) leaking downwards.6 I frequently combine this point with Ren-4 Guanyuan (through which the Penetrating Vessel also flows) to tonify the Kidneys, nourish the Essence and strengthen the Original Qi. KI-14 Siman (Four Fullnesses) This point’s other names include Suifu (‘Fu of Marrow’) and Suizhong (Central Marrow). There are many explanations for the name ‘Four Fullnesses’: • ‘Four’ because it is the fourth point after the Kidney channel enters the trunk. • It lies over the bladder and ‘Fullness’ indicates the bladder full of urine. • ‘Four Fullnesses’ refers to a feeling of fullness in the abdomen radiating in four directions. • ‘Fullness’ indicates hernia for which it is used. • ‘Four Fullnesses’ indicates a feeling of fullness in the abdomen from four stagnations (of Qi, Blood, Food and Dampness). • The Essence of the four limbs and the hundred bones collects in the Field of Elixir (Dan Tian), surplus Essence is transformed into Marrow, enters the bones and then returns to the Extraordinary Vessels; Essence, Qi and Blood ‘fill up’ in the Field of Elixir near this point. The actions of KI-14 Siman are as follows. It: • regulates Qi • treats hernia
• regulates the menses • promotes fertility. Indications in gynecology include: metrorrhagia, irregular menstruation, retention of lochiae, vaginal discharge, infertility and lower abdominal pain. This point also can be used for both deficiency and excess but more frequently for the latter. Thus, in a deficiency, one would prefer KI-13 Qixue but in an excess KI-14 Siman. From this point of view, KI-14 is a very important point for stagnation of Qi and/or Blood in the lower abdomen in women. I use it frequently in combination with the opening points of the Penetrating Vessel for stagnation of Qi or Blood in the abdomen causing such problems as dysmenorrhoea, abdominal pain or menorrhagia. Bearing in mind its name, this point is specific for a feeling of fullness of the abdomen: this differs from a feeling of distension insofar as the latter is merely a subjective symptom while the former is objective too as the abdomen feels hard on palpation. As its alternative names indicate, this point can be tonified to nourish Marrow: for this reason, it is used during and after the menopause to prevent osteoporosis. KI-16 Huangshu (Transporting Point of Membranes) ‘Huang’ means ‘membranes’ and ‘Shu’ means Transporting point (as in the Back-Transporting points). The point is situated at the border between the upper and lower abdomen and it therefore lies at the centre of the ‘membranes’: these include the connective tissue structures lying in the abdomen, i.e. mesentery, omentum and fascia. This point is therefore the Transporting (Shu) point of these structures. It is also the point from where the Kidney channel penetrates deeply into the membranes. These penetrate upwards to the chest and diaphragm and connect with the Girdle Vessel. This point, being near the umbilicus which connected the fetus to the mother, controls the origin of membranes and is like the Original point of all internal organs. ‘Transporting point of membranes’ also means that the point is at the
centre of membranes, it connects downwards with the Kidneys and upwards with the Heart, the throat and tongue. The actions of this point are as follows. It: • regulates Qi • stops pain • moistens dryness • promotes bowel movement • regulates the Penetrating Vessel • harmonizes Kidneys and Heart. The main gynecological indications are irregular periods. Other indications, which help us to understand the nature of this point, include umbilical pain, abdominal distension, constipation, hernia, vomiting, diarrhoea, Cold in the Large Intestine and a feeling of ‘cold under the heart region’. As can be seen from the indications, this point is mainly used for Full conditions characterized by rebellious Qi in the Penetrating Vessel: in gynecology, principally for dysmenorrhoea and irregular periods. However, there is a deeper significance in that this point belongs to the Penetrating Vessel and is situated next to the umbilicus. Through this point, the baby’s umbilical cord connects with the mother’s placenta; the Penetrating Vessel is the precursor of all other Extraordinary Vessels and therefore related to the Pre-Natal Qi. At conception, the Governing, Directing and Penetrating Vessels are formed, representing the spark and organizing force that will give shape to the human form. In the fetus, the umbilicus, the Original Qi and the Gate of Life (Ming Men) lie on the same energetic axis and KI-16, lying right next to the umbilicus and being on the Penetrating Vessel, is like a Transporting point not only for the membranes but also for all the internal organs. Thus, this point can affect the Pre-Natal Qi, the Kidney-Essence and
the Original Qi. KI-18 Shiguan (Stone Gate) ‘Stone’ here indicates fullness, hardness: this refers to the main indication for this point, i.e. fullness and hardness of the epigastrium. ‘Gate’ refers to the pyloric sphincter of the stomach through which the digested food passes on its way to the small intestine. The Great Dictionary of Acupuncture gives a different interpretation of this name, saying that shi can sometimes mean ‘water’: hence shi here would indicate the Water of the Kidneys, and the name would mean ‘Gate of the Kidneys’.7 Yet another interpretation given in the same dictionary is that ‘Stone Gate’ here refers to the blockage of stools (the point treats constipation) and to infertility, i.e. two stone gates are blocking the passage of stools and sperm. The main actions of this point are as follows. It: • softens hardness and dissolves fullness • tonifies the Kidneys • promotes conception. The main gynecological indications are: post-partum abdominal pain, abdominal pain, infertility, a sensation of fullness and hardness under the heart region, ‘evil’ blood in the Yin organ (i.e. old, stagnant Blood). Thus, although this point can be used to tonify the Kidneys and promote fertility in deficiency conditions, its more common use is for Full conditions characterized by stasis of Blood in the abdomen and retention of food in the Stomach and Intestines. The fullness and hardness can also extend to the Heart because the Penetrating Vessel flows to the heart region, causing a feeling of fullness and hardness in this region with a corresponding mental– emotional state of worry, anxiety and bitterness. On a diagnostic level, an important sign for the use of this point is a feeling of hardness of the epigastrium and/or abdomen.
KI-19 Yindu (Yin City) The abdomen is Yin and this point is on the Kidney channel which also pertains to Yin: it is Yin within Yin, hence the name ‘Yin City’. Du indicates an important city, but also a place where water collects; the Kidneys govern Water, hence the name means also ‘Yin-place-where-Water (Kidneys)collects’. The actions of this point are as follows. It: • opens the chest • subdues rebellious Qi • regulates Qi • harmonizes the Stomach. The indications of KI-19 Yindu in the gynecological sphere include: infertility, sensations of heat and cold (as in menopausal problems), a feeling of vexation of the heart and old, stagnant Blood in the viscera. Because of this point’s action on sensations of heat and cold and a feeling of anxiety and vexation of the heart, it can be used, combined with the Penetrating Vessel’s opening points, in menopausal problems. KI-20 Futonggu (Abdominal Penetrating Valley) ‘Fu’ means ‘abdomen’ and is used here only to distinguish this point from BL-66, which is also called ‘Tonggu’. ‘Tong’ means ‘penetrating’ or ‘passing through’. ‘Gu’ can mean both ‘valley’ or ‘grains’ and, by extension, ‘food’. Thus the name of this point can be interpreted in two ways. The ‘valley’ is the space between the muscles of the abdomen (rectus abdominis) where the point lies. The Qi of the Kidneys and Penetrating Vessel passes through this space as if through a mountain valley. If we interpret ‘Gu’ as ‘grains’ or ‘food’, the name of the point means ‘easing the passage of food through the
digestive system’, a clear reference to the many digestive indications of this point. The actions of KI-20 Futonggu are as follows. It: • strengthens the Spleen • harmonizes the Stomach • opens the chest • calms the Mind. The indications relevant to gynecology include abdominal pain and distension, palpitations and mental confusion. The main use of this point in gynecology is for palpitations, mental confusion and anxiety occurring in menopausal problems. Again, this point would be used with the opening points of the Penetrating Vessel (SP-4 Gongsun and P-6 Neiguan) and, if the problem stems from a Kidney deficiency, also with such points as Ren-4 Guanyuan and KI-13 Qixue. KI-21 Youmen (Dark Door) ‘You’ means ‘dark’ and ‘men’ means ‘door’. ‘Dark’ denotes the fact that at this point the Penetrating Vessel goes deeper and disappears into the chest cavity, hence into ‘darkness’. ‘Door’ indicates that it is the border between the more superficial abdominal branch and the deeper thoracic branch of the Penetrating Vessel. ‘Dark’ also refers to the Yin character of this point pertaining both to the Kidney channel and to the Penetrating Vessel. The actions of KI-21 Youmen are as follows. It: • strengthens the Spleen • harmonizes the Stomach • subdues rebellious Qi (of the Penetrating Vessel)
• stops vomiting • calms the Mind. The indications of KI-21 Youmen in the gynecological sphere include palpitations, anxiety, poor memory, abdominal fullness and chest pain in women. The book Acupuncture reports the last symptom from an old classic: this is interesting as it confirms that this point treats the Penetrating Vessel in women in conditions of rebellious Qi.8 KI-21 Youmen is also compared to a door because all types of Qi go through this point on their way up through the diaphragm: Food-Qi (Gu Qi), Qi of the Essence (Jing Qi), Clear Qi (Qing Qi) and Yin and Yang Qi. This point is said to pacify the five viscera by sorting out their clear and turbid essences. Penetrating Vessel: summary and case histories To summarize, the major pathology of the Penetrating Vessel in gynecology is Qi rebelling upwards from the lower abdomen to the chest and throat, with stagnation of Qi and/or Blood. The condition of Qi rebelling upwards may be due to a deficiency of the Kidneys and an Emptiness of the Penetrating Vessel in the lower abdomen. The deficiency below and rebellious Qi above account for contradictory symptoms of heat and cold in women, especially after the age of 40. Since the Penetrating Vessel is the Sea of Blood, this vessel is extremely important in the treatment of dysmenorrhoea from stasis of Blood. Because it controls all Blood Connecting Channels, a deficiency or stasis of Blood in this vessel may cause aches in the muscles and joints resembling Painful Obstruction Syndrome. Case history A 45-year-old woman had been suffering from tiredness, blurred vision, palpitations, a panicky, anxious feeling in the chest with a feeling of energy rising, insomnia, headaches during the periods, pre-menstrual tension with
abdominal distension, a feeling of heat in the face but cold hands and feet. Her tongue was Bluish-Purple and her pulse was Fine but also slightly Firm in all three positions of the right side (Plate 1). Most of her symptoms are due to rebellious Qi in the Penetrating Vessel against a background of Blood deficiency (Fine pulse, tiredness, blurred vision, insomnia). All the other symptoms (palpitations, a panicky, anxious feeling in the chest with a feeling of energy rising, headaches during the periods, pre-menstrual tension with abdominal distension, Firm pulse in all three positions of the right side) are due to rebellious Qi in the Penetrating Vessel. In addition, the stagnation of Qi in the Penetrating Vessel had given rise to Blood stasis as shown by the Purple tongue. The contradiction between the hot feeling of the face and the coldness of the limbs occurs frequently in women. It is due to a deficiency in the descending branch of the Penetrating Vessel (causing cold feet) and to Qi rebelling upwards (causing a feeling of heat in the face). The points used were: • SP-4 Gongsun on the right and P-6 Neiguan on the left to open the Penetrating Vessel. • Ren-4 Guanyuan to tonify Blood in the Penetrating Vessel: this will also have the effect of subduing rebellious Qi by rooting it downwards. • KI-13 Qixue to strengthen the Kidneys and consolidate the root of the Penetrating Vessel. • SP-6 Sanyinjiao to nourish Liver and Kidneys and strengthen the root. • L.I.-4 Hegu on the right and LIV-3 Taichong on the left to harmonize the ascending and descending of Qi and calm the Mind. The laterality of these points was chosen to balance that of the Penetrating Vessel’s opening and associated points.
This patient was treated along these lines for four sessions achieving a complete recovery from her symptoms. Case history
A 23-year-old woman suffered from painful periods. The pain occurred during the period and was very intense and cramp-like. It was relieved by the application of a hot-water bottle. Her tongue was Pale Purple. This is an example of obstruction of the Penetrating Vessel by Cold. The obstruction of the Uterus by Cold has led to stasis of Blood. The points used were: • SP-4 Gongsun on the right and P-6 Neiguan on the left to open the Penetrating Vessel. • Ren-4 Guanyuan and KI-16 Huangshu, with direct moxa cones, to strengthen the Penetrating Vessel and expel Cold from the Uterus. • LIV-3 Taichong, with warming needle, to move Blood and stop pain.
This patient was treated for 9 months along similar lines after which her periods ceased to be painful. Case history A 65-year-old woman complained of hot flushes every 50 minutes after a total hysterectomy 10 years previously. She could not have hormone replacement therapy as she had developed breast cancer (and underwent a mastectomy) 2 years previously. With the hot flushes, she also experienced anxiety with a suffocating feeling in the chest and throat. She suffered from night sweating and insomnia. Her urination was frequent and pale and her feet were generally cold. Her pulse was Deep, slightly Slippery on the right side and slightly Wiry on the left. Her tongue was of a normal colour, Swollen, with a yellow coating and Stomach cracks. This is an example of rebellious Qi in the Penetrating Vessel causing the feeling of heat and anxiety. It is not a typical Empty-Heat pattern as the tongue is not Red. The cold feet are due to the derangement of Qi in the Penetrating Vessel, rebelling upwards and failing to warm the legs in its descending branch. The pathology is also complicated by the presence of Phlegm, as evidenced by the Swollen tongue and Slippery pulse.
The points used were: • SP-4 Gongsun on the right and P-6 Neiguan on the left to open the Penetrating Vessel. • L.I.-4 Hegu on the right and ST-40 Fenglong on the left to harmonize the ascending and descending of Qi thus helping to subdue rebellious Qi, and regulate the Bright Yang to which the Penetrating Vessel is related. These two points will also resolve Phlegm from the digestive system. The laterality of these two points was chosen to balance that of the Penetrating Vessel’s opening and associated points. • Ren-4 Guanyuan to nourish the Uterus, consolidate the root and strengthen the Penetrating Vessel.
This patient required a lengthy treatment for about 18 months due to her age and also to the hysterectomy. This surgical procedure always somewhat hinders treatment in gynecological problems as it removes the uterus which stores Blood. Case history A 45-year-old woman suffered from pre-menstrual tension manifesting with breast distension, depression, headaches, insomnia, abdominal distension, a panicky feeling at night accompanied by a feeling of heat, palpitations, cold feet, heavy and painful periods. Her tongue was Pale, slightly Bluish and her pulse was Weak. Diagnosis If we interpret these manifestations according to patterns, they are very complicated; but if we see them in the light of channel pathology, we find that nearly all the manifestations are due to a pathology of the Penetrating Vessel. The central pathology is Qi of the Penetrating Vessel rebelling upwards, disturbing the chest and harassing the Mind. In fact, rebellious Qi flowing upwards causes the abdominal and breast distension; when it flows to the
heart it causes palpitations and the panicky feeling with heat sensation. Since Qi rebels upwards, it fails to flow in the Penetrating Vessel’s descending branch to warm the feet. Stagnation of Qi in the Penetrating Vessel causes the painful periods. Case history A 13-year-old girl suddenly experienced a violent abdominal pain. She was taken to hospital and she underwent an appendectomy after the surgeon diagnosed appendicitis. This diagnosis turned out to be wrong as the appendix was found to be normal. The abdominal pain continued after her operation: it was on the left side, starting under the left hypochondrial region, radiating to the lower abdomen just across the symphysis pubis. After two weeks, her first period arrived and this was painful too. She then experienced a severe headache and visual hallucinations. A week later she started retching uncontrollably, bringing up phlegm; again, with hallucinations and abdominal pain. A week later she experienced retching again, with a severe abdominal pain and urinary retention. Her tongue had a sticky coating and her pulse was Wiry. Diagnosis Although this condition appears quite complex, most of the symptoms can be explained as being due to rebellious Qi in the Penetrating Vessel. All her symptoms are related to the onset of the period and the stagnation of Qi and Blood in the Penetrating Vessel. This vessel arises from between the kidneys, and flows down to ST-30 Qichong and then up the abdomen along the Kidney channel to the chest, heart, throat, face and eyes. Thus, the abdominal pain experienced by this girl was due to stagnation of Qi of the Penetrating Vessel in the lower abdomen. At the same time, the Qi of this vessel rebelled upwards causing the headache. The Penetrating Vessel is also the Sea of Blood and stagnant Blood in this vessel follows rebellious Qi
upwards and clouds the Mind causing hallucinations and a headache. This vessel also flows through the urinary system and Qi stagnation caused the urinary retention. Treatment principle The treatment principle adopted was to nourish the Kidneys, subdue rebellious Qi, pacify the Penetrating Vessel, move Qi and invigorate Blood. The points used were: • SP-4 Gongsun (on the right) and P-6 Neiguan (on the left) to regulate and harmonize the Penetrating Vessel. • BL-51 Huangmen and KI-14 Siman, points of the Penetrating Vessel, to move Qi in the lower abdomen. • L.I.-4 Hegu on the right to regulate the ascending and descending of Qi, which helps to subdue its rebellion. • ST-37 Shangjuxu and ST-39 Xiajuxu on the left to nourish the Sea of Blood of the Penetrating Vessel which helps to subdue rebellious Qi. • SP-6 Sanyinjiao on the right to nourish Blood and pacify the Liver. • LIV-3 Taichong on the left to move Qi, subdue rebellious Qi in the Penetrating Vessel and pacify the Liver.
After four weekly treatments, she did not experience any recurrence of abdominal pain, headache or hallucinations, and her periods became painless.
Directing vessel (ren mai) The Directing Vessel is very widely used in gynecological problems for a great variety of conditions. It nourishes Blood and Yin, regulates the Uterus, promotes conception, maintains pregnancy, regulates delivery and promotes breast milk. Compared with the Penetrating Vessel, the Directing Vessel controls conception, fertility, pregnancy, puberty and menopause, while the Penetrating Vessel has more control over the menstrual cycle itself. Another difference is that the Directing Vessel is better for nourishing Yin, the Penetrating Vessel for nourishing Blood (apart from invigorating Blood). However, these differences are only relative, so that the Directing Vessel obviously also influences the menstrual cycle and also can nourish Blood. In the treatment of gynecological problems, the Directing Vessel can be used for the following therapeutic aims: • To nourish Blood and strengthen the Uterus. • To regulate the Uterus and the menstrual cycle. • To nourish Kidney-Yin and Kidney-Essence. Of course, there are other uses for the Directing Vessel not related to gynecology: for example, it is excellent for treating asthma from Lung and Kidney deficiency. I use the opening and associated points of this vessel in exactly the same way as for the Penetrating Vessel: needle the opening point LU-7 Lieque first on the right side (in women), and the associated point, KI-6 Zhaohai, on the left side, inserted second. The needles are retained for about 20–25 minutes and withdrawn in the reverse order. Apart from obtaining the needling sensation (deqi), it is not necessary to perform any other needling manipulation. I nearly always combine the opening and associated points of the Directing Vessel (LU-7 Lieque and KI-6 Zhaohai) with points on the vessel itself. The manipulation of these and the use of needles or moxa depends on
the treatment aim. Thus, to nourish Blood and strengthen the Uterus, one would use Ren-4 Guanyuan with moxa cones. To regulate the Uterus and the menstrual cycle, one would needle (no moxa) points such as Ren-4 Guanyuan, Ren-6 Qihai or Ren-7 Yinjiao, although Ren-4 is the main one. To nourish Kidney-Yin and the Kidney-Essence, Ren-4 Guanyuan is the most appropriate point: this is needled without moxa in the case of KidneyYin, but with moxa in the case of Kidney-Essence deficiency occurring against a background of Yang deficiency. The Directing Vessel is very effective as a treatment for menopausal problems by nourishing Yin and Essence. I shall now discuss the actions and indications of the main points on the Directing Vessel, dealing with only those points which are relevant to gynecology and, for them, only the gynecological indications; in a broad sense the discussion will include, for example, some urinary problems that are very frequently associated with gynecological conditions. REN-1 Huiyin (Meeting of Yin) The meaning of this name is obvious as Ren-1 is the beginning point of the Directing Vessel which governs all the Yin of the body. Yin here could also allude to the two Yin orifices, i.e. anus and urethra, in between which this point is situated. Ren-1’s other names include Jin Men meaning ‘Golden Door’ (this point being the ‘door’ into the Directing Vessel), Hai Di meaning ‘Seabed’ (this point being the lowermost of the Directing Vessel which pertains to Yin and Water, hence the ‘sea’ metaphor), and Gui Cang meaning ‘Ghost Store’ (which alludes to the old use of this point for possession by evil spirits; it was, in fact, one of the 13 ‘ghost points’ of Sun Si Miao). The actions of this point include the following. It: • promotes resuscitation • stops convulsions
• regulates the two lower orifices • tonifies the Kidneys • regulates Directing and Penetrating Vessels • regulates the periods. Indications in the gynecological sphere include prolapse of the vagina, pain and swelling of the vagina, amenorrhoea, genital pain and itchiness, irregular periods. It is interesting to note that some of the other indications (haemorrhoids, epilepsy, manic-depression (dian kuang), prolapse of the anus, convulsions, nocturnal emissions) are related more to the Governing than the Directing Vessel: this is because both Governing and Directing Vessels emerge at this point and because there is a close relation between these two vessels which form a continuous energetic circuit. Ren-1 Huiyin can be combined with SP-6 Sanyinjiao (with moxa stick) for post-partum convulsions; and with Ren-3 Zhongji and SP-6 Sanyinjiao for urethritis. Because it is the point from which the Directing Vessel emerges (and the Penetrating and Governing Vessels as well), Ren-1 Huiyin is very powerful and should be used sparingly. REN-2 Qugu (Crooked Bone) The name of this point is a clear reference to the pubic bone on the edge of which it is situated. Other names include Niao Bao which means ‘urinary bladder’ and Sui Shu which means ‘transporting point of Marrow’. The actions of this point are as follows. It: • promotes the transformation of urine • regulates the periods
• stops pain • resolves Dampness. The indications in the gynecological sphere include hypogastric pain, Painful Urination Syndrome, incontinence of urine, vaginal itching, irregular periods, dysmenorrhoea, red–white vaginal discharge, uterine myoma, uterine prolapse and Cold in the Uterus. The point Ren-2 Qugu (used with 7 moxa cones) can be combined with LIV-3 Taichong, Ren-4 Guanyuan, KI-7 Fuliu, SP-6 Sanyinjiao and ST-25 Tianshu (used with 100 moxa cones) for red–white vaginal discharge. In addition to stopping vaginal discharges and leakage of urine, this point also stops nocturnal emissions: thus, it is clear that it has a ‘firming’ action on fluids in the Lower Burner. In this context, it has an action that is similar to Ren-1 Huiyin and is a good alternative when the latter point cannot be used. REN-3 Zhongji (Central Supreme Ultimate or Central North Star) ‘Ji’ means either ‘Supreme Ultimate’, i.e. the Dao, or ‘North Star’. All Chinese books explain that this point is so named because it lies in the exact centre of the body dividing it into two equal halves, upper and lower, just as the North Star appears to be an immobile star around which all others revolve. The point’s central position indicates its importance. However, the statement that this point lies at the centre of the body dividing it into two equal halves does not appear to be verified in practice. In fact, in most people, the vertical centre falls approximately at the level of Ren-1 Huiyin. One possible explanation of this discrepancy might be that Chinese people tend to have shorter legs than Westerners: however, Chinese acupuncture charts also show Ren-1 as being approximately at the vertical centre. The actions of Ren-3 Zhongji are as follows. It: • tonifies the Kidneys
• tonifies Yang • regulates menstruation • stops leucorrhoea • warms the Essence • regulates the Bladder. Indications in the gynecological sphere for this point include incontinence of urine, retention of urine, irregular periods, menorrhagia, infertility, retention of lochiae, itching of vagina, leucorrhoea and retention of placenta. Like the Kidney points on the Penetrating Vessel, this point can be used in Full or Empty conditions. In Full conditions, it treats mainly the Bladder and genitals for urinary problems in women, vaginal discharges and itching, etc. In Empty conditions, it tonifies the Uterus and the Kidneys. However, I tend to use this point more for its action on the Bladder (for which it is the Front-Collecting point) and genitals; to tonify the Uterus and the Kidneys in Empty conditions I usually prefer Ren-4 Guanyuan. The point Ren-3 Zhongji can be combined with many different points: • BL-23 Shenshu, L.I.-4 Hegu and SP-6 Sanyinjiao for amenorrhoea. • Extra point Zigong (three cun lateral to Ren-3) for menorrhagia and infertility. • BL-23 Shenshu and SP-9 Yinlingquan alternated with SP-6 Sanyinjiao and Ren-6 Qihai for frequent urination. • BL-23 Shenshu, Ren-6 Qihai and SP-6 Sanyinjiao for irregular periods. • Ren-7 Yinjiao and Ren-5 Shimen for retention of lochiae. • SP-6 Sanyinjiao for retention of placenta.
• G.B.-21 Jianjing for retention of placenta. REN-4 Guanyuan (Gate Origin) The word ‘origin’ refers to Original Qi (Yuan Qi), thus the name indicates that this point can be a ‘gate’ of access to the Original Qi. Alternatively, because the Defensive Qi here exits from the Lower Burner, this point is therefore the gate between Interior and Exterior. Ren-4 has an extraordinary number of alternative names such as Zi Hu (‘Door of Child’), Dan Tian (‘Field of Elixir’), Xue Hai (‘Sea of Blood’), Xue Shi (‘Room of Blood’), San Jie Jiao (‘Three Knots Crossing’), Da Zhong Ji (‘Big Zhongji’, i.e. Ren-3), Chan Men (‘Door of Childbirth’), Da Hai (‘Big Sea’), Bao Men (‘Door of Birth’), Chi Shu (‘Keeping the Pivot’), Kun Lun (‘Kunlun Mountains’), Niao Shui (‘Urine’), Zi Gong (‘Palace of the Child’), Xia Ji (‘Lower Rule’), Zi Chu (‘Abode of the Child’) and Xia Huang (‘Lower Membranes’). All these names highlight the character and functions of Ren-4 in relation with the Uterus, Blood, childbirth, the Field of Elixir and fertility. The actions of Ren-4 Guanyuan are as follows. It: • tonifies the Original Qi • treats Painful Urinary Syndrome • tonifies the Kidneys • consolidates the Essence • tonifies Yang (with moxa) • nourishes Yin (without moxa) • warms and regulates Blood • nourishes Blood
• resolves Dampness. The indications relevant to gynecology include abdominal pain, urinary problems in women, irregular periods, amenorrhoea, dysmenorrhoea, leucorrhoea, menorrhagia, retention of lochiae, retention of placenta, Running Piglet Syndrome in women, Blood abdominal masses below the navel and pain radiating from the back to the umbilicus and genitals. The Penetrating Vessel connects with the Directing Vessel at this point, and if we analyse the indications we can see, in fact, that some of them pertain to the Penetrating Vessel’s pathology: abdominal pain, dysmenorrhoea, retention of lochiae, retention of placenta, Running Piglet Syndrome, pain radiating from the back to the umbilicus and genitals and, among the non-gynecological indications, blood in stools. The importance of this point in gynecology cannot be overemphasized. It tonifies practically every vital substance: Yang (with moxa), Yin (without moxa), Blood, Essence, the Uterus and the Original Qi. By tonifying the root in the Lower Burner, it also has a powerful calming influence on the Mind by making Qi descend to the Field of Elixir: thus, it is an excellent point for anxiety and agitation stemming from a Kidney deficiency (with or without Empty-Heat). I use this point very frequently in combination with the opening and associated points of the Directing Vessel, i.e. LU-7 Lieque on the right and KI-6 Zhaohai on the left, for a great variety of conditions. Without moxa, these three points can nourish Kidney-Yin, regulate the Uterus and nourish Blood in menopausal problems. If there are pronounced hot flushes, anxiety and sweating, the three points can be combined with HE-6 Yinxi and KI-7 Fuliu. The points would therefore be placed as follows: LU-7 Lieque on the right, KI-6 Zhaohai on the left, Ren-4 Guanyuan, HE-6 Yinxi on the left and KI-7 Fuliu on the right. The laterality of the last two points is chosen to balance the opening and associated points of the Directing Vessel (Fig. 7.5).
Figure 7.5 Combination of Directing Vessel points (1). If the Kidneys are severely deficient, the point KI-13 Qixue (bilateral) could be added. When used with moxa cones, Ren-4 Guanyuan tonifies Kidney-Yang.
This can be done in menopausal problems from Kidney-Yang deficiency even if there are hot flushes. These are usually due to the simultaneous deficiency of both Kidney-Yin and Kidney-Yang: if the tongue is Pale, the point Ren-4 can be warmed with moxa and this will not aggravate the hot flushes. Ren-4 combines particularly well with Ren-15 Jiuwei to tonify the Kidneys and calm the Mind. The latter point Ren-15 could be added to the above-mentioned combinations of points where there is pronounced anxiety and agitation against a background of Kidney deficiency. These two points Ren-4 and Ren-15 are particularly indicated if the lower abdomen feels flaccid and the area below the xiphoid process feels hard. Another good combination is that of Ren-4 with Du-20 Baihui for mental depression against a background of Kidney deficiency. Other combinations of Directing and Governing Vessel points will be discussed shortly when dealing with the Governing Vessel. As a point of the Penetrating Vessel as well, Ren-4 also influences the ancestral muscles (zong jin), i.e. the rectus abdominis; thus, its use is indicated if these feel either very flaccid (Empty conditions) or very tight (Full conditions). One of the alternative names of Ren-4 is Xiahuang, i.e. ‘Lower Membranes’: this means that this point controls all the connective tissue of the abdomen, such as fascia, omentum and mesenterium. Again, it can be used either to tonify these structures when they are slack or to relax them when they are tense: the necessary therapeutic approach can easily be determined by palpation. REN-5 Shimen (Stone Door) There are various explanations for the meaning of this name. ‘Stone’ symbolizes hardness and one of the indications for this point is ‘hardness and pain of the abdomen’. Another explanation is that, in old China, an infertile woman was called ‘stone woman’ and the use of direct moxa on this point supposedly can render a woman infertile and also terminate a pregnancy.
Thus, ‘Stone Door’ indicates a door that cannot be opened, i.e. the fertilizing sperm cannot penetrate the woman’s uterus. According to others, ‘stone’ here refers to cinnabar as in the ‘Field of Cinnabar’ (dan tian) where this point is situated. Yet another explanation is that the Qi of the Directing Vessel goes in and out at this point, like a door; this last explanation would contradict the previous one according to which a stone door is one that cannot be opened. Alternative names for this point include Li Ji (‘Beneficial Mechanism’), Jing Lu (‘Essence’s Dew’), Dan Tian (‘Field of Elixir’) and Ming Men (‘Gate of Life’), which clearly reflect this point’s role with regard to Essence, Gate of Life and Field of Elixir. The name Li Ji can be interpreted differently because the word li is composed of the radicals for ‘standing grain’ (ready to be harvested) and ‘knife’ or ‘reaping hook’, indicating the cutting of standing grain for reaping and therefore ‘benefiting’. However, the cutting motion of the knife is also ‘separating’ and the name of this point could therefore also refer to the separation of fluids in the Lower Burner: in fact, this point is the Front-Collecting (Mu) point for the Triple Burner (especially the Lower Burner), one of the main functions of which is to separate, transport and transform fluids. This interpretation would also be in accordance with the view of this point as the place where the Qi of the Directing Vessel goes in and out since it is Qi that separates and transforms fluids. The actions of Ren-5 Shimen are as follows. It: • regulates Qi • stops pain • regulates the Water Passages • warms the Kidneys • invigorates Yang • regulates the menses.
The main indications in the gynecological sphere are abdominal distension, umbilical pain, Running Piglet Syndrome in women, oedema, urinary difficulty in women, amenorrhoea, vaginal discharge, menorrhagia and retention of lochiae. The main emphasis of this point is on separating and transforming fluids in the Lower Burner: it is therefore a very important point for women’s urinary problems (which are often wrongly labelled ‘cystitis’), candida infections of the vagina and oedema in pregnancy. However, Ren-5 is the Front-Collecting point of the Triple Burner, which, in addition to its role in separating and transforming fluids, also acts as the ‘envoy’, ‘avenue’ or ‘ambassador’ of the Original Qi emerging from the space between the two kidneys; thus, the Triple Burner, and therefore this point, is related to the Original Qi and the Fire of the Gate of Life.9 This point can therefore be used to tonify and warm Kidney-Yang and the Gate of Life: in women, thus for amenorrhoea occurring against a background of Kidney-Yang deficiency. Obviously one would use moxa to treat Yang deficiency, contrary to the idea that the use of this point with moxa would render a woman infertile; however, were this idea possible, it would presumably happen only with a large number of moxa cones used over a sustained period. Ren-5 Shimen can be combined with SP-5 Shangqiu to treat abdominal hardness and pain extending to the genitals. The Compendium of Acupuncture (1601) states that this point can be combined with SP-6 Sanyinjiao when a woman has too many children! This indication is presumably based on the idea that this point can render a woman infertile or terminate a pregnancy. Ren-5 can be combined with KI-7 Fuliu for Blood Painful Urination Syndrome in women. REN-6 Qihai (Sea of Qi) The point’s name clearly refers to its function as a point of concentration, or gathering, of Qi. In fact, one of its alternative names is Xia Qi Hai (‘Lower Sea of Qi’); xia means ‘lower’, the implication being that there is an upper Sea of Qi. This is indeed Ren-17 Shanzhong, which is the Gathering point
(hui xue) of Qi. Other names for Ren-6 include Xia Huang (‘Lower Membranes’), Huang Zhi Yuan (‘Source of Membranes’), Bo Yang (‘Navel’) and Ji Yang (‘Small Navel’). The first two names refer to the statement in the first chapter of the Spiritual Axis according to which Ren-6 Qihai is the Source point of Membranes (huang); assuming the ‘membranes’ are the abdominal fascia, omentum and mesenterium, this point is the concentration of the pre-natal energy that shaped these structures and can affect them when they are too slack or too tight in a way similar to KI-16 Huangshu. Ren-6’s other names of ‘Navel’ and ‘Small Navel’ presumably refer to the above-mentioned function of influencing ‘membranes’, i.e. since the point is the source of these structures, in relation to these it is like a ‘navel’. Bo Yang is actually the name that the first chapter of the Spiritual Axis uses for the Source point of Membranes and some authors think this is Ren-8 rather than Ren-6. However, Ren-6’s other names of ‘Lower Membranes’ and ‘Source of Membranes’ seem to confirm that this point is indeed the Source point of Membranes. The actions of Ren-6 Qihai are as follows. It: • tonifies Qi • tonifies Yang • regulates the periods • consolidates the Essence • tonifies the Original Qi • tonifies the Kidneys • warms the Lower Burner • resolves Dampness. The indications of this point in the gynecological sphere include
abdominal pain, irregular periods, dysmenorrhoea, amenorrhoea, menorrhagia, leucorrhoea, oedema in women and feeling of cold arising from the lower abdomen. This point is a powerful tonic of Qi and Yang. Comparing it with Ren-4 Guanyuan, one can say that Ren-6 tonifies Qi and Yang, while Ren-4 nourishes Blood and Yin (although, with moxa, this latter point can also tonify Kidney-Yang). However, Ren-6’s importance lies also in the fact that, besides tonifying Qi, it can move Qi in the lower abdomen: it is therefore very important in gynecology for abdominal pain from stagnation of Qi and also for fluids pathology in the lower part of the body (because fluids rely on Qi for their movement, separation and transformation). Similarly to Ren-4 Guanyuan, Ren-6 Qihai is frequently combined with the opening and associated points of the Directing Vessel, to regulate the Uterus and either tonify or move Qi, as in cases of abdominal pain and distension in cases of pre-menstrual syndrome. This combination could be used to tonify and raise Qi and regulate the Uterus in cases of prolapse of the uterus; it could also be used when the uterus is not actually prolapsed but there is a bearing-down sensation in the lower abdomen, perhaps frequent urination, menorrhagia (from Qi not holding Blood) and a chronic vaginal discharge, all symptoms of deficiency and sinking of Qi. A possible combination would be: LU-7 Lieque on the right, KI-6 Zhaohai on the left, Du-20 Baihui, Ren-6 Qihai, ST-36 Zusanli (bilateral) and SP-6 Sanyinjiao, also bilateral (Fig. 7.6). This combination would tonify and raise Qi and strengthen the Uterus.
Figure 7.6 Combination of Directing Vessel points (2). To move Qi in the lower abdomen in case of abdominal pain and distension, dysmenorrhoea (from Qi stagnation) and pre-menstrual tension, one might use the following combination: LU-7 Lieque on the right, KI-6
Zhaohai on the left, P-6 Neiguan on the left, LIV-3 Taichong on the right and Ren-6 Qihai (Fig. 7.7).
Figure 7.7 Combination of Directing Vessel points (3).
There are several traditional combinations of points with Ren-6 Qihai: • With LIV-1 Dadun, KI-10 Yingu, LIV-3 Taichong, KI-2 Rangu, SP-6 Sanyinjiao and Ren-3 Zhongji for menorrhagia (presumably from BloodHeat). • With Ren-3 Zhongji, BL-30 Baihuanshu, BL-23 Shenshu for red–white leucorrhoea. • With SP-6 Sanyinjiao for Blood masses after childbirth. • With Ren-3 Zhongji, G.B.-26 Daimai, BL-23 Shenshu and SP-6 Sanyinjiao for irregular periods. • With Ren-4 Guanyuan and Ren-12 Zhongwan for stubborn Painful Obstruction Syndrome when herbs do not help. • With Ren-4 Guanyuan for retention of lochiae. REN-7 Yinjiao (Yin Crossing) The name of this point alludes to the fact that the three Extraordinary Vessels (Governing, Directing and Penetrating) all meet here. The Great Dictionary of Chinese Acupuncture gives a more complicated explanation: The Qi of the Original Yang intersects with Yin. The essence of ‘Dew-Water’ mixes with Yin Qi, the Water separates upwards and mixes with the essence of the Directing Vessel; Yang Qi goes up and down, the Original Yin infuses into the Field of Elixir, Water and Fire cross, hence the name Yin Crossing.10 Other names for this point include Shao Guan (‘Lesser Gate’), Heng Hu (‘Horizontal Door’) and Dan Tian (‘Field of Elixir’). The actions of Ren-7 Yinjiao are as follows. It:
• regulates the periods • stops leucorrhoea • promotes Water transformation • resolves oedema • nourishes Kidney-Yin. The main indications in the gynecological field are irregular periods, menorrhagia, leucorrhoea, abdominal pain, oedema in women, urinary difficulty, Running Piglet Syndrome in women, feeling of hardness of the abdomen, abdominal pain extending to the genitals, contraction of the limbs in women, infertility, retention of lochiae, feeling of cold and pain below the umbilicus. Judging by the actions and indications, this point has two broad ranges of action: the first in transforming fluids and resolving oedema, and the second in nourishing Yin. These two functions should not be seen as contradictory since oedema is a pathological accumulation of fluids and not an expression of normal fluids. To resolve oedema and transform fluids, Ren7 should be used with moxa, while to nourish Yin it should be needled. I use it particularly for its latter function, i.e. to nourish Yin, especially in menopausal problems. Ren-7 Yinjiao can be combined with Ren-5 Shimen for oedema with hot abdominal skin, dark urine and feeling of fullness; with Ren-3 Zhongji and extra point Shiqizhuixia (on the Governing Vessel between L-1 and the sacrum), all with direct moxa, for malposition of the fetus; and with ST-36 Zusanli and Ren-9 Shuifen (with moxa cones) for oedema, abdominal fullness and a feeling of ‘empty distension’. REN-8 Shenque (Spirit Palace) The name of this point depends on how we interpret the word que. This
word can mean ‘imperial palace’ or ‘two watch towers on either side of a palace gate’. In this sense the name of the point would be ‘Palace of Shen’ or ‘Abode of Shen’. This interpretation is certainly plausible as the Shen of a human being is formed by the union of the father’s and mother’s Essences and the newly formed being is linked to the mother via the umbilical cord: thus the point Ren-8 Shenque is the place where the Shen of the fetus first resides. The metaphor of que as ‘imperial palace’ would also suit the nature of the point as the Shen resides in the Heart which is the Emperor. The analogy of the palace is also meaningful as the point Ren-8 is at the centre of the body and is central to a group of points. Just as there is the triad of Heaven above, Earth below and Person in the middle, we have Ren-10 Xiawan and Ren-9 Shuifen above (‘Heaven’), Ren-4 Guanyuan and Ren-7 Yinjiao below (‘Earth’) and Ren-8 Shenque in the middle with KI-13 Qixue and KI-16 Huangshu to the left and right sides (‘Person’) (see Fig. 7.8).
Figure 7.8 Position of Ren-8 Shenque and surrounding points.
Thus, the umbilicus and Ren-8 are at the centre of this group of points forming a doorway through which the Shen communicates with the Pre-Natal Qi. When the Essences of mother and father unite, the fetus is formed, and the umbilical cord links it to the mother’s Gate of Life. The Fire of the Gate of Life in the fetus is of pre-natal origin and gives rise to Water as well as the Kidneys. Like an unopened lotus flower, the Five Elements come into being, the mother’s Qi is transformed, in 10 months the fetus is complete and its Shen infuses through the centre of the umbilicus and forms the new being.11 However, the word que can have a second interpretation, meaning something that is ‘missing’, ‘incomplete’, ‘absent’, ‘vacant’. Thus, the main feature of this point is not that it is a ‘gate’ or ‘door’ through which energies go in and out but that it is like an empty space, something missing: this is obviously the placenta which was attached to the fetus via the umbilical cord. Hence this point is the space formerly occupied by the placenta and through which the Shen first entered the fetus and was nourished by the mother’s Essence and Corporeal Soul (Po). The implication of this is that this is the point that more than any other connects us to the Pre-Natal Essence. Thus, the interpretations of que as an imperial palace or as something ‘missing’ are not contradictory: this is the place where the Shen first entered through the empty space left by the placenta, but it is also the residence of the Shen during gestation. It is also interesting that there is an extra point one cun either side of the umbilicus called Hun She which means ‘House of the Ethereal Soul’: it is significant that this point is so close to Ren-8 as the latter is related to Shen and the former to the Ethereal Soul which represents the ‘coming and going of Shen’. The actions of Ren-8 Shenque are as follows. It: • warms the Yang • subdues rebellious Qi
• promotes Water transformation • rescues from collapse • tonifies the Kidneys. The main indications in the gynecological field are oedema in women, umbilical pain, post-partum abdominal distension, post-partum urinary problems and fetus too low. This point is used in gynecology mostly to tonify the Kidneys and strengthen the Essence and Original Qi in very deficient conditions, for problems such as menorrhagia (from Kidney-Qi deficiency), amenorrhoea or infertility. The point also has a mental effect on the Mind and Spirit, so it can be used in post-natal depression. One traditional combination of this point (with 27 moxa cones) is with Ren-15 (15 moxa cones) for excessive sexual activity in young people causing breathlessness.12 REN-9 Shuifen (Water Separation) The name of this point clearly refers to the separation of clear from turbid fluids occurring in the Intestines, which this point affects. The actions of Ren-9 Shuifen are as follows. It: • regulates the Water Passages • regulates Qi • stops pain. This point has no major gynecological indications but it is frequently used in women to promote the transformation and separation of fluids in oedematous conditions. It can be used for fluid retention in any part of the body. When used for oedema, it is particularly effective if moxa cones are applied to it. Among the traditional combinations are the following: with Ren-5
Shimen for hypogastric pain and urinary frequency; with Ren-6 (moxa) for Yang oedema; with Ren-14 Juque and Ren-6 Qihai for umbilical pain; with SP-6 Sanyinjiao and BL-20 Pishu for Yin oedema. I use Ren-9 (often with Ren-12 Zhongwan too) in all cases of fluids pathology, i.e. oedema, Dampness and Phlegm. As Ren-9 is in the Middle Burner, it will help the separation of fluids in the Upper and Lower Burner, as well as in the Middle Burner itself. REN-10 Xiawan (Lower Epigastrium) The name of this point must be correlated with Ren-12 Zhongwan (meaning ‘Central Epigastrium’) and Ren-13 Shangwan (‘Upper Epigastrium’). These three points therefore control the upper, middle and lower part of the stomach. More specifically, Ren-13 Shangwan controls the upper part of the stomach, cardia and oesophagus; Ren-12 Zhongwan the stomach’s body and fundus; Ren-10 Xiawan, the lower part of the stomach, pylorus and duodenum. Another name for this point is Xia Guan which means ‘Lower Tube’ or ‘Lower Duct’, a reference to the duodenum. Yet another name is You Men which means ‘Dark Door’, a reference to the passage from the stomach to the small intestine, i.e. the pylorus. The actions and indications of this point are not specific to gynecology, but I use it frequently to stimulate the descending of Stomach-Qi especially in conditions with Phlegm. One of the main indications for the use of this point is therefore a feeling of fullness, distension or stuffiness of the epigastrium. It is a meeting point with the Spleen channel and it therefore also promotes the transforming and transporting of the Spleen. I also find that Ren-10 Xiawan has a pronounced effect on calming the Mind when this is disturbed by emotional problems such as worry and pensiveness affecting the Spleen and Stomach. REN-12 ZHONGWAN (Central Epigastrium)
The name of this point refers to the central part of the Stomach, which it controls. The ‘central’ in its name could refer to the Central Qi (Zhong Qi) of the Stomach and Spleen, to the fact that the point is at the centre between Ren-15 Jiuwei and Ren-8 Shenque, or to the Centre in terms of Earth Element. Other names include Zhong Guan (‘Central Duct’, in analogy with Ren-10 Xiawan being the ‘Lower Duct’), Wei Wan (‘Stomach Epigastrium’), Xia Ji (‘Upper Regulation’), Tai Cang (‘Supreme Granary’) and Wei Mu (‘Front-Collecting Point of the Stomach’). The actions of this point are as follows. It: • harmonizes the Stomach • strengthens the Spleen • tonifies all Yang organs • makes Qi of all Yang organs descend • calms the fetus • resolves Dampness. This point does not have specific gynecological indications but it is a major point to tonify Stomach and Spleen and resolve Dampness. I find also that it has a calming effect on the Mind, in a similar way to Fu Shen Sclerotium Poriae pararadicis which resolves Dampness, mildly tonifies the Spleen and calms the Mind. REN-14 Juque (Great Palace or Great Opening) Ju means ‘great’; que, which is the same character as in Shenque (Ren-8), already discussed above, is translated as ‘gate’ in most books, the ‘great’ referring to the Emperor, i.e. the Heart. Others translate que as ‘palace’ and the name would therefore mean ‘Great Palace’ of the Emperor, i.e. the Heart.
However if we interpret que as an ‘opening’, as ‘something missing’, in the same way as for Ren-8 Shenque, then the point Ren-14 Juque is the corresponding point to Ren-8 in the Upper Burner. The Mind (Shen) depends on the Essence (and therefore Kidneys) which is controlled by Ren8. The Mind also resides in the Heart which is controlled by Ren-14: thus, we could see Ren-14 Juque as an ‘upper Ren-8 Shenque’ affecting the Mind not through the Kidneys, but through the Heart. The actions of this point are as follows. It: • calms the Mind • calms the Heart • opens the chest • stops pain. This point has no specific gynecological indications but I use it frequently in gynecological problems associated with emotional stress such as sadness, worry, grief and shock affecting the Heart. It combines well with either Ren-4 Guanyuan or Ren-8 Shenque: the combination of either of these points with Ren-14 Juque tonifies the Kidneys, the Essence and the Original Qi and calms the Mind. As explained above, the combination of these points treats both of the main organs that affect the Mind, i.e. Kidneys and Heart. Interestingly, one of the old combinations was Ren-14 Juque and KI-9 Zhubin for kuang disease, i.e. the manic phase of a manic-depressive disorder. REN-15 Jiuwei (Dove Tail) ‘Dove tail’ probably refers to the Connecting (Luo) channel of the Directing Vessel which starts from this point and fans out over the upper abdomen, although most books say that the ‘dove tail’ is the rib-cage. Other names for this point include Wei Yi (‘Tail Screen’), Shen Fu (‘Fu organ of the Mind’)
and Xin Yan, whose meaning is ambiguous: xin means ‘Heart’ while yan can mean both ‘be disgusted with, detest, be fed up with’ and ‘be satisfied’. The first interpretation might be significant, indicating the use of this point for emotional problems such as frustration, anger or indignation affecting the Heart. The actions of this point are as follows. It: • calms the Heart • calms the Mind • opens the chest • stops breathlessness • resolves Phlegm from the Heart. This point does not have specific gynecological indications but I often use it when treating women with emotional problems due to sadness, worry, grief, shock or guilt and occurring against a background of Kidney deficiency and Heart stagnation. The point is extremely effective when the above emotions manifest themselves on a physical level with a feeling of oppression or tightness of the chest. It combines particularly well with Du-24 Shenting to calm the Mind when there is pronounced anxiety; and with Du-20 Baihui when there is sadness and depression. According to the first chapter of the Spiritual Axis, it is the point of Gao, i.e. fat tissues. These tissues are of pre-natal origin as the fetus in the first month is said to be pure Gao. There is an interesting connection between the relationship of the Directing Vessel with fat tissues (Gao) and hormone levels. After the menopause some androstanedione is converted to oestrogen in fat tissues: thus, this confirms the relationship among fat tissues, Gao, the Directing Vessel and its role in hormone production in women. Directing Vessel: case histories
Case history A woman of 41 had had a large fibroid in the uterus for several years. Her periods were very heavy and painful and the menstrual blood was dark. Her lower abdomen was extremely hard and the fibroid was clearly felt on palpation. She was treated several times using the opening and associated points of the Directing Vessel (LU-7 Lieque on the right and KI-6 Zhaohai on the left), producing a complete normalization of her periods and a very marked softening of her lower abdomen. The size of the abdominal swelling was also markedly reduced. Obviously a fibroid of that size cannot be dissolved, but the use of the Directing Vessel at least normalized her periods, took the menstrual pain away and made her lower abdomen much more comfortable. Case history A woman of 38 complained of persistent vaginal candida infection. She experienced itching and a white discharge. Apart from this she complained of tiredness since the birth of her first (and only) child 3 years previously, and of lower backache. Her periods were slightly delayed, with a cycle of about 35 days. Her tongue was slightly Red, peeled in patches and with a thick, slightly yellow coating (Plate 2). Her pulse was Weak on the left Rear position. This patient’s condition was clearly due to a deficiency of Kidney-Yin, evidenced by the backache, the Weak Kidney pulse and the Red and peeled tongue. In addition, there was Dampness in the genital system, clearly shown by the symptom of thrush and the thick tongue coating. The treatment principle was to nourish Kidney-Yin and resolve Dampness from the Lower Burner. Apart from other points over a period of months, I frequently used the Directing Vessel and the following is an example of a point combination: • LU-7 Lieque on the right and KI-6 Zhaohai on the left to open the Directing
Vessel and nourish the Kidneys. • Ren-12 Zhongwan and ST-28 Shuidao to resolve Dampness from the Lower Burner. • Ren-3 Zhongji, SP-9 Yinlingquan and BL-32 Ciliao to resolve Dampness from the genital system.
After treating her for about 1 year, the vaginal candida infection did not recur. Case history A 35-year-old woman had been suffering from tiredness and depression since the birth of her child 11 years previously. She also suffered from recurrent sinusitis (with a thick, yellow nasal discharge) and pre-menstrual headaches: these occurred on the sides of the head (Gall Bladder channel) and were throbbing in nature. She also complained of pre-menstrual tension and the menses were occasionally heavy with dark, clotted blood. Her tongue was Pale and Swollen and her pulse was Weak on both Rear positions. This woman suffered from a Kidney-Yang deficiency with Liver-Yang and Liver-Fire rising. Apart from this, nearly all her symptoms indicate a disharmony of the Directing Vessel; the tiredness and depression after childbirth, the pre-menstrual tension, the heavy period with dark blood and the headache before the periods. While the headaches are clearly due to Liver-Yang rising, there is also some Liver-Fire as evidenced by the sinusitis. The sinusitis is related partly to the Directing Vessel, as this vessel flows over the face to the bottom of the eyes, but also to Liver-Fire rising to the face: the thick, yellow nasal discharge indicates Liver-Fire as opposed to LiverYang. The treatment principle was to regulate the Directing Vessel, tonify and warm the Kidneys, subdue Liver-Yang and clear Liver-Fire. This patient was treated for several months during which I used the Directing Vessel several times. The following is an example of a Directing Vessel combination:
• LU-7 Lieque on the right and KI-6 Zhaohai on the left to open and regulate the Directing Vessel. • Ren-4 Guanyuan to tonify the Kidneys and strengthen the Directing Vessel. • P-6 Neiguan on the left and LIV-3 Taichong on the right to pacify the Liver, subdue Yang, calm the Mind and settle the Ethereal Soul. The laterality of these two points is aimed at balancing that of the opening and associated points of the Directing Vessel. • Du-20 Baihui to lift mood and relieve depression. Although this point would be contraindicated in Yang rising, it is combined here with Ren-4 Guanyuan which draws Qi down to the Field of Elixir. The Governing and Directing Vessels form a continuous, unbroken circuit and Du-20 and Ren-4 in combination harmonize the ascending and descending of Qi within it.
Governing vessel (du mai) The Directing and Penetrating vessels are Yin in nature, they regulate menstruation, fertility, conception and pregnancy and are of paramount importance in women’s physiology, pathology and treatment. These two vessels both flow in the abdomen and their points are of fundamental importance in the treatment of gynecological problems as we have just discussed. The Governing Vessel is somewhat less important in gynecology as it flows along the spine in the back. However, it is important to remember what was said about the pathway of the Governing Vessel in Chapter 2 on physiology, i.e. that, before ascending along the spine, the Governing Vessel also circles around the pubic bone and vagina and problems in that area in women can be related to a pathology of this vessel in the presence of a general deficiency of Yang. Moreover, the abdominal branch of the Governing Vessel ascending up the midline of the abdomen and, described in the same chapter, would seem to indicate that this vessel can have an influence on the genital system in women too. The Golden Mirror of Medicine (Yi Zong Jin Jian, 1742) says: The Governing vessel arises within the lower abdomen, externally in the abdomen, internally in the ‘Bao’ [‘Uterus’] … also called Dan Tian in both men and women: in women it is the uterus, in men it is the Room of Sperm. The Governing Vessel would be chosen where a woman shows a marked deficiency of Yang and of the Fire of the Gate of Life. Thus it could be used for amenorrhoea, delayed cycle or infertility which occur against a background of pronounced Kidney-Yang deficiency (manifesting with chilliness, a Pale and wet tongue and a Deep and Slow pulse). It should also be remembered that the menstrual cycle is the result of the ebb and flow of Kidney-Yin and Kidney-Yang: the former reaches the Uterus through the Directing and Penetrating Vessels and the latter through the Governing Vessel. Thus, the Governing Vessel represents the Yang part of
the menstrual cycle: without it, there would be no menstrual cycle. The opening and associated points of the Governing Vessel are S.I.-3 Houxi (on the right) and BL-62 Shenmai (on the left), inserted in this order and withdrawn in the reverse order. In women, very often the Directing and Governing Vessels can be used together, needling S.I.-3 Houxi on the right, BL-62 Shenmai on the left, LU-7 Lieque on the left and KI-6 Zhaohai on the right, in this order (Fig. 7.9). The needles are withdrawn in the reverse order.
Figure 7.9 Governing and Directing Vessels in combination. For example, I use the opening and associated points of both the Governing and Directing Vessels when treating lower backache in women, but only if the backache stems from the midline on the spine itself. In other
cases too these two vessels can be combined in women. For example, when treating a woman suffering from amenorrhoea stemming from a deficiency of Kidney-Yang, one might use the following combination of points: S.I.-3 Houxi on the right, BL-62 Shenmai on the left, LU-7 Lieque on the left, KI-6 Zhaohai on the right, Ren-4 Guanyuan (with moxa cones) retaining the needles for about 20 minutes and, after the patient turns over, BL-23 Shenshu, retained for only 5–10 minutes. The use of both the Governing and the Directing Vessels is also helpful in gynecological problems accompanied by mental–emotional problems. This is because the abdominal branch of the Governing Vessel flows through the heart, and this vessel has a strong influence on the mental–emotional state. This is all the more so because the Governing Vessel connects Kidneys, Heart and Brain: one could therefore say that it influences the Mind in three ways, i.e. through the Kidneys (residence of the Essence which is the foundation of Qi and Shen and of the Will-Power), the Heart (residence of the Mind) and Brain (residence of the Mind according to several doctors such as Sun Si Miao, Li Shi Zhen and Wang Qing Ren). Due to its relation with the Kidneys, Heart and Brain, the Governing Vessel is often used clinically for depression in gynecology, often combined with Directing Vessel points. An example of a combination for a woman suffering from Blood deficiency, Kidney-Yang deficiency and depression is: S.I.-3 Houxi on the right, BL-62 Shenmai on the left, LU-7 Lieque on the left, KI-6 Zhaohai on the right, Ren-4 Guanyuan (with moxa cones) and Du-20 Baihui (Fig. 7.10).
Figure 7.10 Combination of Governing and Directing Vessel points for depression.
If the patient suffered from Blood deficiency, Kidney-Yang deficiency, amenorrhoea and anxiety rather than depression, an example of a possible
combination is: S.I.-3 Houxi on the right, BL-62 Shenmai, LU-7 Lieque on the left, KI-6 Zhaohai on the right, Ren-4 Guanyuan (with moxa cones), Ren-15 Jiuwei and Du-24 Shenting (Fig. 7.11).
Figure 7.11 Combination of Governing and Directing Vessel points for anxiety.
I shall now discuss the actions and indications of the main Governing Vessel points used in gynecology, restricting myself to indications relevant to gynecological problems, although in a broad sense these may include, for example, urinary problems (a frequent accompaniment to certain gynecological conditions). SHIQIZHUIXIA (Point Below the 17th Vertebra) This is an extra point on the Governing Vessel situated in the depression between the spinous processes of L-5 and S-1. The actions of this point are as follows. It: • tonifies the Kidneys • benefits the Bladder • stops pain • invigorates the sinews. The indications of this point in the gynecological sphere include urinary difficulty, dysmenorrhoea (especially with pain extending to the sacrum), malposition of fetus, sciatica, menorrhagia, incontinence of urine and dysuria during pregnancy. This is a very important point on the Governing Vessel. Although it does tonify the Kidneys, it is more frequently used to move Qi and Blood. Its use for malposition of the fetus is very ancient and is first mentioned in the Thousand Golden Ducats Prescriptions (AD 652) by Sun Si Miao.13 He suggests using 50 moxa cones on this point. This point is excellent for lower backache over the sacrum and can be used also for dysmenorrhoea, especially, but not exclusively, if the pain extends to such an area. Shiqizhuixia extends its influence to the Bladder, promoting the transformation of urine: it can therefore be used for urinary difficulty during pregnancy or urinary
incontinence following childbirth particularly when this occurs as a consequence of an epidural. Especially for urinary problems, it is desirable that the needling sensation propagates downwards. In sciatica, this point is invaluable, especially when the pain and tingling extend all the way down to the foot along the Bladder channel. The needle is inserted at a depth of 0.3– 0.5 cun. DU-2 YAOSHU (Transporting Point of the Back) The name of the point is self-evident, indicating the importance of this point for the lower back. Other names include Bei Jie (‘Freeing the Back’), Yao Hu (‘Door to the Back’), Sui Kong (‘Hole of Marrow’) and Sui Fu (‘Fu of Marrow’). The actions of this point are as follows. It: • regulates menstruation • clears Heat • scatters Cold • resolves Dampness. The main indications in the gynecological sphere include stiffness of the back, lower backache extending to the hypogastrium, amenorrhoea and blood in the urine. The apparent contradiction in this point’s ability to clear Heat and scatter Cold can be explained by the choice between moxa and needles: with direct moxa cones it scatters Cold, while with needle (reducing method) it can clear Heat. For example, it can be used in amenorrhoea from Cold, with direct moxa cones. The main combinations mentioned in the classics include: with Du-16 Fengfu for weakness of the legs; with Du-1 Changqiang, BL-28 Pangguangshu, ST-30 Qichong, BL-31 Shangliao, BL-34 Xialiao and G.B.-29 Juliao for sacral backache. This last combination is useful for sacral
backache extending to the hypogastrium during the periods. Finally, and intriguingly, the Great Compendium of Acupuncture (1601) combines this point with BL-13 Feishu for stiffness of the back.14 DU-4 Mingmen (Gate of Life) The point is in between the two kidneys where the Motive Force (Dong Qi) pulsates and where the placenta attaches to the umbilical cord. It therefore determines our life or ‘destiny’ insofar as it influences our constitution from conception. In fact, the Fire of the Gate of Life is of pre-natal origin as explained in Chapter 2 on physiology. The actions of this point are as follows. It: • warms and tonifies Kidney-Yang and the Gate of Life • relaxes the sinews • stops convulsions • benefits the back • rescues the Yang (in Collapse of Yang). The main indications in the gynecological sphere include: leucorrhoea, frequent urination, infertility, forgetfulness (as in menopause) and threatened miscarriage. The most important thing to note is that this point tonifies Kidney-Yang and scatters Cold especially when used with moxa cones: used in this way it is the closest acupuncture equivalent to using Rou Gui Cortex Cinnamomi and Fu Zi Radix Aconiti lateralis preparata in herbal medicine. In gynecology, it is therefore used for a variety of problems such as leucorrhoea, amenorrhoea and dysmenorrhoea, provided they stem from a deficiency of Kidney-Yang. It also has a strong mental–emotional effect because when the Fire of the Gate of Life is weak, the person feels depressed, exhausted and lacks will-power. Since the Governing Vessel
enters the brain, this point also treats the forgetfulness that sometimes accompanies other menopausal symptoms. An intriguing combination is this point needled with a golden needle, together with BL-23 Shenshu with moxa stick, for backache, frequent urination and a feeling of depression (literally ‘a suffering and exhausted feeling of the Shen’) experienced if the patient wakes in the middle of the night.15 Common combinations of Governing and Directing Vessel points The points of the Governing and Directing Vessels are combined very frequently in gynecological problems. I shall now discuss common combinations. Du-19 Houding and Ren-15 Jiuwei These points are used to calm the Mind. Du-19 calms the Mind and extinguishes (Internal) Wind while Ren-15 calms the Mind and nourishes the Heart; their combination has a powerful calming effect. Ren-15 also relieves anxiety that manifests with a feeling of oppression in the chest. I use this combination frequently to treat menopausal problems involving such feelings as anxiety, insomnia and a feeling of oppression of the chest. Du-20 Baihui and Ren-15 Jiuwei These points calm the Mind and lift mood. Du-20 improves the mood and lifts depression, Ren-15 calms the Mind, and their combination achieves both simultaneously. Excellent for mental depression with anxiety, it is, again, frequently used in menopausal problems. Du-14 Dazhui and Ren-4 Guanyuan
Both are used with direct moxa cones, to tonify and warm Yang. Du-14, with moxa, warms all the Yang channels and the Bladder, while Ren-4, with moxa, tonifies and warms Kidney-Yang which is the foundation for all the Yang energies of the body. Thus this combination tonifies the Bladder and KidneyYang and Yang-Qi in general. I use it for amenorrhoea occurring against a background of Kidney-Yang deficiency. Du-16 Fengfu and Ren-24 Chengjiang This combination is used to treat occipital headache.16 Du-20 Baihui and Ren-12 Zhongwan These points are used to tonify the Stomach and Spleen and to lift mood. A good combination to lift depression occurring against a background of deficiency of Stomach and Spleen, I use it very frequently for gynecological problems stemming from Blood deficiency. Du-24 Shenting and Ren-4 Guanyuan These points nourish Kidney-Yin, strengthen the Original Qi and so calm the Mind. This combination is suitable for severe anxiety occurring against a background of Kidney-Yin deficiency. It is particularly indicated for anxiety as it roots Qi in the Lower Burner and draws it downwards away from the head and the Heart where it harasses the Mind. This combination is also used for menopausal problems occurring against a background of Kidney deficiency. Yintang and Ren-4 Guanyuan These points are used to calm the Mind and nourish the Kidneys: this combination is similar to the previous one as it roots Qi in the Lower Burner
by nourishing the Kidneys and strengthening the Original Qi. While the previous combination is better for anxiety and worrying, this one is better for insomnia. Du-20 Baihui and Ren-4 Guanyuan These points calm the Mind, nourish the Kidneys, strengthen the Original Qi and lighten the mood. This combination lifts the mood and relieves depression by nourishing the Kidneys and strengthening the Original Qi. It is suitable for depression and anxiety occurring against a background of Kidney deficiency. Du-20 Baihui and Ren-6 Qihai These points tonify and raise Qi. Ren-6 tonifies Qi in general while Du-20 raises Qi: the combination of these two points is excellent to tonify and raise Qi in case of prolapse. However, its use need not be confined to such conditions; it also has a powerful mood-lifting effect in depression. Du-20 Baihui and Ren-3 Zhongji These are used to tonify and raise Qi and regulate the Bladder. This combination is excellent for frequency of urination without burning, deriving from sinking of Qi of the Spleen and Kidneys. It is very frequent in women, especially after childbirth. Case history A 35-year-old woman had been trying to conceive for 4 years. Her periods were regular and scanty with bright red blood. She suffered from dull headaches during and after the periods and experienced floaters. She also suffered from a ‘nagging’ lower abdominal pain, which was eased by the application of a hot-water bottle. She had been suffering from allergic rhinitis
since the age of 17, manifesting with sneezing and a profuse runny nose with a clear, watery discharge. She occasionally suffered from backache, dizziness, tinnitus and palpitations. She always felt cold, particularly her feet. Her tongue was of a normal colour and Swollen. Her pulse was Weak on both Rear positions and slightly Wiry on the left side. Diagnosis
From the point of view of patterns, this patient suffered from Blood deficiency of the Liver (scanty period, dull headaches with the period and floaters) and Heart (palpitations), some stagnation of Qi (abdominal pain, Wiry pulse) and Kidney-Yang deficiency (infertility, backache, dizziness, tinnitus, allergic rhinitis and Weak pulse on both Rear positions). From the point of view of channels, the Governing, Directing and Penetrating Vessels are all involved. In fact, the allergic rhinitis is due to a deficiency of the Governing Vessel (which flows through the nose), the abdominal pain is due to rebellious Qi in the Penetrating Vessel and the infertility and scanty periods are due to a deficiency of the Directing Vessel.
Girdle vessel (Dai mai) As discussed in Chapter 3 on pathology, the Girdle Vessel can be used in gynecology for irregular periods, dysmenorrhoea and leucorrhoea. Because of the Girdle Vessel’s gynecological sphere of influence, some doctors say that in terms of energy, it is part of the Directing Vessel. The symptomatology of the Girdle Vessel in gynecology can be differentiated according to its deficiency or excess condition. When it is deficient, the Girdle Vessel is slack and does not restrain the Essence, Spleen-Qi sinks, and Liver, Kidneys and the Directing and Penetrating Vessels also become deficient. When the Girdle Vessel is slack, Qi cannot rise, the organs sag, the fetus may be miscarried, there are vaginal discharges and prolapses may occur. The treatment principle is to tonify Pre- and Post-Natal Qi, raise the clear Qi and consolidate the Girdle Vessel. In excess conditions, the ‘Girdle Vessel is not harmonized’, due to its being ‘tight’. The main symptomatology includes fullness of the abdomen, backache radiating to the lower abdomen, a feeling of heaviness of the body, coldness of the back, a feeling as if sitting in water and a feeling of heaviness of the abdomen as if carrying 5000 coins. In gynecology, the Girdle Vessel is very useful for abdominal pain from Fullness, Dampness in the genital system and dysmenorrhoea. The opening and associated points of the Girdle Vessel are G.B.-41 Zulinqi on the right and T.B.-5 Waiguan on the left, inserted in this order and withdrawn in the reverse order. These points are often combined with the beginning point of the Girdle Vessel, G.B.-26 Daimai. While it is not necessary to apply any particular manipulation to the opening and associated points apart from obtaining a needling sensation, when using G.B.-26 Daimai, it is preferable to obtain a needling sensation that propagates downwards towards the lower abdomen and hypogastrium. Sometimes it can also propagate towards the back. I shall now discuss the actions and indications, in the gynecological
sphere, of all the points of the Girdle Vessel, i.e. LIV-13 Zhangmen, G.B.-26 Daimai, G.B.-27 Wushu and G.B.-28 Weidao. As before, I shall include indications that are not strictly speaking gynecological, such as urinary difficulty, but that are, nevertheless, very frequently associated with gynecological problems. LIV-13 Zhangmen (Movement Door or Chapter Door) Zhang indicates a movement in music (as in a ‘movement’ of a symphony) and, by extension, a chapter in a book. The character, however, also implies something that is a whole but coming to its end (again, like a movement in music). ‘Movement’ here alludes to the nature of this point as the Gathering point of all the Yin organs: thus the energy of all the Yin organs gathers here, as in a movement in music, and goes in and out, hence the ‘door’. The character for ‘door’ in an acupuncture point always implies a movement of Qi, in this case a clear reference to the free flow of Liver-Qi, on whose channel this point lies. The actions of this point are as follows. It: • promotes the smooth flow of Liver-Qi • harmonizes Liver and Spleen • relieves retention of food • benefits the Stomach and Spleen • benefits the Gall Bladder. The indications more relevant to gynecology include abdominal pain and distension and a cold feeling in the back. The main relevance of this point in gynecology is from its being on the Girdle Vessel. It can be used when the Girdle Vessel is either Empty (too ‘slack’) or Full (too ‘tight’). Since it harmonizes the Liver and Spleen, moves Liver-Qi and gathers the energy of all Yin organs, this point can be used, together with the opening and
associated points of the Girdle Vessel, in pre-menstrual problems related to this vessel: the main symptoms of this would be distension of the breasts and hypochondrium and abdominal pain extending to the loins. One of the indications of this point is also colourless, turbid urine: it is useful in urinary conditions after childbirth from stagnation of Liver-Qi. An indication for the use of the Girdle Vessel is a pulse that is Tight or Wiry on both Middle positions. G.B-26 Daimai (Girdle Vessel ) The name of this point, the starting point of the Girdle Vessel, is self-evident. The actions of this point are as follows. It: • regulates the menses • strengthens the Spleen • consolidates the Girdle Vessel • resolves Dampness. In the gynecological field, the main indications for the use of this point are irregular periods, red–white vaginal discharge, a feeling as if sitting in water, a feeling as if carrying a bag of water around the waist, softness of the lower back and abdomen, backache radiating to the abdomen, hypogastric pain aggravated by anxiety in women and weakness of the back. This point is very frequently used in combination with the opening and associated points of the Girdle Vessel to resolve Dampness and move Qi in the Lower Burner for such symptoms as excessive vaginal discharge, painful periods, a feeling of heaviness of the abdomen and headaches at period time. For a patient with the above symptoms stemming from Dampness and Qi stagnation, an example of a combination of points would be: G.B.-41 Zulinqi on the right, T.B.-5 Waiguan on the left (opening and associated points of the Girdle Vessel), G.B.-26 Daimai (bilateral), P-6 Neiguan on the right and
LIV-3 Taichong on the left, inserted in this order (Fig. 7.12).
Figure 7.12 Combination of Girdle Vessel points. In this combination, the laterality of P-6 Neiguan and LIV-3 Taichong
balances that of the opening and associated points of the Girdle Vessel. These two points will pacify the Liver, move Qi, calm the Mind and settle the Ethereal Soul. Furthermore, since they pertain to Terminal Yin (Pericardium and Liver) and G.B.-41 and T.B.-5 to Lesser Yang, these two pairs of points will harmonize Interior and Exterior. A traditional combination for the point G.B.-26 Daimai is with Ren-4 Guanyuan, Ren-6 Qihai, SP-6 Sanyinjiao, BL-30 Baihuanshu and P-5 Jianshi for red–white vaginal discharge. G.B-27 Wushu (Five Pivots) ‘Wu’ means ‘five’ and, in Chinese numerology, this number represents ‘change’ and occupies a central place; thus, in this sense, here it means ‘central’. One reason this point is the ‘central pivot’ is that it is at the centre of four points: G.B.-25 Jingmen and G.B.-26 Daimai above, and G.B.-28 Weidao and G.B.-29 Juliao below. Another reason is that it occupies a more or less central position in the body at the intersection of a vertical (Gall Bladder) and horizontal channel (the Girdle Vessel). Yet another reason is that this point pertains to the Lesser Yang, which is the ‘hinge’ of the Yang channels. The actions of G.B.-27 Wushu are as follows. It: • regulates menstruation • consolidates the Girdle Vessel • regulates Qi • stops pain. The main indications of this point in the gynecological sphere include prolapse of the vagina, red–white vaginal discharge, cord-like swellings and palpable masses on the sides of the umbilicus, irregular periods and hypogastric pain.
G.B-28 Weidao (Linking Path) ‘Linking path’ is an allusion to the Girdle Vessel’s linking of the leg channels it intersects. The actions of this point are as follows. It: • regulates menstruation • consolidates the Girdle Vessel • promotes Water transformation • stops pain. The main indications of this point in the gynecological field are hypogastric pain, prolapse of the vagina, irregular periods, excessive vaginal discharge and oedema. This is an important point to resolve Dampness in the Lower Burner and promote the transformation of fluids for such symptoms as oedema (of the lower part of the body) or excessive vaginal discharge. Case history A 38-year-old woman had been suffering from pre-menstrual tension for many years. She also complained of a persistent vaginal discharge, abdominal pain extending to the back and a bearing-down feeling of the abdomen. Her tongue was Swollen and had a thick, yellow coating on the root. Her pulse was Weak. This woman’s symptoms indicate a disharmony of the Girdle Vessel with Dampness infusing downwards. She was treated for several months during which I used the Girdle Vessel several times. The following is an example of a Girdle Vessel’s point combination: • G.B.-41 Zulinqi on the right and T.B.-5 Waiguan on the left to open the Girdle Vessel.
• G.B.-26 Daimai to strengthen and ‘tighten’ the Girdle Vessel. • ST-28 Shuidao and SP-9 Yinlingquan to resolve Dampness from the Lower Burner.
Case history A 45-year-old woman complained of excessive sticky, white vaginal discharge. However, this was not the chief reason for her seeking treatment: her main problem was a persistent pain in the left groin which extended upwards to the left abdomen and back. The pain was dull and constant and was associated with a slight urinary incontinence. On interrogation, it transpired that she also experienced a feeling of heaviness and a bearingdown sensation: in her words, she felt as ‘if everything wants to drop out’. Her pulse was very Weak on both rear positions. Diagnosis In terms of patterns, there is a clear pattern of Dampness in the Lower Burner which causes the bearing-down sensation, the feeling of heaviness and the excessive vaginal discharge. In terms of channels, the Girdle Vessel is diseased by being too ‘slack’: this causes the sinking of Qi resulting in vaginal discharge and the bearing-down sensation. The groin pain extending to the lateral abdomen and back also strongly indicates a pathology of the Girdle Vessel. The weakness of the pulse on both Rear positions clearly indicates a deficiency of the Kidneys and the sinking of Qi is related to this deficiency also. Furthermore, the Girdle Vessel communicates with the Kidney’s Divergent channel and a deficiency of the Kidneys affects this vessel. Treatment principle I used the following points:
• G.B.-41 Zulinqi on the right and T.B.-5 Waiguan on the left to regulate the Girdle Vessel. • G.B.-26 Daimai on the left to regulate the Girdle Vessel and raise Qi. • SP-12 Chongmen as a local point in the groin. • KI-4 Dazhong on the left to tonify the Kidneys; the Connecting point, it was chosen to affect the Bladder channel in the back. • Ren-6 Qihai, with 7 moxa cones, to tonify and raise Qi.
After only one treatment there was already a marked improvement and four treatments in total were enough to eliminate her problems completely.
Yin stepping vessel (yin qiao mai) The Yin Stepping Vessel is particularly used in gynecology for Excess patterns of the Lower Burner such as abdominal masses, lumps, cysts, fibroids, difficult delivery and retention of placenta. It is also useful to resolve adhesions following gynecological operations such as those for endometriosis or hysterectomy. The opening and associated points of the Yin Stepping Vessel are KI-6 Zhaohai (inserted on the right) and LU-7 Lieque (inserted on the left), in this order. If I use this vessel to treat a unilateral pain, then I use the opening and associated points unilaterally on the same side. The Yin Stepping Vessel absorbs Excess of Yin and is therefore mostly used in Full conditions characterized by stagnation of Qi and/or Blood in the legs (medial side) and abdomen. Please note that the Yin Stepping Vessel is used specifically when the abdominal pain is unilateral. A particular sign indicating the use of this vessel is when the pulse is Tight or Wiry on both Rear positions, indicating a stagnation in the Lower Burner. In gynecology, this vessel is therefore used for dysmenorrhoea (especially when the pain is unilateral), abdominal masses, retention of placenta and abdominal adhesions following operations such as a hysterectomy. Case history A 41-year-old woman complained of primary infertility, having tried to conceive for the previous 15 years. She also complained of a stabbing, sharp abdominal pain in both sides of the groin around mid-cycle. Her periods were regular and scanty (they lasted 3 days), not painful and the menstrual blood was of a normal red colour. Her tongue was slightly Purple with teethmarks and her pulse was Weak on the whole but also slightly Wiry on both Rear positions. This is a good example of a disharmony of the Yin Stepping Vessel with slight stasis of Blood in the Lower Burner, abdominal pain from stagnation
and infertility: the Wiry pulse on both Rear positions is typical of a Yin Stepping Vessel pathology. Here infertility is caused not by a deficiency (although there is some Spleen deficiency as evidenced by the Weak pulse and tongue teethmarks) but by stagnation. The principle of treatment adopted was to eliminate stasis of Blood and regulate the Yin Stepping Vessel. I did not consider it necessary to tonify as the deficiency was secondary to the stagnation. This patient was treated for 3 months, at the end of which she became pregnant. I continued treating her during the pregnancy and she delivered a healthy baby 9 months later. Before she became pregnant I used the Yin Stepping Vessel each time (but not after she became pregnant) and the following is an example of a point combination: • KI-6 Zhaohai on the right and LU-7 Lieque on the left to regulate the Yin Stepping Vessel. • LIV-3 Taichong (bilateral) to move Blood and eliminate stasis.
Case history A 55-year-old woman complained of persistent lower abdominal pain following two abdominal operations: the first for a hysterectomy and the second for adhesions. Her tongue was slightly Purple and her pulse was Slow and Tight on both Rear positions. I used the Yin Stepping Vessel in succession for 10 fortnightly treatments with very good results. The points used were: • KI-6 Zhaohai on the right and LU-7 Lieque on the left to regulate the Yin Stepping Vessel. • ST-27 Daju and ST-28 Shuidao to move Qi and Blood in the abdomen.
Yin linking vessel (yin wei mai) The Yin Linking Vessel is excellent to nourish Blood and calm the Mind in women. It affects the Heart and it can therefore be used for amenorrhoea, delayed cycle or scanty periods especially when associated with depression, anxiety and a feeling of tightness of the chest. The opening and associated points of this vessel are P-6 Neiguan (inserted on the right) and SP-4 Gongsun (inserted on the left), in this order. I frequently associate these points to the beginning point of this vessel, KI-9 Zhubin, needled bilaterally. KI-9 ZHUBIN (Building for the Guest) The Kidney channel is the host building for the Yin Linking Vessel which is the guest. KI-9 is the beginning point and also the Accumulation point of the Yin Linking Vessel. Another explanation of the name is that ‘bin’ with a different radical also means ‘knee-cap’. This point has this name, therefore, because it strengthens the knees.17 The actions of this point are as follows: • benefits the Kidneys • calms the Heart • regulates Qi • stops pain. There are no gynecological indications for this point apart from hypogastric pain. However, I do use this point frequently in combination with the opening and associated points of the Yin Linking Vessel to tonify the Kidneys, nourish Blood and calm the Mind in women. The calming effect of this point is also documented from the old classics, which mention dian
kuang (manic-depressive disorders) as one of its main indications. Case history A 35-year-old woman complained of tiredness, insomnia, depression and slight anxiety. Her symptoms started after the birth of her child 3 years previously. Her periods were regular and scanty, lasting 3 days. She also complained of dizziness and blurred vision. Her tongue was Pale and her pulse was Choppy. This is a clear example of Blood deficiency. I treated the Yin Linking Vessel several times in succession with good results. An example of a Yin Linking Vessel point combination is: • P-6 Neiguan on the right and SP-4 Gongsun on the left to open the Yin Linking Vessel. • KI-9 Zhubin, beginning point of this vessel, to open the chest and calm the Mind.
Gynecological extra points Some extra points on the lower abdomen and back have an important action on gynecological problems. I shall now discuss the most important ones. Jingzhong (Centre of Menses) This point is situated three cun from Ren-6 Qihai. It is specific for irregular periods. Qimen (Door of Qi) This point is situated three cun from Ren-4 Guanyuan. It is particularly effective with moxibustion. Qimen regulates the periods and promotes conception. It is used for infertility, threatened miscarriage (with moxa), menorrhagia, cystitis, retention of urine, Stone Painful Urination Syndrome and haemorrhaging after childbirth. Zigongxue (Uterus Point) This point is situated three cun from Ren-3 Zhongji. It can be needled and moxa can be used. Zigongxue regulates the periods, promotes fertility, regulates Qi and stops pain. It is used for infertility, prolapse of the uterus, irregular periods, dysmenorrhoea and menorrhagia. Waisiman (Outside Siman) This point is situated one cun lateral to KI-14 Siman. It is used for irregular
periods deriving from stagnation of Qi and Blood. Jueyun (Terminating Pregnancy) This point is situated three-tenths of a cun below Ren-5 Shimen. Using this point with needling is supposed to make a woman infertile. It is obviously forbidden in pregnancy. For the same reason, the old texts recommended use of this point to induce childbirth at full term, used with 7, or a multiple of 7, moxa cones.18 Baomen and Zihu (Door of Uterus and Door of Baby) These points are symmetrical and are situated two cun lateral to Ren-4 Guanyuan, Baomen on the left and Zihu on the right. Although they coincide with ST-28 Shuidao, for some reason they are sometimes also listed as extra points. They are used for infertility, threatened miscarriage (with moxa cones), retention of placenta (the needle is reinforced first and then reduced), cold leucorrhoea (with 30 moxa cones), abdominal masses and difficult childbirth. Jinggong (Palace of the Essence) This point is situated three cun lateral to the space between the second and third lumbar vertebrae. It coincides with the point BL-52 Zhishi. It nourishes the Essence and can be used for infertility and prolonged, chronic vaginal discharge. Finally, two more points situated on the Bladder channel should be mentioned in connection with gynecology. BL-51 Huangmen (Door of Membranes)
The name of this point is related to huang, the ‘membranes’, i.e. the connective tissue of superficial and deep fascia. The point is level with BL-22 Sanjiaoshu, Back-Transporting point of the Triple Burner. The Qi of the Triple Burner is essential for the proper movement and transportation of Qi in all physiological processes and in the membranes, hence the image of ‘door’ in the point’s name indicates the entering and exiting of the Qi of the Triple Burner. From this point, the Qi of the Triple Burner extends upwards to the diaphragm and chest, and downwards to the point BL-52 Baohuang and uterus and bladder. The actions of this point are as follows. It: • regulates Qi • eliminates stagnation • clears Heat • dissolves swelling. The main indications of BL-51 Huangmen in the gynecological field are post-partum abdominal pain, breast lumps and breast pain. It is interesting that the action of this point extends upwards to the breast and downwards to the abdomen as the fascia extend continuously all over the abdomen and chest. Also, the Triple Burner, to which this point is related, extends its influence on the movement of Qi all over the body. BL-53 Baohuang (Bladder Membranes) The name of this point is related to the previous one. The membranes and the Qi of the Triple Burner extend upwards to the chest and breast, and downwards to the bladder, uterus and genitals. Thus, although this point’s name is usually translated as relating to the urinary bladder, bao also means ‘uterus’; this point does indeed affect the lower abdomen, bladder, uterus and genitals.
In gynecology, the two main indications are fullness and hardness of the lower abdomen and swelling of external genitalia.
Herbal treatment of the extraordinary vessels Although the Extraordinary Vessels obviously form part of any acupuncture treatment strategy, some of the old doctors did mention herbs and herbal formulae affecting them and sometimes also referred to certain foods beneficial to them. As a general principle, meat tonifies the Extraordinary Vessels and, in particular, the Governing, Directing and Penetrating vessels. Two sayings in Chinese medicine state that ‘Blood and meat nourish Yin’ and ‘Blood and flesh have qing’; qing here can be translated as ‘feelings’. This means that, as a food derived from animals, meat has certain qualities that vegetable foods lack: because meat has this quality of ‘feelings’, it is closer in its nature to human beings and it therefore nourishes the Extraordinary Vessels and the reproductive system. Second, looking at foods in the same way as herbs and analysing their energy, meat is warm without being drying and tonifies without giving rise to Dampness: a warm, tonic herb with such characteristics is rare indeed. I shall list below the main herbs mentioned in connection with each Extraordinary Vessel. For the sake of completeness I shall include the herbs for Extraordinary Vessels whose treatment has not been discussed. Governing Vessel There are two categories of herbs affecting the Governing Vessel, one influencing the spine, Marrow and brain, the other influencing the Yang channels governed by this vessel. In other words, the former category of herbs affects the Governing Vessel’s substance itself, i.e. spine, Marrow and brain, while the latter affects the Governing Vessel only as a channel and consists mostly of herbs that expel Wind. Spine, Marrow and brain
Lu Rong Cornu Cervi pantotrichum, Lu Jiao Cornu Cervi, Lu Jiao Shuang Cornu Cervi degelatinatum, and the bone-marrow of beef and goat. For reasons explained above, these ingredients that affect the very substance of the Governing Vessel are all of animal origin.19 Yang channels, especially Bladder and Gall Bladder Fu Zi Radix Aconiti lateralis preparata, Rou Gui Cortex Cinnamomi, Gan Jiang Rhizoma Zingiberis, Chuan Jiao Pericarpium Zanthoxyli, Gui Zhi Ramulus Cinnamomi, Xi Xin Herba Asari and Gao Ben Rhizoma Ligustici. These herbs are all hot in energy, in keeping with the Governing Vessel’s Yang nature. Also, Fu Zi Radix Aconiti lateralis preparata and Rou Gui Cortex Cinnamomi warm the Fire of the Gate of Life (Ming Men) which of course stems from the Governing Vessel. Another interesting observation is that the herbs Gui Zhi Ramulus Cinnamomi, Xi Xin Herba Asari and Gao Ben Rhizoma Ligustici all expel Wind-Cold and are indicated in the treatment of the Greater Yang syndrome of invasion of Wind-Cold: they are therefore the equivalent of using Governing Vessel points such as Du-14 Dazhui or Du-16 Fengfu which expel external Wind. A further interesting observation is that these same Wind-expelling herbs are also used to treat the manifestations of cold or allergic rhinitis (i.e. sneezing and a runny nose), because the Governing Vessel flows through the nose. Directing Vessel The main herbs that nourish the Directing Vessel are: Gui Ban Plastrum Testudinis, Bie Jia Carapax Trionycis, E Jiao Colla Corii asini, Zi He Che Placenta Hominis, Zhi Mu Rhizoma Anemarrhenae, Huang Bo Cortex Phellodendri, Xuan Shen Radix Scrophulariae, Sheng Di Huang Radix Rehmanniae and Gou Qi Zi Fructus Lycii. If we analyse this list of herbs, three categories can be discerned. The
first four substances are animal products which nourish the Directing Vessel for the reasons explained above. In particular, Gui Ban Plastrum Testudinis is of prime importance in nourishing the Directing (and also the Penetrating) Vessel. Sheng Di Huang Radix Rehmanniae and Gou Qi Zi Fructus Lycii form a second group of herbs which nourish Kidney- and Liver-Yin. The third group of herbs clears Empty-Heat and pathological Minister Fire from Kidney-Yin deficiency, i.e. Zhi Mu Rhizoma Anemarrhenae, Huang Bo Cortex Phellodendri and Xuan Shen Radix Scrophulariae. The formula that tonifies the Directing Vessel is Da Bu Yin Wan Great Tonifying Yin Pill. Of the Three Treasures formulae, Ease the Journey-Yin and Ease the Journey-Yang nourish the Directing Vessel. Penetrating Vessel There are two categories of herbs that affect the Penetrating vessel: the first category serves to strengthen it, the second to subdue rebellious Qi. For the first category, see the listing given above for the Directing Vessel; the main herb being Gui Ban Plastrum Testudinis. As to the second, the herbs that subdue rebellious Qi in the Penetrating Vessel are: Yan Hu Suo Rhizoma Corydalis, Chuan Lian Zi Fructus Toosendan, Xiang Fu Rhizoma Cyperi, Yu Jin Radix Curcumae, Chen Xiang Lignum Aquilariae resinatum, Tao Ren Semen Persicae, Dang Gui Radix Angelicae sinensis, Qing Pi Pericarpium Citri reticulatae viride, Wu Zhu Yu Fructus Evodiae, Cong Bai Bulbus Allii fistulosi and Xiao Hui Xiang Fructus Foeniculi. Girdle Vessel Herbs that affect the Girdle Vessel include those that infuse to the Lower Burner, consolidate and have an astringent property. Some of the herbs (such as Sheng Ma Rhizoma Cimicifugae) have an ascending movement and may be used to treat pathological conditions of the Girdle Vessel characterized by the ‘belt’ being too slack and Qi sinking. The astringent quality of some of
these herbs would treat persistent vaginal discharges which are a major symptom of this vessel. Herbs that enter the Girdle Vessel include: Wu Wei Zi Fructus Schisandrae, Shan Yao Rhizoma Dioscoreae, Qian Shi Semen Euryales, Fu Pen Zi Fructus Rubi, Sang Piao Xiao Ootheca Mantidis, Dang Gui Radix Angelicae sinensis, Bai Shao Radix Paeoniae alba, Xu Duan Radix Dipsaci, Long Gu Fossilia Ossis mastodi, Ai Ye Folium Artemisiae argyi, Sheng Ma Rhizoma Cimicifugae and Gan Cao Radix Glycyrrhizae. In case of a Girdle Vessel disharmony with a prolapsed uterus, one can use Liang Shou Tang Two Receiving Decoction. This is because tonifying the Governing and Directing Vessels to correct a prolapse is not enough, as one must also tonify the ‘umbilical area’ by tightening the Girdle Vessel. For the same purpose, one can also use Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction plus Ba Ji Tian Radix Morindae officinalis, Du Zhong Cortex Eucommiae, Gou Ji Rhizoma Cibotii, Xu Duan Radix Dipsaci and Wu Wei Zi Fructus Schisandrae to tonify the Extraordinary Vessels, consolidate the Girdle Vessel and raise clear Qi. The fetus depends on the Kidneys and the Directing Vessel, but also on the Girdle Vessel. If the Girdle Vessel is slack, Qi cannot rise, the fetus is not stabilized and the mother may miscarry. In such a case, one should tonify the Girdle Vessel with Shou Tai Wan Fetus Longevity Pill. If there is a Girdle Vessel disharmony with Dampness infusing down to the genital system, one can use Gan Jiang Ling Zhu Tang GlycyrrhizaZingiberis-Poria-Atractylodes Decoction which warms the Spleen, resolves Dampness, opens the Girdle Vessel and strengthens the back. For backache radiating to the abdomen, some doctors use pungent herbs to scatter and sweet ones to moderate urgency such as Yan Hu Suo Rhizoma Corydalis, Dang Gui Radix Angelicae sinensis, Sang Ji Sheng Herba Taxilli, Gou Qi Zi Fructus Lycii and Xiao Hui Xiang Fructus Foeniculi. Dang Gui enters both the Penetrating and Girdle Vessels. Dang Gui Shao Yao San Angelica-Paeonia Powder treats the Girdle Vessel for such symptoms as abdominal pain, irregular periods, oedema and
leucorrhoea. It contains a high proportion of Bai Shao, which treats abdominal pain from the Girdle Vessel disorder, and Chuan Xiong, which moves Qi of the Penetrating Vessel. Yang Stepping Vessel Herbs that enter the Yang Stepping Vessel include: Ma Huang Herba Ephedrae, Fang Feng Radix Saposhnikoviae, Cang Zhu Rhizoma Atractylodis, Zhi Gan Cao Radix Glycyrrhizae preparata and Fang Ji Radix Stephaniae tetandrae. Yin Stepping Vessel The herbs that affect this vessel are: Yan Hu Suo Rhizoma Corydalis, Gua Lou Fructus Trichosanthis, Ban Xia Rhizoma Pinelliae preparatum, Dan Nan Xing Rhizoma Arisaematis preparatum, Zhi Mu Rhizoma Anemarrhenae, Huang Bo Cortex Phellodendri, Yuan Zhi Radix Polygalae, Suan Zao Ren Semen Ziziphi spinosae and Shi Chang Pu Rhizoma Acori tatarinowii. Formulae that affect this vessel include Si Wu Tang Four Substances Decoction and Ban Xia Tang Pinellia Decoction (which is composed only of Ban Xia Rhizoma Pinelliae preparatum and Shu Mi, husked sorghum). Yang and Yin Linking Vessels Some herbs affect both the Yang and Yin Linking Vessels. These include: Lu Jiao Shuang Cornu Cervi degelatinatum, Xiao Hui Xiang Fructus Foeniculi, Dang Gui Radix Angelicae sinensis, Gui Zhi Ramulus Cinnamomi, Bai Shao Radix Paeoniae alba and Huang Qi Radix Astragali. Yang Linking Vessel
Herbs that affect this vessel are those that harmonize Nutritive and Defensive Qi, i.e. Gui Zhi Ramulus Cinnamomi, Bai Shao Radix Paeoniae alba and Huang Qi Radix Astragali. Yin Linking Vessel The herbs that affect this vessel are Dang Gui Radix Angelicae sinensis and Chuan Xiong Radix Chuanxiong.
The four pathologies of the extraordinary vessels and herbal treatment The herbs used for the Extraordinary Vessels can be distinguished according to four pathologies: 1. Disharmony of Yin and Yang. 2. Deficiency. 3. Excess. 4. Rebellious Qi or Sinking Qi.
Disharmony of Yin and Yang This involves primarily the Yin and Yang Stepping Vessels (Yin and Yang Qiao Mai) whose role it is to harmonize the quantity of Yin and Yang and to absorb excesses of either. A disharmony of Yin and Yang may arise when “one tonifies, but it is not enough; one expels pathogenic factors, but there is still left over”. The formula to use is Ban Xia Tang Pinellia Decoction mentioned above.
Deficiency
• Yang Linking Vessel (alternation of hot and cold feeling): Huang Qi Jian Zhong Tang Astragalus Strengthening the Centre Decoction. • Yin Linking Vessel (chest discomfort): • Kidneys deficiency: Si Ni Tang Four Rebellious Decoction • Liver deficiency: Dang Gui Si Ni Tang Angelica Four Rebellious Decoction • Spleen deficiency: Li Zhong Tang Regulating the Centre Decoction. • Governing Vessel: meat (it warms without drying and tonifies without giving rise to Dampness).
Excess
• Yang Linking Vessel (alternation of hot and cold feeling): Xiao Chai Hu Tang Small Bupleurum Decoction. • Yin Linking Vessel (chest discomfort): • Kidneys: Jin Ling Zi Wan Melia Pill • Liver: Shi Xiao San Breaking into a Smile Powder • Spleen: Cheng Qi Tang Conducting Qi Decoction. • Governing/Directing/Penetrating Vessels (Kidney Empty-Heat): Huang Bo Cortex Phellodendri and Zhi Mu Rhizoma Anemarrhenae.
Rebellious or Sinking Qi
• Upwards: • Penetrating Vessel (Kidney Empty-Heat signs): Gui Ban Plastrum Testudinis, Huang Bo Cortex Phellodendri and Zhi Mu Rhizoma Anemarrhenae • Penetrating Vessel (Stomach-Qi rebellious): Ban Xia Rhizoma Pinelliae preparatum. • Downwards (sinking Qi): Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction.
Formulae for the directing and penetrating vessels Various formulae can be used for different patterns of the Directing and Penetrating Vessels. All these are very common in gynecology. Directing and Penetrating Vessels Empty
Diseases
Delayed periods, scanty periods, amenorrhoea, infertility. Clinical manifestations
Backache, tiredness, depression, dizziness, lower abdomen feels soft on palpation. Treatment principle
Tonify the Liver and Kidneys, nourish the Directing and Penetrating Vessels. Herbal treatment
– Da Bu Yuan Jian Great Tonifying the Original [Qi] Decoction. – Gui Shen Wan Restoring the Kidneys Pill. – Shou Tai Wan Fetus Longevity Pill.
Directing and Penetrating Vessels unstable This consists not only in a deficiency of these two vessels but also in a state of instability: for this reason, a deficiency of these vessels may lead to delayed periods, amenorrhoea or infertility, whereas when the Directing and Penetrating Vessels are ‘unstable’, in addition to being deficient, the opposite occurs, i.e. excessive bleeding or bleeding at the wrong time. Diseases
Early periods, heavy periods, bleeding between periods, Flooding and Trickling, chronic vaginal discharge, miscarriage, persistent lochial discharge after childbirth. Clinical manifestations
Pallor, tiredness, bearing-down feeling, depression, backache, feeling cold, frequent urination, Pale tongue. Treatment principle
Tonify and raise Qi, strengthen the Spleen, tonify the Kidneys, consolidate the Directing and Penetrating Vessels. Herbal treatment
– Gu Chong Tang Consolidating the Penetrating Vessel Decoction. – An Chong Tang Calming the Penetrating Vessel Decoction.
– Yi Qi Gu Chong Tang Benefiting Qi and Consolidating the Penetrating Vessel Decoction. Directing and Penetrating Vessels deficient and Cold
Diseases
Irregular periods, abdominal pain, amenorrhoea, infertility, abdominal pain after childbirth. Clinical manifestations
Abdominal pain that is better with massage and with application of heat, scanty periods with pale and dilute blood, cold limbs, Pale and wet tongue. Treatment principle
Tonify Kidney-Yang, expel Cold, warm the Centre and the Uterus. Herbal treatment
– Wen Jing Tang Warming the Menses Decoction. – Dang Gui Jian Zhong Tang Angelica Strengthening the Centre Decoction. Full Cold in the Directing and Penetrating Vessels
Diseases
Late periods with abdominal pain, infertility, abdominal pain after childbirth. Clinical manifestations
Pale complexion, abdominal pain that is worse with pressure and better with the application of heat, scanty periods with red blood but with dark, small clots, cold limbs, thick, white tongue coating. Treatment principle
Warm the Uterus, expel Cold, resolve Dampness, invigorate Blood, stop pain. Herbal treatment
– Shao Fu Zhu Yu Tang Lower Abdomen Eliminating Stasis Decoction. – Wen Jing Tang Warming the Menses Decoction. Empty-Heat in the Directing and Penetrating Vessels
Diseases
Early periods, long periods, Flooding and Trickling, heavy periods.
Clinical manifestations
Heavy periods, malar flush, feeling of heat in the evening, night sweating, fivepalm heat, Red tongue without coating. Treatment principle
Clear Empty-Heat, nourish Yin, consolidate the Directing and Penetrating Vessels. Herbal treatment
– Liang Di Tang Two ‘Di’ Decoction. – Yi Yin Jian One Yin Decoction. Full-Heat in the Directing and Penetrating Vessels
Diseases
Early periods, heavy periods, Flooding and Trickling, epistaxis during periods, persistent lochial discharge after childbirth, fever after childbirth. Clinical manifestations
Heavy periods with bright red or dark red blood, red face, feeling of heat, mental restlessness, agitation, thirst, Red tongue with yellow coating.
Treatment principle
Drain Heat, cool Blood. Herbal treatment
– Qing Jing San Clearing the Menses Powder. – Bao Yin Jian Protecting the Yin Decoction. – Qing Re Gu Jing Tang Clearing Heat and Consolidating the Menses Decoction. – Qing Gan Yin Jing Tang Clearing the Liver and Guiding the Period Decoction. – Jie Du Huo Xue Tang Expelling Toxin and Invigorating Blood Decoction. Damp-Heat in the Directing and Penetrating Vessels
Diseases
Excessive vaginal discharge, abdominal pain that is worse with pressure, heavy periods, mid-cycle bleeding, long periods. Clinical manifestations
White or yellow, sticky vaginal discharge, abdominal pain, burning on urination, cloudy urine, loose stools with mucus, yellow, sticky tongue coating. Treatment principle
Clear Heat, drain Dampness, consolidate the Directing and Penetrating Vessels. Herbal treatment
– Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction. Stagnant Heat in the Directing and Penetrating Vessels This is Heat deriving from long-term stagnation of Qi. Diseases
Early periods, heavy periods, pre-menstrual syndrome. Clinical manifestations
Early periods, heavy periods with bright red blood, abdominal pain and distension, breast distension, irritability, Red sides of the tongue. Treatment principle
Pacify the Liver, clear Heat, move Qi, eliminate stagnation, consolidate the Penetrating Vessel. Herbal treatment
– Dan Zhi Xiao Yao San Moutan-Gardenia Free and Easy Wanderer Powder. – Hua Gan Jian Transforming the Liver Decoction. Dampness and stasis of Blood in the Directing and Penetrating Vessels
Diseases
Irregular periods, painful periods, Flooding and Trickling, excessive vaginal discharge, abdominal masses, infertility. Clinical manifestations
Abdominal pain of a stabbing nature with fixed location, painful periods with dark blood and clots, Purple tongue. Treatment principle
Invigorate Blood, eliminate stasis, drain Dampness, regulate the Directing and Penetrating Vessels.
Herbal treatment
– Tao Hong Si Wu Tang Persica-Carthamus Four Substances Decoction. – Shao Fu Zhu Yu Tang Lower Abdomen Eliminating Stasis Decoction. – Qing Re Tiao Xue Tang Clearing Heat and Regulating Blood Decoction. – Cang Fu Dao Tan Tang Atractylodes-Cyperus Conducting Phlegm Pill. End notes 1. Heilongjiang Province National Medical Research Group 1984 An Explanation of the Great Compendium of Acupuncture (Zhen Jiu Da Cheng Jiao Shi ), People’s Health Publishing House, Beijing, p. 643. The Great Compendium of Acupuncture itself was published in 1601..
2. Ibid., pp 641–664, pp 984–992..
3. Ibid., p. 650..
4. Acupuncture Group of the Tianjin College of Traditional Chinese Medicine 1986 Experience in the Treatment of Depression with the Crossing Points of the Extraordinary Vessels, Journal of Chinese Medicine (Zhong Yi Za Zhi ) 27(4): 50..
5. Wang Luo Zhen 1985 A Compilation of the Study of the Eight Extraordinary Vessels (Qi Jing Ba Mai Kao Jiao Zhu ), Shanghai Science Publishing House, Shanghai, pp 109–113. The Study of the Eight Extraordinary Vessels (Qi Jing Ba Mai Kao) by Li Shi Zhen was published in 1578..
6.
Yang Jia San 1988 Great Dictionary of Chinese Acupuncture (Zhong Guo Zhen Jiu Da Ci Dian ), Beijing Physical Training College Publishing House, Beijing, p. 243..
7. Ibid., p. 256..
8. Yang Jia San 1989 Acupuncture (Zhen Jiu Xue Beijing, p. 361..
), People’s Health Publishing House,
9. Clavey proposes a different interpretation of the Classic of Difficulties passage describing the Triple Burner as the ‘envoy’ (shi) of the Original Qi. He proposes that the real meaning is “the Triple Burner makes the Original Qi separate into its different uses around the body”. See Clavey S 1995 Fluid Physiology and Pathology in Traditional Chinese Medicine, Churchill Livingstone, Melbourne, p. 21..
10. Great Dictionary of Chinese Acupuncture, p. 418..
11. Ibid., p. 739..
12. Ibid., p. 739..
13. Ibid., p. 14..
14. An Explanation of the Great Compendium of Acupuncture, p. 984..
15. Acupuncture, p. 381..
16. Wang Guo Rui 1329 The Jade Dragon Classic of Spiritual Acupuncture from Bian Que (Bian Que Shen Ling Zhen Jiu Yu Long Jing) cited in Chen You Bang 1990 Chinese Acupuncture Therapy (Zhong Guo Zhen Jiu Zhi Liao Xue ), China Scientific Publishing House, Beijing, p. 216..
17. Acupuncture, p. 355..
18. Great Dictionary of Chinese Acupuncture, p. 766..
19.
Obviously, the spine, marrow and brain of beef should not be eaten in countries where herds are affected by bovine spongiform encephalopathy (BSE)..
SECTION 4 Menstrual Irregularities
Introduction 8. EARLY PERIODS 201 9. LATE PERIODs 211 10. IRREGULAR PERIODS 225 11. HEAVY PERIODS 231 12. SCANTY PERIODS 239 13. LONG PERIODS 249 14. PAINFUL PERIODS 255 15. BLEEDING BETWEEN PERIODS 285 16. NO PERIODS 295 17. FLOODING AND TRICKLING 319 18. PRE-MENSTRUAL SYNDROME 357
Menstrual irregularities may involve many different aspects of menstruation, such as the regularity of the cycle, duration of the period, amount of bleeding and pain, or the absence of menstruation altogether. Irregularities of the cycle include: • Early Periods (the periods come consistently early). • Late Periods (the periods come consistently late). • Irregular Periods (the periods come sometimes early and sometimes late). • Bleeding between Periods.
• Early or Late Menopause.
Irregularities in the duration of the period itself include Long Periods (a short period would be classified as Scanty Period). A period is defined as long when it lasts well over 5 days but the bleeding itself is not heavy. Irregularities in the amount of bleeding include: • Heavy Periods (the bleeding is heavy but contained within normal period time). • Scanty Periods (the bleeding is scanty, either in duration or in amount). • Flooding and Trickling (menorrhagia or metrorrhagia).
The last category of disease is somewhat different from the others because it encompasses irregularities in cycle, duration and amount all at the same time. In fact, Flooding and Trickling refers to two separate symptoms
called beng lou ( ) in Chinese. Beng means ‘flooding’ and it indicates a period that starts suddenly, is extremely heavy and may come early or last more than 5 days. Lou means ‘leaking’ or ‘trickling’ and it indicates a period that may last well beyond the 5 days, sometimes up to 2 weeks, with a trickle rather than a flood of blood. Irregularities in pain include Painful Periods. Absence of menstruation is called amenorrhoea (which I shall refer to as No Periods, see Ch. 16). Figure S4.1 represents some of the menstrual irregularities graphically.
Figure S4.1 Menstrual irregularities.
Aetiology and diagnosis The aetiology of menstrual irregularities includes all the usual factors such as overwork, emotional stress, excessive physical work, exposure to cold, too many children too close together, hereditary Kidney weakness, surgery, etc. The diagnosis of menstrual irregularities must be based on a careful analysis of the cycle, amount of bleeding, colour and density of blood, clots and smell (see Ch. 5). Of course, it is extremely important to consider factors such as the use of the contraceptive pill or intra-uterine device which alter the manifestations of the period substantially. The differentiation must be based on a careful discrimination of Empty, Full, Cold or Heat conditions.
Principles of treatment The main principle of treatment, to be used in conjunction with other ones as appropriate, is to ‘regulate the periods’. In a broad sense, this involves regulating Yin and Yang and Qi and Blood. In fact, ultimately all menstrual irregularities can be attributed to a disharmony of Yin and Yang. One could say that when Yang is in excess, the periods come early (and are usually heavy) and when Yin is in excess, the periods come late (and are usually scanty).1 Yin and Yang in the human body ultimately have their basis in the Original Yang and Original Yin which reside in the Kidney: hence the importance of tonifying the Kidneys to regulate the periods. Harmonizing Qi and Blood, on the other hand, involves treating the Liver, Spleen, Stomach and Heart. In a narrow sense, ‘regulating the periods’ encompasses various methods of treatment and primarily: • harmonizing Qi and Blood • tonifying the Kidneys • strengthening the Spleen • harmonizing the Liver.
The Complete Works of Jing Yue by Zhang Jing Yue (1624) says: “To regulate the periods, one must tonify the Spleen and Kidneys in order to nourish Blood and nourish the Kidneys in order to calm Blood.”2 From an acupuncture perspective, ‘regulating the periods’ nearly always involves using the Directing Vessel (Ren Mai) with LU-7 Lieque on the right and KI-6 Zhaohai on the left, usually together with Ren-4 Guanyuan. If the periods are painful, then the Penetrating Vessel (Chong Mai) is more indicated with SP-4 Gongsun on the right with P-6 Neiguan on the left, often together with KI-14 Siman.
Harmonizing Qi and Blood When harmonizing Qi and Blood, one must distinguish clearly whether the predominant pathology is of Qi or of Blood: in the former case, one must regulate Qi, in the latter, one must invigorate and harmonize Blood. As a general principle, if the period comes early, one must regulate Qi first and then regulate Blood; if the period comes late, one must first of all tonify. Harmonizing Blood ‘Harmonizing Blood’ generally includes nourishing and invigorating Blood at the same time. The formula Si Wu Tang Four Substances Decoction is a prime example of this method of treatment, and for this reason various modifications of it are incorporated in many gynecological prescriptions. In fact, Shu Di Huang Radix Rehmanniae preparata both nourishes Blood and tonifies the Kidneys; Bai Shao Radix Paeoniae alba both nourishes Blood and pacifies the Liver; Dang Gui Radix Angelicae sinensis nourishes Blood and it also moderately invigorates Blood; and Chuan Xiong Rhizoma Chuanxiong invigorates Blood. Thus, this formula achieves all the three above methods of treatment, i.e. harmonizing Blood, tonifying the Kidneys and harmonizing the Liver: this explains its paramount importance in gynecology. There are several variations of Si Wu Tang, but the main two are one where Sheng Di Huang Radix Rehmanniae is substituted for Shu Di Huang, and one where Chi Shao Radix Paeoniae rubra is substituted for Bai Shao. The former substitution renders the formula suitable to nourish Yin and cool Blood; the latter enhances the Blood-invigorating power of the formula.
Tonifying the Kidneys Tonifying the Kidneys is essential in menstrual irregularities because they are the origin of the Heavenly Gui that produces menstrual blood. The Kidneys are therefore responsible not only for menarche and menopause but also, together with the Liver, for the regularity of the periods and fertility. Their importance in gynecology derives also from the fact that they are the origin and foundation of both Water and Fire (in the form of physiological Minister Fire). As we have seen in Chapter 2 on physiology, the physiological Minister Fire is a ‘formless’ Fire that actually generates Water: Fire and Water are therefore inseparable and nourish each other. In fact, it is through the agency of Minister Fire that the ‘periods Water’ (Jing shui) turns into menstrual Blood.
Strengthening the Spleen Strengthening the Spleen is also important because the Spleen is the postnatal source of Blood and it helps the Liver in storing Blood. Thus, when Blood is deficient in gynecology, one usually needs to tonify both Liver and Spleen. Another aspect of the Spleen’s functions that affects gynecological problems is sinking of Spleen-Qi: this can cause not only prolapses but also excessive bleeding or Flooding and Trickling. Thus, strengthening Spleen-Qi includes raising Spleen-Qi.
Harmonizing the Liver Harmonizing the Liver includes nourishing Liver-Blood, moving Liver-Qi and pacifying the Liver. These functions are closely linked as they correspond to the Yin and Yang aspects of the Liver, Liver-Blood being Yin and Liver-Qi being Yang. Regulating these two aspects is crucial if menstruation is to occur regularly. Whenever an irregularity of the cycle occurs, no matter what other pathogenic factor may be present, there is usually an underlying Liver disharmony. This happens because although the Kidneys are the origin of menstrual Water and of the Heavenly Gui, and are therefore responsible for menarche and menopause, once the periods have started during puberty the Liver then ‘takes over’ and brings on the periods every month. In fact, the Liver stores Blood and provides it to the Directing and Penetrating Vessels for the periods to occur every month. It is for this reason that Dang Gui Radix Angelicae sinensis, which nourishes Blood and enters the Liver, is such an important herb in gynecology. On the other hand, Liver-Qi is also crucial for the period to occur regularly because in the pre-menstrual phase it is its free flow that moves Blood and brings on the period. Bearing in mind the above principles of treatment, it is easy to see why the formula Xiao Yao San Free and Easy Wanderer Powder is so important in gynecology: in fact, it nourishes Liver-Blood, pacifies the Liver, moves Liver-Qi and strengthens the Spleen. The Directing and Penetrating Vessels (Ren and Chong Mai) are crucial for a regular menstruation to occur as they regulate the Uterus and menstrual blood. In fact, when the Directing Vessel is open and the Penetrating Vessel flourishing, the periods occur at the right time. However, these two vessels are closely linked to the Kidneys and Liver and therefore by tonifying the Kidneys, harmonizing Qi and Blood and harmonizing the Liver we indirectly also regulate the Directing and Penetrating Vessels. Important as it is that women’s periods be regulated, this should not take precedence over the treatment of other diseases; in fact, if another disease is present, this should be treated first. For example, if a woman suffers from a chronic infection due to a residual pathogenic factor, this should be treated
before regulating the periods. Other examples of conditions requiring prior treatment are diabetes, a consumption disease (lao), asthma, etc. Also, in some cases, a menstrual irregularity may be the symptom of a systemic disease such as a platelet deficiency causing heavy periods, or tuberculosis causing scanty periods, or anorexia causing amenorrhoea. When considering herbs to include in a prescription for gynecological problems, one must take care not to injure the Kidneys, Spleen or Liver. Thus, when tonifying the Kidneys, one must exercise caution and not use too many tonics that may damage the Spleen. When tonifying the Spleen, one must not use too drying substances that may injure the Kidneys. When harmonizing Qi and pacifying the Liver, one must not use too many hot, pungent herbs that may injure Kidney-Yin and Liver-Yin. From the acupuncture point of view, ‘regulating the periods’ is best achieved by using the opening points of the Directing Vessel and a point on this vessel in the lower abdomen. Thus, to regulate the periods, I often use LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) together with Ren4 Guanyuan: this last point is very effective when direct moxa cones are applied (unless there is Yin deficiency). If there is a pronounced Kidney deficiency, KI-13 Qixue can be added: this point will also strengthen the Penetrating Vessel which is the Sea of Blood. If the periods are painful, I choose the Penetrating Vessel instead, needling the points SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), together with Ren-4 Guanyuan, ST-29 Guilai and KI-14 Siman. To harmonize Blood, I use ST-36 Zusanli and SP-6 Sanyinjao with reinforcing method to nourish Blood and LIV-3 Taichong or LIV-8 Ququan with even method to invigorate Blood and pacify the Liver. ST-36 and SP-6 will automatically also tonify the Spleen. End notes 1. Nanjing College of Traditional Chinese Medicine 1979 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Nanjing College of Traditional Chinese Medicine, Nanjing, p. 28..
2. Cited in Luo Yuan Kai 1986 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Shanghai Science and Technology Press, Shanghai, p. 36..
CHAPTER 8 Early Periods
AETIOLOGY 201 PATHOLOGY 202 IDENTIFICATION OF PATTERNS AND TREATMENT 202 QI DEFICIENCY 202 Spleen-Qi deficiency 202 Kidney-Qi not firm 204 BLOOD-HEAT 205 Full-Heat: Liver Blood-Heat 205 Full-Heat: stagnant Liver-Qi turning into Fire with Blood-Heat 206 Full-Heat: Heart-Fire 207 Liver- and Kidney-Yin deficiency with Empty-Heat 208 PROGNOSIS AND PREVENTION 209 Early Periods are defined as periods that come consistently up to 9 days early so that the cycle is less than 28 days long; the definition applies if this happens more than twice in succession. The amount of bleeding may be normal, scanty or excessive.
Aetiology
Excessive physical work, irregular diet Excessive physical work or a diet lacking in nourishment weaken the Spleen; when Spleen-Qi is deficient, it may fail to hold blood in the vessels and this may leak out giving rise to a period before the right time. This is an Empty type of bleeding. Overwork, menopausal decline of Kidney-Qi Overwork often causes Kidney-Yin deficiency; because the deficient Kidney cannot sustain and consolidate the Directing and Penetrating Vessels (Ren and Chong Mai), blood leaks out and the period occurs before time. This is also an Empty type of bleeding and is due to Kidney-Qi not holding blood. Irregular diet, invasion of external Heat Excessive consumption of hot, spicy foods and alcohol may lead to BloodHeat which affects the Directing and Penetrating Vessels. The blood in these vessels is agitated, it overflows from the vessels and the period comes before the right time. This may also occur when external Heat penetrates the Interior and enters the Blood portion. This is a Full type of bleeding. Emotional stress Emotional stress deriving from anger, repressed anger, resentment, frustration or guilt results in stagnation of Liver-Qi and, over time, this may lead to Liver-Fire. Fire may invade the Blood portion (especially since the Liver
stores Blood) and cause Blood-Heat. Hot Blood pushes out of the vessels and the period occurs before the right time. This is also a Full type of bleeding. The periods may come early also when emotional stress affects the Heart and the Mind. As we have seen, the descending of Heart-Qi to the Uterus induces the start of menstrual bleeding. If the Mind is affected by emotional stress, it may induce Heart-Qi to descend prematurely. This may happen in case of shock, fear, worry and guilt. Chronic illness, overwork, too many children, chronic bleeding A long, chronic illness, overwork or having too many children too close together may cause Liver- and Kidney-Yin deficiency which eventually creates Empty-Heat. This enters the Blood portion and causes Blood-Heat so that the blood pushes out of the vessels and the period comes before time. This is a mixed Full and Empty type of bleeding: Full because of the EmptyHeat, Empty because it derives from Yin deficiency. This situation may also arise from chronic bleeding itself. For example, a woman may suffer from excessive bleeding from Qi deficiency; after many years, the excessive loss of Blood may lead to Yin deficiency and this to Empty-Heat. Empty-Heat makes the Blood reckless and causes the period to come early.
Pathology Thus, the pathology of this condition falls into two broad groups, the first from Qi deficiency, the second from Blood-Heat. Within the first group is Spleen-Qi or Kidney-Qi deficiency; within the second group, Full-Heat or Empty-Heat (see Fig. 8.1). Deficient Qi (whether Spleen- or Kidney-Qi) fails to hold blood in the vessels. Blood-Heat (whether deriving from Full- or Empty-Heat) pushes the blood out of the vessels.
Figure 8.1 Pathology of early periods. The aetiological factors under the first two situations given above lead to deficient Spleen-Qi and Kidney-Qi, respectively, not holding blood. The aetiological factors under the next two situations lead to Full-Heat and those under the last situation lead to Empty-Heat. The pattern of Empty-Heat is more likely to occur in older women. The treatment can be given according to the four phases of the menstrual cycle. For example, in cases of Qi deficiency, treatment could be given only during and after the period (first and second phases); in cases of Full-Heat, it could be administered before and during the period (fourth and first phases); and in cases of Empty-Heat, it could be given during and at mid-cycle (first and third phases).
The patterns discussed are: • Qi deficiency: • Spleen-Qi deficiency • Kidney-Qi not firm. • Blood-Heat: • Full-Heat: Liver Blood-Heat; Stagnant Liver-Qi turning into Fire with Blood-Heat; Heart-Fire. • Empty-Heat: Liver- and Kidney-Yin deficiency with Empty-Heat.
Identification of patterns and treatment All the herbal prescriptions in the following chapters are detailed in Appendix 1 on p. 937.
Qi deficiency
Spleen-Qi deficiency
Clinical manifestations Early period, pale and dilute menstrual blood, loose stools, epigastric distension, tiredness. Tongue: Pale. Pulse: Weak. Treatment principle Strengthen the Spleen, tonify and raise Qi, consolidate the Penetrating Vessel, contain blood. Acupuncture ST-36 Zusanli, SP-6 Sanyinjao, Ren-12 Zhongwan, BL-20 Pishu, Du-20 Baihui, Ren-4 Guanyuan, Ren-6 Qihai. All with reinforcing method, moxa is applicable. Explanation
– ST-36, SP-6, Ren-12 and BL-20 strengthen the Spleen and tonify Qi. – Du-20 raises Qi. – Ren-4 tonifies the Uterus and consolidates the Directing and Penetrating Vessels. – Ren-6 tonifies and raises Qi. Herbal treatment
a Prescription
– GUI PI TANG – Tonifying the Spleen Decoction Explanation This famous prescription is widely used to stop bleeding from Qi deficiency. This is because it tonifies Qi and it enters the Blood portion. – Huang Qi, Ren Shen and Bai Zhu tonify and raise Qi. – Dang Gui nourishes Blood and enters the Blood portion. – Fu Shen, Suan Zao Ren, Long Yan Rou and Yuan Zhi calm the Mind. – Mu Xiang moves Qi and is added to counteract and balance the cloying nature of Qi and Blood tonics. – Zhi Gan Cao, Sheng Jiang and Hong Zao harmonize. Hong Zao also nourishes Blood. b Prescription
– JU YUAN JIAN Variation – Raising the Original [Qi] Decoction Variation Explanation
The original formula, composed of the first five herbs, tonifies and raises Qi to stop bleeding. – Ren Shen, Huang Qi and Bai Zhu tonify and raise Qi. – Zhi Gan Cao harmonizes and also tonifies Qi. – Sheng Ma, in combination with Huang Qi, raises Qi. – E Jiao is added to the original formula to enter the Blood portion so as to affect the periods. – Hai Piao Xiao (also called Wu Zei Gu) is astringent and absorbing, thus helping to prevent bleeding before the period. c Prescription
– BU ZHONG YI QI TANG – Tonifying the Centre and Benefiting Qi Decoction Explanation This well-known formula tonifies and raises Qi. It is suitable to treat Early Periods because it contains Dang Gui which enters the Blood portion. – Huang Qi, Ren Shen and Bai Zhu tonify and raise Qi. – Dang Gui nourishes Blood and enters the Blood portion. – Chen Pi resolves Dampness: it is added to counteract and balance the cloying nature of Qi and Blood tonics.
– Sheng Ma and Chai Hu, in combination with Huang Qi, raise Qi. Comparison of Gui Pi Tang, Ju Yuan Jian and Bu Zhong Yi Qi Tang To compare and contrast these three formulae, Gui Pi Tang is particularly suitable if the patient also suffers from anxiety and palpitation deriving from emotional problems. The second formula, Ju Yuan Jian, is very similar to the third, Bu Zhong Yi Qi Tang, but it is more astringent than the latter and it is therefore suitable if the period, besides being early, is also heavy. Bu Zhong Yi Qi Tang, on the other hand, is better if the patient suffers from depression. Modifications These modifications apply to all three prescriptions. • If the bleeding is heavy add Long Gu Fossilia Ossis mastodi and Mu Li Concha Ostreae. • If there is Yang deficiency, add herbs that warm the Uterus, scatter Cold and stop bleeding such as Ai Ye Folium Artemisiae argyi, Pao Jiang Rhizoma Zingiberis preparatum (fried) or Bu Gu Zhi Fructus Psoraleae. • If there is stasis of Blood, add Qian Cao Gen Radix Rubiae, Yi Mu Cao Herba Leonori and San Qi Radix Notoginseng. • If the period is scanty and there is a Kidney deficiency with loose stools, add Lu Jiao Shuang Cornu Cervi degelatinatum and Du Zhong Cortex Eucommiae. Three Treasures remedies
– TONIFY QI AND EASE THE MUSCLES
This remedy is a variation of Bu Zhong Yi Qi Tang: it tonifies and raises Qi, enters the Blood portion and resolves Dampness. It is suitable if the patient suffers from depression. The tongue presentation appropriate to this remedy is a Pale body with a sticky, white coating. – CALM THE SHEN This remedy is a variation of the formula Gui Pi Tang which tonifies Qi and Blood of the Spleen and Heart: it can be used to stop bleeding from Qi deficiency. The tongue presentation appropriate to this remedy is a Pale body. Summary Spleen-Qi deficiency
Clinical manifestations
Early period, pale and dilute menstrual blood, loose stools, epigastric distension, tiredness. Tongue: Pale. Pulse: Weak. Treatment principle
Strengthen the Spleen, tonify and raise Qi, consolidate the Penetrating Vessel, contain blood. Acupuncture
ST-36 Zusanli, SP-6 Sanyinjao, Ren-12 Zhongwan, BL-20 Pishu, Du-20 Baihui, Ren-4 Guanyuan, Ren-6 Qihai. All with reinforcing method, moxa is applicable. Herbal treatment
Pre scriptions
• GUI PI TANGTonifying the Spleen Decoction • JU YUAN JIAN Variation Raising the Original [Qi] Decoction Variation • BU ZHONG YI QI TANGTonifying the Centre and Benefiting Qi Decoction Three Treasures re me die s
• TONIFY QI AND EASE THE MUSCLES • CALM THE SHEN
Kidney-Qi not firm
Clinical manifestations Early period, pale, dilute menstrual blood, lower backache, dizziness, nocturia, feeling cold. Tongue: Pale, Swollen. Pulse: Deep and Weak. Treatment principle Strengthen the Kidneys, tonify Qi, warm Yang, consolidate the Directing and Penetrating Vessels. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, KI-7 Fuliu, BL-23 Shenshu, ST-36 Zusanli, BL-20 Pishu, Du-20 Baihui, Ren-4 Guanyuan, KI-13 Qixue, Ren-6 Qihai. All with reinforcing method, moxa is applicable. Explanation
– LU-7 and KI-6 regulate the Directing Vessel and tonify the Uterus. – KI-3, KI-7 and BL-23 tonify the Kidneys. – ST-36 and BL-20 tonify the Spleen. When Kidney-Yang is deficient, it is usually necessary to tonify the Spleen too. – Du-20 raises Qi.
– Ren-4 and KI-13 consolidate the Directing and Penetrating Vessels and strengthen the Uterus. Ren-4 is particularly effective with direct moxa cones. – Ren-6 tonifies and raises Qi. Herbal treatment
Prescription
– GUI RONG BU CHONG TANG and SHOU TAI WAN – Plastrum Testudinis-Colla Cornu Cervi Tonifying the Penetrating Vessel Decoction and Fetus Longevity Pill Explanation The first nine herbs constitute the formula Gui Rong Bu Chong Tang, and the last four the formula Shou Tai Wan. The former tonifies and raises Qi, consolidates the Directing and Penetrating Vessels, strengthens and warms the Uterus and stops bleeding. The second formula tonifies the Kidneys and is usually prescribed for threatened miscarriage. – Dang Shen, Huang Qi and Zhi Gan Cao tonify and raise Qi. – Lu Jiao Jiao and Gui Ban tonify the Kidneys and strengthen the Directing and Penetrating Vessels and the Governing Vessel. – Ai Ye and Pao Jiang warm the Uterus and stop bleeding. – Bai Shao and Wu Zei Gu nourish Blood and, being astringent and absorbent, they stop bleeding.
– Tu Si Zi and Xu Duan tonify Kidney-Yang and calm the fetus. – Sang Ji Sheng and E Jiao nourish Liver-Blood and calm the fetus in threatened miscarriage. Modifications If there is Blood and Essence deficiency, add Gou Qi Zi Fructus Lycii and Shan Zhu Yu Fructus Corni. Three Treasures remedy
– EASE THE JOURNEY-YANG This remedy tonifies Kidney-Yang, and strengthens the Directing and Penetrating Vessels. It can be used for Early Periods because it contains Mu Li which is absorbent and can stop bleeding. The tongue presentation appropriate to this remedy is a Pale body. Summary Kidney-Qi not firm
Clinical manifestations
Early period, pale, dilute menstrual blood, lower backache, dizziness, nocturia, feeling cold. Tongue: Pale, Swollen. Pulse: Deep and Weak. Treatment principle
Strengthen the Kidneys, tonify Qi, warm Yang, consolidate the Directing and
Penetrating Vessels. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, KI-7 Fuliu, BL-23 Shenshu, ST-36 Zusanli, BL-20 Pishu, Du-20 Baihui, Ren-4 Guanyuan, KI-13 Qixue, Ren-6 Qihai. All with reinforcing method, moxa is applicable. Herbal treatment
Pre scription
• GUI RONG BU CHONG TANG and SHOU TAI WAN, Plastrum TestudinisColla Cornu Cervi Tonifying the Penetrating Vessel Decoction and Fetus Longevity Pill Three Treasures remedy
• EASE THE JOURNEY-YANG
Blood-heat
Full-Heat: Liver Blood-Heat
Clinical manifestations Early period that is heavy with bright red or dark red blood, anxiety, mental restlessness, red face, thirst, dark urine, dry stools. Tongue: Red with a yellow coating. Pulse: Rapid, Overflowing, Full and Wiry in the Middle level. Treatment principle Clear Heat, cool Blood, regulate the periods. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, L.I.-11 Quchi, SP-10 Xuehai, BL-17 Geshu, SP-6 Sanyinjiao, LIV-2 Xingjian, LIV-3 Taichong, KI-2 Rangu, SP-8 Diji. All with reducing or even method. Explanation
– LU-7 and KI-6 regulate the Directing Vessel and the periods. – Ren-4 strengthens the Uterus. – L.I.-11, SP-10 and BL-17 clear Heat and cool Blood. – SP-6 regulates the periods and cools Blood. – LIV-2 drains Liver-Fire and therefore helps to cool Blood as, in this
case, Blood-Heat is related to the Liver. – LIV-3 and KI-2 in combination cool Blood. – SP-8, Accumulation point, stops uterine bleeding. Herbal treatment
a Prescription
– QING JING SAN – Clearing the Menses Powder Explanation
– Mu Dan Pi cools Blood and stops bleeding. – Bai Shao ‘calms’ Blood to stop bleeding. – Shu Di Huang nourishes Blood. – Di Gu Pi and Qing Hao clear Heat. – Fu Ling and Huang Bo drain Dampness. Modifications If the periods are very heavy, add Di Yu Radix Sanguisorbae, Huai Hua Flos Sophorae immaturus and Qian Cao Gen Radix Rubiae.
b Prescription
– QIN LIAN SI WU TANG – Scutellaria-Coptis Four Substances Decoction Explanation
– Huang Qin and Huang Lian clear Heat. – Mai Men Dong and Sheng Di Huang nourish Yin and cool Blood. Sheng Di Huang also calms Blood and stops bleeding. – Chuan Xiong, Dang Gui and Bai Shao harmonize Blood. Bai Shao also calms Blood and helps to stop bleeding. This formula is particularly suitable if there is some Damp-Heat too, as the first two herbs resolve Damp-Heat. Women’s Treasure remedy
– COOL THE MENSES This remedy clears Heat, cools Blood and stops uterine bleeding. The tongue presentation appropriate to this remedy is a Red body. Summary Full Heat: Liver Blood-Heat
Clinical manifestations
Early period that is heavy with bright red or dark red blood, anxiety, mental restlessness, red face, thirst, dark urine, dry stools. Tongue: Red with a yellow coating. Pulse: Rapid, Overflowing, Full and Wiry in the Middle level. Treatment principle
Clear Heat, cool Blood, regulate the periods. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, L.I.-11 Quchi, SP-10 Xuehai, BL-17 Geshu, SP-6 Sanyinjiao, LIV-2 Xingjian, LIV-3 Taichong, KI-2 Rangu, SP-8 Diji. All with reducing or even method. Herbal treatment
Pre scriptions
• QING JING SANClearing the Menses Powder • QIN LIAN SI WU TANGScutellaria-Coptis Four Substances Decoction Women’s Treasure remedy
• COOL THE MENSES
Full-Heat: stagnant Liver-Qi turning into Fire with Blood-Heat
Clinical manifestations Early period that is usually heavy with dark blood and clots, abdominal pain, pre-menstrual breast distension, irritability, bitter taste, dry throat. Tongue: Red, redder sides. Pulse: Wiry and Rapid. Treatment principle Clear and pacify the Liver, move Qi, clear Heat, cool Blood, regulate the period. Acupuncture LIV-2 Xingjian, LIV-3 Taichong, Ren-4 Guanyuan, LIV-14 Qimen, L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, SP-6 Sanyinjiao, SP-8 Diji. All with reducing or even method. Explanation
– LIV-2 drains Liver-Fire. – LIV-3 and KI-2 in combination cool Blood. LIV-3 also pacifies the Liver. – Ren-4 tonifies the Uterus. – LIV-14 pacifies the Liver.
– L.I.-11 and SP-10 cool Blood. – SP-6 cools Blood and pacifies the Liver. – SP-8, in combination with LIV-3, clears Heat deriving from stagnant Liver-Qi and stops uterine bleeding. Herbal treatment
a Prescription
– DAN ZHI XIAO YAO SAN – Moutan-Gardenia Free and Easy Wanderer Powder Explanation This is a variation of the formula Xiao Yao San Free and Easy Wanderer Powder which moves Qi and pacifies the Liver. Shan Zhi Zi Fructus Gardeniae and Mu Dan Pi Cortex Moutan are added to clear Heat. This variation is specific to clear Liver-Fire when it derives from stagnant LiverQi. b Prescription
– QING GAN DA YU TANG – Clearing the Liver and Eliminating Stagnation Decoction
Explanation This formula is essentially a variation of Dan Zhi Xiao Yao San mentioned above. It also clears Liver-Fire, pacifies the Liver and eliminates stagnation: it is specific for stagnant Liver-Qi turning into Liver-Fire. To compare this formula with the previous one, Dan Zhi Xiao Yao San, the present formula has a wider therapeutic range because it also subdues Liver-Yang and resolves Dampness. – Chai Hu and Bo He move Qi and pacify the Liver. – Dang Gui and Bai Shao nourish Liver-Blood: this is necessary to pacify the Liver. – Ju Hua subdues Liver-Yang. – Shan Zhi Zi and Mu Dan Pi clear Liver-Fire. – Ju Ye and Chen Pi move Qi and resolve Dampness. – Zhi Gan Cao harmonizes. c Prescription
– EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai1 Explanation This formula is used when stagnant Liver-Qi leads to Heat which damages Liver-Blood. – Dang Gui, Chi Shao and Chuan Xiong nourish and invigorate Blood and
regulate the periods. – Chai Hu and Bai Ji Li pacify the Liver, move Qi and eliminate stagnation. – Shan Zhi Zi and Huang Qin clear Liver-Heat. – Ban Xia and Ju Pi Luo harmonize the Centre and resolve Dampness. – Fu Ling resolves Dampness. – Gan Cao harmonizes. Modifications
• If the periods start and stop and the menstrual blood has clots (which indicates stasis of Blood), add Ze Lan Herba Lycopi, Dan Shen Radix Salviae miltiorrhizae and Yi Mu Cao Herba Leonuri. • If there is abdominal pain, add Xiang Fu Rhizoma Cyperi, Wu Yao Radix Linderae, Chuan Lian Zi Fructus Toosendan and Yan Hu Suo Rhizoma Corydalis. • If the period is heavy, remove Dang Gui Radix Angelicae sinensis. d Prescription
– TANG SHI SHU JIE FANG2 – Dr Tang’s Pacifying [the Liver] and Eliminating Stagnation Formula Explanation
– Chai Hu, Xiang Fu, Ba Yue Zha and Mei Gui Hua pacify the Liver, move Qi and eliminate stagnation. – Dang Gui and Bai Shao nourish Liver-Blood and pacify the Liver. – Mu Dan Pi, Shan Zhi Zi and Xia Ku Cao clear Liver-Heat. – Chuan Xiong invigorates Blood. Summary Full-Heat: stagnant Liver-Qi turning into Fire with Blood-Heat
Clinical manife stations
Early period that is usually heavy with dark blood and clots, abdominal pain, pre-menstrual breast distension, irritability, bitter taste, dry throat. Tongue: Red, redder sides. Pulse: Wiry and Rapid. Tre atme nt principle
Clear and pacify the Liver, move Qi, clear Heat, cool Blood, regulate the period. Acupuncture
LIV-2 Xingjian, LIV-3 Taichong, Ren-4 Guanyuan, LIV-14 Qimen, L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, SP-6 Sanyinjiao, SP-8 Diji. All with reducing or even method. He rbal tre atme nt
Prescriptions
• DAN ZHI XIAO YAO SANMoutan-Gardenia Free and Easy Wanderer Powder • QING GAN DA YU TANGClearing the Liver and Eliminating Stagnation Decoction • EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai • TANG SHI SHU JIE FANGDr Tang’s Pacifying [the Liver] and Eliminating Stagnation Formula
Full-Heat: Heart-Fire
Clinical manifestations Early period, heavy period, palpitations, anxiety, insomnia, mental restlessness, red face, thirst. Tongue: Red with yellow coating, redder tip with red points. Pulse: Overflowing, Rapid. Treatment principle Drain Fire, clear the Heart, calm the Mind. Acupuncture HE-8 Shaofu, HE-5 Tongli, P-7 Daling, Ren-4 Guanyuan, KI-16 Huangshu. The first three with reducing method; the others with even method. Explanation
– HE-8 drains Heart-Fire and calms the Mind. – HE-5 regulates Heart-Qi and regulates its descending. – P-7 calms the Mind. – Ren-4 directs the treatment to the Uterus. – KI-16 harmonizes the connection of Heart and Kidneys with the Uterus. It therefore regulates the descending of Heart-Qi to the Uterus.
Herbal treatment
Prescription
– QING XIN PING GAN TANG Variation – Clearing the Heart and Balancing the Liver Decoction Variation Explanation
– Huang Lian and Mai Men Dong in combination drain Heart-Fire. – Bai Shao regulates the Liver. – Bai Wei clears Liver-Heat. – Dan Shen regulates the descending of Heart-Qi to the Uterus and calms the Mind. – Long Gu and Suan Zao Ren are astringent and help to stop bleeding. – Qian Cao Gen stops bleeding. Summary Full-Heat: Heart-Fire
Clinical manife stations
Early period, heavy period, palpitations, anxiety, insomnia, mental restlessness, red face, thirst. Tongue: Red with yellow coating, redder tip with red points. Pulse: Overflowing, Rapid. Tre atme nt principle
Drain Fire, clear the Heart, calm the Mind. Acupuncture
HE-8 Shaofu, HE-5 Tongli, P-7 Daling, Ren-4 Guanyuan, KI-16 Huangshu. The first three with reducing method; the others with even method. He rbal tre atme nt
Prescription
• QING XIN PING GAN TANG Variation Clearing the Heart and Balancing the Liver Decoction Variation
Liver- and Kidney-Yin deficiency with Empty-Heat
Clinical manifestations Early period which may be scanty or heavy, malar flush, a feeling of heat in the evening, dizziness, tinnitus, five-palm heat, night sweating. Tongue: Red without coating. Pulse: Floating-Empty or Fine and Rapid. Treatment principle Nourish Yin, clear Empty-Heat, regulate the periods. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-3 Taixi, LIV-8 Ququan, SP-6 Sanyinjiao, KI-2 Rangu. All with reinforcing method except for KI-2 which should be needled with reducing or even method. No moxa. Explanation
– LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and regulate the periods. – Ren-4, KI-3, LIV-8 and SP-6 nourish Liver- and Kidney-Yin. – KI-2 clears Empty-Heat. Herbal treatment
a Prescription
– LIANG DI TANG – Two ‘Di’ Decoction Explanation
– Sheng Di Huang, Xuan Shen and Mai Men Dong nourish Yin. Both Sheng Di Huang and Xuan Shen also cool Blood and therefore stop bleeding. – Di Gu Pi clears Empty-Heat. – Bai Shao and E Jiao nourish Blood, which helps to nourish Yin. Both herbs also ‘calm’ Blood and therefore help to stop bleeding. b Prescription
– QING JING SAN Variation – Clearing the Menses Powder Variation Explanation The first seven herbs constitute the formula Qing Jing San (with Sheng Di Huang substituted for Shu Di Huang) which mostly clears Empty-Heat to stop excessive or early menstrual bleeding.
– Xuan Shen and Mai Men Dong were added to nourish Yin. – Zhi Mu clears Empty-Heat. Modifications
• If there are symptoms and signs of Liver-Yang rising (such as headache, irritability and pronounced dizziness), add Bai Ji Li Fructus Tribuli, Gou Teng Ramulus Uncariae cum Uncis and Tian Ma Rhizoma Gastrodiae. • If the Heat is pronounced, add Nu Zhen Zi Fructus Ligustri lucidi and Han Lian Cao Herba Ecliptae. c. Prescription
– DI GU PI YIN (from Golden Mirror of Medicine, Yi Zong Jin Jian) – Cortex Lycii Decoction Explanation This formula is a variation of Si Wu Tang Four Substances Decoction (the first four herbs). The first four herbs constitute a variation of Si Wu Tang (with Sheng Di Huang substituted for Shu Di Huang) which harmonizes Blood. Sheng Di Huang cools and calms Blood and stops bleeding. – Di Gu Pi and Mu Dan Pi clear Heat and cool Blood. Women’s Treasure remedies
– EASE THE JOURNEY-YIN This remedy nourishes Kidney-Yin and clears Empty-Heat. It is suitable for bleeding syndromes because it contains Mu Li Concha Ostreae and Suan Zao Ren Semen Ziziphi spinosae which are astringent. The tongue presentation appropriate to this remedy is a Red body without coating. – CLEAR EMPTY-HEAT AND COOL THE MENSES Summary Liver- and Kidney-Yin deficiency with Empty-Heat
Clinical manifestations
Early period which may be scanty or heavy, malar flush, a feeling of heat in the evening, dizziness, tinnitus, five-palm heat, night sweating. Tongue: Red without coating. Pulse: Floating-Empty or Fine and Rapid. Treatment principle
Nourish Yin, clear Empty-Heat, regulate the periods. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-3 Taixi, LIV-8 Ququan, SP-6 Sanyinjiao, KI-2 Rangu. All with reinforcing method except for KI-2 which should be needled with reducing or even method. No moxa. Herbal treatment
Pre scriptions
• LIANG DI TANGTwo ‘Di’ Decoction • QING JING SAN Variation Clearing the Menses Powder Variation • DI GU PI YIN (from Golden Mirror of Medicine, Yi Zong Jin Jian) Cortex Lycii Decoction Women’s Treasure remedies
• EASE THE JOURNEY-YIN • CLEAR EMPTY-HEAT AND COOL THE MENSES
This remedy cools Blood, clears Empty-Heat and stops bleeding. Its emphasis is on clearing Empty-Heat rather than nourishing Yin. The tongue presentation appropriate to this remedy is a Red body without coating.
Prognosis and prevention The problem of early periods and a short cycle can usually be resolved with acupuncture and/or Chinese herbs. As usual, it will take a minimum of three menstrual cycles to regulate the cycle. The pattern from Empty-Heat is more difficult to treat and it may take several months of therapy. Women suffering from Spleen-Qi or Kidney-Qi deficiency should pay attention to getting enough rest and avoiding excessive exercise or lifting; they should also avoid having excessive amounts of cold, raw foods and iced drinks. Those suffering from Full-Heat should avoid eating hot, spicy foods and drinking alcohol. Patients suffering from Empty-Heat and Yin deficiency should have adequate rest and avoid working long hours: ‘resting more’ means that they should take a short rest after lunch (preferably lying down), do no overtime and pace their activities. In other words, they should pace themselves so as never to reach the point of exhaustion. End notes 1. Long Jiajun, Zhang Qi, Shen Kang, Lin Hongyang 1996 Dr Zhang Jian Zhai’s Experience in Treating Gynaecological Diseases (Zhang Jian Zhai Zhi Liao Fu Ke Bing Jing Yan), Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi
), China Academy of Traditional Chinese Medicine, Beijing, No. 1, p. 16..
2. Hu Xi Ming 1990 Great Treatise of Secret Formulae in Chinese Medicine (Zhong Guo Zhong Yi Mi Fang Da Quan
), Culture Publishing House, Shanghai, Vol. 2, p. 211..
CHAPTER 9 Late Periods
Aetiology 211 Pathology 212 Identification of patterns and treatment 212 Blood deficiency 212 Cold in the Uterus: Full-Cold 213 Cold in the Uterus: Empty-Cold 213 Kidney-Yang deficiency 217 Liver-Qi stagnation 220 Prognosis and prevention 222 The periods are defined as Late Periods when they arrive late so that the menstrual cycle is longer than 28–30 days consistently (or at least for 3 consecutive months). It can be up to 40–50 days long. If the periods are only occasionally late, this may be due to external circumstances such as emotional upsets or travelling. Obviously, if after always being regular the period is suddenly late one month, then this might indicate pregnancy.
Aetiology
Chronic illness, excessive physical work, chronic bleeding, excessive breastfeeding A long, chronic illness or excessive physical work weaken the Spleen and often lead to Qi and Blood deficiency. Chronic bleeding (such as in menorrhagia) may also induce Blood deficiency when it is prolonged. Breastfeeding for too long (e.g. 2 years) may also lead to Blood deficiency because breast milk and Blood come from the same source. Whatever the cause, when Blood is deficient, the Directing and Penetrating Vessels are also devoid of Blood and the period cannot occur at the proper time and becomes consistently late. Irregular diet, exposure to cold and dampness, invasion of cold Excessive consumption of raw, cold foods over a long period of time leads to internal Cold and possibly Yang deficiency. Excessive exposure to cold and damp weather or living in a damp environment also lead to internal Cold and Dampness. Whatever the cause, Cold can invade the Blood portion and cause the Blood to congeal, new Blood cannot be generated, the Directing and Penetrating Vessels become empty, the Sea of Blood cannot fill the Uterus, hence the periods come consistently late. This is a very common cause of Late Periods (and also of painful periods) in girls who are exposed to very cold and damp conditions by playing sports in shorts in all weather conditions. Cold and dampness are particularly detrimental in young girls around their puberty time because the body is then very vulnerable and easily affected by any cause of disease, be it from the weather or emotions. Hereditary Kidney weakness, overwork, too many children too
close together All the above causes may lead to a Kidney weakness; the Kidneys fail to nourish the Directing and Penetrating Vessels, the Kidney-Essence cannot be transformed into Blood, the Sea of Blood cannot fill the Uterus, hence the periods come late. Emotional stress Longstanding emotional stress may lead to Liver-Qi stagnation; when this stagnation lasts for a long time it may induce Blood stasis, the Directing and Penetrating Vessels become obstructed, hence the periods come late. The Jade Ruler of Gynaecology (1774) says: Pensiveness, worry, fear, and preoccupation injure Heart-Qi, Spleen-Qi loses nourishment, stagnation ensues, the digestion is impaired, the appetite lessened, hence Blood becomes deficient and dry, menstrual bleeding is scanty and the period comes late.1
Pathology The main pathological factors in Late Periods are: • Blood deficiency • Cold in the Uterus (which may be of the Full- or Empty-type) • Kidney-Yang deficiency • Qi stagnation. The pattern of Kidney-Yang deficiency occurs more frequently in older women; all the other patterns can appear at any age. As explained above, invasion of Cold and Dampness is probably the most common cause of Late Periods in young women or girls. As they grow and develop, this may become complicated by other causes of disease such as overwork or emotional stress.
Identification of patterns and treatment
Blood deficiency
Clinical manifestations Late and scanty periods, pale menstrual blood, dull-pale complexion, blurred vision, dizziness, palpitations, insomnia, tiredness. Tongue: Pale and Thin. Pulse: Choppy. Treatment principle Nourish Blood, regulate the periods. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-13 Qixue, LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-23 Shenshu, BL-17 Geshu. All with reinforcing method, moxa is applicable. Explanation
– LU-7 and KI-6 regulate the Directing Vessel (Ren Mai), regulate the periods and nourish Yin and Blood. – Ren-4 nourishes Blood and strengthens the Uterus. It is particularly effective with direct moxa cones. – KI-13, a point of the Penetrating Vessel, strengthens the Uterus and tonifies the Penetrating Vessel.
– LIV-8, ST-36 and SP-6 tonify Qi and Blood. – BL-20 and BL-23 nourish Blood. – BL-17 (with direct moxa cones) nourishes Blood. Herbal treatment
a Prescription
– REN SHEN YANG RONG TANG – Ginseng Nourishing and Flourishing Decoction Explanation
– Ren Shen, Bai Zhu and Huang Qi tonify Qi to nourish Blood. – Dang Gui, Bai Shao and Shu Di Huang nourish Blood. – Rou Gui warms the Fire of the Gate of Life. – Wu Wei Zi nourishes the Essence. – Yuan Zhi calms the Mind. – Fu Ling and Chen Pi resolve Dampness. – Zhi Gan Cao harmonizes. Modifications
• If there are signs of Yin deficiency, remove Rou Gui Cortex Cinnamomi and add E Jiao Colla Corii asini and Mai Men Dong Radix Ophiopogonis. b Prescription
– DA BU YUAN JIAN – Great Tonifying the Original [Qi] Decoction Explanation This prescription tonifies Qi and Yang and nourishes Blood, Essence and Yin. It is therefore suitable if the patient’s condition is very depleted. – Ren Shen and Shan Yao tonify Qi and the Original Qi. – Shu Di Huang and Dang Gui nourish Blood. – Du Zhong tonifies Kidney-Yang and strengthens the back. – Shan Zhu Yu and Gou Qi Zi nourish Yin and the Essence and strengthen Liver and Kidneys. Gou Qi Zi also nourishes Blood. – Zhi Gan Cao harmonizes. c Prescription
– YI YIN JIAN Variation
– One Yin Decoction Variation Explanation The first seven herbs constitute the formula Yi Yin Jian which nourishes both Yin and Blood. This prescription is therefore suitable if the Blood deficiency has begun to turn into Yin deficiency. Zhi Mu and Di Gu Pi clear Empty Heat and can be omitted if there is none. Table 9.1 compares and contrasts the above three formulae. Table 9.1 Differences among three formulae for Late Periods from Blood deficiency
Women’s Treasure remedy
– PRECIOUS SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. It has been modified with
the addition of Kidney tonics. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Blood deficiency
Clinical manifestations
Late and scanty periods, pale menstrual blood, dull, pale complexion, blurred vision, dizziness, palpitations, insomnia, tiredness. Tongue: Pale and Thin. Pulse: Choppy. Treatment principle
Nourish Blood, regulate the periods. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-13 Qixue, LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-23 Shenshu, BL-17 Geshu. All with reinforcing method, moxa is applicable. Herbal treatment
Pre scriptions
• REN SHEN YANG RONG TANGGinseng Nourishing and Flourishing Decoction
• DA BU YUAN JIANGreat Tonifying the Original [Qi] Decoction • YI YIN JIAN Variation One Yin Decoction Variation Women’s Treasure remedy
• PRECIOUS SEA
Case history A 22-year-old woman had been suffering from Late Periods ever since she stopped taking the contraceptive pill. Her periods came about every 3 months. She had started taking the contraceptive pill 3 years before but had to stop taking it as it caused tiredness, abdominal distension and fluid retention. Besides coming every 3 months, the period was also hesitant in starting, going through a stop–start phase before starting properly. When it did come, it was rather scanty and the blood was bright red. Besides, this, she was still suffering from abdominal distension which had persisted after she stopped taking the contraceptive pill. On questioning, it transpired that she also suffered from dizziness, occasional tinnitus, backache, frequent urination, hair falling out, constipation, blurred vision and brittle nails. Her complexion was dull-pale. Her tongue was slightly Pale and her pulse was Weak and Choppy. Diagnosis This is a clear case of deficiency of both Blood and Kidney-Yang. The Blood deficiency manifestations are: late and scanty period, dull-pale complexion, constipation, blurred vision, dizziness, hair falling out, brittle nails, Pale tongue and Choppy pulse. The manifestations of Kidney-Yang deficiency are: late period, backache, frequent urination, dizziness, tinnitus, Weak pulse. As can be seen, there is an overlap between Blood and Kidney-Yang deficiency so
that some manifestations (such as the late period, dizziness and Pale tongue) can be attributed to either deficiency. In addition, there was also some stagnation of Qi causing the abdominal distension and some stasis of Blood causing the period to start hesitantly: however, these are secondary conditions as there are no other manifestations indicating them. Treatment principle As the Root of the condition was a deficiency of both Blood and KidneyYang, I adopted the treatment principle of nourishing Blood and tonifying Kidney-Yang. A secondary aim of treatment was to move Qi and invigorate Blood. I treated her with both acupuncture and herbs. Acupuncture was particularly indicated to move Qi and Blood so that I could concentrate on tonifying Blood and Kidney-Yang with the herbs. Acupuncture
The acupuncture points used were selected from the following: • LU-7 Lieque on the right and KI-6 Zhaohai on the left to regulate the Directing Vessel and strengthen the Uterus. • Ren-4 Guanyuan with moxa cones, to nourish Blood, strengthen the Uterus and tonify the Kidneys. • ST-36 Zusanli and SP-6 Sanyinjiao to tonify Qi and Blood. • KI-3 Taixi, with warming needle, to tonify Kidney-Yang. • BL-20 Pishu and BL-23 Shenshu to tonify the Kidneys and nourish Blood.
It was not necessary to add specific points to move Qi and Blood as the above points would have that effect too. Herbal treatment
The prescription used was a variation of the formula Da Bu Yuan Jian Great Tonifying the Original [Qi] Decoction. • Ren ShenRadix Ginseng 3 g • Shan YaoRadix Dioscoreae 6 g • Shu Di HuangRadix Rehmanniae preparata 9 g • Du ZhongCortex Eucommiae 6 g • Dang GuiRadix Angelicae sinensis 6 g • Shan Zhu YuFructus Corni 3 g • Gou Qi ZiFructus Lycii 6 g • Zhi Gan CaoRadix Glycyrrhizae preparata 3 g • Rou Cong RongHerba Cistanches 4.5 g • Tu Si ZiSemen Cuscutae 6 g • Huang JingRhizoma Polygonati 6 g • Xiang FuRhizoma Cyperi 4.5 g • Yi Mu CaoHerba Leonuri 4.5 g
Explanation The first eight herbs constitute the original formula which nourishes Blood and tonifies Kidney-Yang. • Rou Cong Rong and Tu Si Zi were added to strengthen the Yang-tonifying effect. Rou Cong Rong also treats constipation. • Huang Jing tonifies Qi, Blood and Essence.
• Xiang Fu and Yi Mu Cao were added to move Qi and invigorate Blood.
After prescribing this formula for 1 month, I added Gui Ban Plastrum Testudinis and Lu Jiao Cornu Cervi to nourish the Directing Vessel and the Governing Vessel. After taking this prescription for a further 2 months, her period arrived after an interval of 11 weeks. She continued to take the same formula and her periods gradually came at shorter intervals, i.e. 9-, 7- and finally 5-week intervals.
Cold in the Uterus: Full-Cold
Clinical manifestations Late periods, scanty bleeding with dark blood and clots, painful periods, abdominal pain which is relieved by the application of heat and worsened by pressure, feeling cold, abdomen very tight on palpation. Tongue: Pale, thick, white coating. Pulse: Full and Tight.
Cold in the Uterus: Empty-Cold
Clinical manifestations Late periods, scanty bleeding with small, dark, stringy clots, painful periods, abdominal pain that is relieved by application of both heat and pressure, abdomen loose on palpation, tiredness, feeling cold. Tongue: Pale. Pulse: Deep, Weak, Slow. Treatment principle Full-Cold: warm the Uterus, scatter Cold, regulate the periods. Empty-Cold: tonify Yang, expel Cold, regulate the periods. Acupuncture With acupuncture, the same point can treat Full- or Empty-Cold, the main difference being only in the needle manipulation. Ren-4 Guanyuan, Ren-6 Qihai, ST-29 Guilai, SP-8 Diji, SP-6 Sanyinjiao, ST-36 Zusanli, Du-4 Mingmen, BL-32 Ciliao, ST-25 Tianshu. Reducing method in case of Full-Cold and reinforcing method in case of Empty-Cold. Moxa must be used. Explanation
– Ren-4, with moxa, warms the Uterus. – Ren-6, with moxa, moves Qi and expels Cold from the lower abdomen.
– ST-29, with moxa, can expel Cold from the Uterus. – SP-8 and SP-6 move Blood and stop pain. – ST-36 tonifies Qi and helps to scatter Cold. – Du-4 strongly tonifies the Fire of the Gate of Life and is more suitable for Empty-Cold. – BL-32 with direct moxa cones, expels Cold from the Uterus. – ST-25, with moxa cones, expels Cold and invigorates Blood. This action is due to two factors: first, as a point of the Bright Yang, it is rich in Qi and Blood and can therefore invigorate Blood; second, as the Bright Yang is in relation with the Penetrating Vessel, this point can stimulate this vessel’s Sea of Blood. Herbal treatment
Full-Cold
a Prescription
– WEN JING TANG – Warming the Menses Decoction Explanation
– Wu Zhu Yu, Gui Zhi and Sheng Jiang scatter Cold and warm the Uterus. – Dang Gui, Chuan Xiong, E Jiao and Bai Shao nourish and invigorate Blood. This is necessary because Cold obstructs the Uterus and the vessels and prevents the generation of new Blood. – Dang Shen tonifies Qi to nourish Blood. – Mai Men Dong nourishes Yin. This is necessary as Blood deficiency can lead to Yin deficiency. – Mu Dan Pi is added to clear any Empty-Heat deriving from Blood deficiency. – Ban Xia is added here not to resolve Phlegm, but to regulate the Qi of the Penetrating Vessel. In fact, this vessel, arising from the Uterus, is closely linked to the Stomach channel (through the point ST-30 Qichong) and is frequently subject to rebellious Qi: harmonizing Stomach-Qi with Ban Xia will help to subdue rebellious Qi in the Penetrating Vessel. – Zhi Gan Cao harmonizes. b Prescription
– EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai2 Explanation This formula is essentially a variation of Wen Jing Tang Warming the Menses Decoction from which tonics (such as E Jiao Colla Corii asini and Dang Shen Radix Codonopsis) and cold herbs (such as Mai Men Dong Radix Ophiopogonis and Mu Dan Pi Cortex Moutan) have been removed.
Compared with Wen Jing Tang, this formula is less tonifying and has a stronger Cold-expelling action: it is therefore suitable when the Cold symptoms are pronounced (with a very Pale tongue and a Slow-Tight pulse) and the periods, besides being late, are also painful. – Dang Gui and Bai Shao nourish Blood. – Fu Ling and Fu Shen drain Dampness. – Rou Gui, Ai Ye, Sheng Jiang and Wu Zhu Yu warm the Uterus and expel Cold. – Chuan Xiong invigorates Blood. – Ban Xia and Chen Pi harmonize the Centre and dry Dampness. – Zhi Gan Cao harmonizes. Modifications
• If there is abdominal pain with a feeling of masses, add Pu Huang Pollen Typhae and Wu Ling Zhi Faeces Trogopterori. Empty-Cold
a Prescription
– AI FU NUAN GONG WAN – Artemisia-Cyperus Warming the Uterus Pill
Explanation
– Ai Ye, Wu Zhu Yu and Rou Gui scatter Cold and warm the Uterus. Rou Gui tonifies the Fire of the Gate of Life. – Xiang Fu moves Qi and helps to expel Cold. – Dang Gui, Chuan Xiong and Bai Shao nourish Blood. This is necessary because Cold obstructs the Uterus and prevents the generation of new Blood. – Huang Qi tonifies Qi to nourish Blood. – Sheng Di Huang nourishes Yin to help to nourish Blood. – Xu Duan tonifies Kidney-Yang. b Prescription
– DA YING JIAN – Big Nutritive Qi Decoction Explanation
– Dang Gui, Shu Di Huang and Gou Qi Zi nourish Blood. It is necessary to do this for the same reasons as are given for the previous two formulae. – Zhi Gan Cao tonifies Qi to nourish Blood.
– Du Zhong tonifies Kidney-Yang. – Niu Xi nourishes the Liver and invigorates Blood. – Rou Gui expels Cold and tonifies the Fire of the Gate of Life. c Prescription
– YI PI WEN SHEN TANG – Benefiting the Spleen and Warming the Kidneys Decoction Explanation This prescription is suitable if the deficiency of Yang predominates over the Cold. – Ren Shen, Bai Zhu, Shan Yao and Gan Cao tonify Qi to nourish Blood. – Ba Ji Tian and Tu Si Zi tonify Kidney-Yang. – Dang Gui nourishes Blood. Of the above three formulae for Empty-Cold, Ai Fu Nuan Gong Wan is the strongest at expelling Cold. Da Ying Jian is better for nourishing Blood and warming and is therefore applicable when the deficiency predominates. The third, Yi Pi Wen Shen Tang, is better to tonify Spleen- and Kidney-Yang and is also suitable when the deficiency predominates over Cold. Table 9.2 illustrates differences among the three prescriptions for Empty-Cold. Table 9.2 Differences among three prescriptions for Late Periods from EmptyCold
Women’s Treasure remedy
– WARM THE MANSION This remedy is a variation of the formula Ai Fu Nuan Gong Wan Artemisia-Cyperus Warming the Uterus Pill which warms the Uterus and tonifies Kidney-Yang. The tongue presentation appropriate to this remedy is a Pale body. Summary Cold in the Uterus
Full-Cold
Clinical manife stations
Late periods, scanty bleeding with dark blood and clots, painful periods, abdominal pain which is relieved by the application of heat and worsened by pressure, feeling cold, abdomen very tight on palpation. Tongue: Pale, thick, white coating. Pulse: Full and Tight. Empty-Cold
Clinical manifestations
Late periods, scanty bleeding with small, dark, stringy clots, painful periods, abdominal pain that is relieved by application of both heat and pressure, abdomen loose on palpation, tiredness, feeling cold. Tongue: Pale. Pulse: Deep, Weak, Slow. Treatment principle
Full-Cold: warm the Uterus, scatter Cold, regulate the periods. Empty-Cold: tonify Yang, expel Cold, regulate the periods. Acupuncture
With acupuncture, the same point can treat Full- or Empty-Cold, the main difference being only in the needle manipulation. Ren-4 Guanyuan, Ren-6 Qihai, ST-29 Guilai, SP-8 Diji, SP-6 Sanyinjiao, ST-36 Zusanli, Du-4 Mingmen, BL-32 Ciliao, ST-25 Tianshu. Reducing method in case of Full-Cold and reinforcing method in case of Empty-Cold. Moxa must be used. Herbal treatment
Full-Cold
Prescriptions
• WEN JING TANGWarming the Menses Decoction • EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai Empty-Cold
Pre scriptions
• AI FU NUAN GONG WANArtemisia-Cyperus Warming the Uterus Pill • DA YING JIANBig Nutritive Qi Decoction • YI PI WEN SHEN TANGBenefiting the Spleen and Warming the Kidneys Decoction Women’s Treasure remedy
• WARM THE MANSION
Kidney-Yang deficiency
Clinical manifestations Late periods, scanty, pale blood, sore back, nocturia, dizziness, tinnitus, frequent, pale urination, feeling cold. Tongue: Pale. Pulse: Weak, Deep. Treatment principle Tonify Yang, strengthen the Kidneys, warm the Uterus. Acupuncture BL-23 Shenshu, Du-4 Mingmen, KI-3 Taixi, Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), ST-36 Zusanli, SP-6 Sanyinjiao. All with reinforcing method. Moxa can be used if there is a pronounced Kidney-Yang deficiency. Explanation
– BL-23 and Du-4 tonify and warm Kidney-Yang, especially if direct moxa cones are used. – Ren-4 and KI-3 tonify the Kidneys. If there is a pronounced Yang deficiency, one should use moxa on Ren-4. – LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and tonify the Kidneys. – ST-36 and SP-6, with warm needle (moxa on the needle), tonify Qi and
Yang in general. Herbal treatment
a Prescription
– JIN GUI SHEN QI WAN – Golden Chest Kidney-Qi Pill Explanation This well-known formula from the Discussion on Cold-induced Diseases tonifies and warms Kidney-Yang. – Fu Zi and Gui Zhi tonify Yang, expel Cold and strengthen the Fire of the Gate of Life. Some sources have Rou Gui Cortex Cinnamomi rather than Gui Zhi Ramulus Cinnamomi. – Shu Di Huang nourishes the Kidneys. – Shan Zhu Yu nourishes the Liver. – Shan Yao tonifies the Spleen. – Ze Xie balances Shu Di Huang to clear any Heat that might derive from it. – Mu Dan Pi similarly balances Shan Zhu Yu to clear any Heat from the Liver.
– Fu Ling balances Shan Yao to drain any Dampness that might derive from it. b Prescription
– CONG RONG TU SI ZI WAN – Cistanche-Cuscuta Pill Explanation This formula tonifies Kidney-Yang and nourishes Blood. – Rou Cong Rong, Tu Si Zi, Fu Pen Zi, and Yin Yang Huo tonify and warm Kidney-Yang. Tu Si Zi also nourishes the Kidney-Essence and Rou Cong Rong warms the Uterus. – Gou Qi Zi, Dang Gui, Shu Di Huang, Sang Ji Sheng and Zi He Che nourish Blood. Gou Qi Zi and Zi He Che also nourish the Essence. – Ai Ye warms the Uterus. c Prescription
– GU YIN JIAN – Consolidating the Yin Decoction Explanation
This formula tonifies Qi and Blood and mildly tonifies Kidney-Yang. – Ren Shen, Shan Yao and Zhi Gan Cao tonify Qi. Ren Shen also tonifies the Original Qi and Shan Yao also tonifies the Kidneys. – Shu Di Huang tonifies the Kidneys and nourishes Blood. – Shan Zhu Yu tonifies the Liver and Kidneys. – Yuan Zhi calms the Mind. – Wu Wei Zi nourishes the Kidneys and the Essence (as well as the Lungs) and calms the Mind. – Tu Si Zi tonifies Kidney-Yang and Kidney-Essence. Modifications
• If there is a pronounced deficiency of Kidney-Yang with internal Cold, add Fu Zi Radix Aconiti lateralis preparata, Rou Gui Cortex Cinnamomi and Bu Gu Zhi Fructus Psoraleae. To compare and contrast these three formulae, the first is the strongest at tonifying and warming Kidney-Yang and is the hottest: therefore it is the best to expel Cold. The second also tonifies Kidney-Yang but it does not expel Cold; in addition it nourishes Blood so it is more suitable for gynecological problems. The third tonifies both Qi and Blood, strengthens the Directing and Penetrating Vessels, tonifies the Kidneys and Liver and calms the Mind: it is specific for menstrual irregularities from Kidney-Yang deficiency (see Table 9.3). Table 9.3 Comparison of Jin Gui Shen Qi Wan, Cong Rong Tu Si Zi Wan and Gu Yin Jian, for Late Periods from Kidney-Yang deficiency
Three Treasures remedy
– STRENGTHEN THE ROOT This remedy tonifies Qi and Blood, strengthens Kidney-Yang, warms the Uterus, expels Cold and tonifies the Directing and Penetrating Vessels. The tongue presentation appropriate to this remedy is a Pale, Swollen and wet body. Women’s Treasure remedy
– UNICORN PEARL This remedy tonifies Kidney-Yang and the Kidney-Essence. The tongue presentation appropriate to this remedy is a Pale and wet body. Summary
Kidney-Yang deficiency
Clinical manifestations
Late periods, scanty, pale blood, sore back, nocturia, dizziness, tinnitus, frequent, pale urination, feeling cold. Tongue: Pale. Pulse: Weak, Deep. Treatment principle
Tonify Yang, strengthen the Kidneys, warm the Uterus. Acupuncture
BL-23 Shenshu, Du-4 Mingmen, KI-3 Taixi, Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), ST-36 Zusanli, SP-6 Sanyinjiao. All with reinforcing method. Moxa can be used if there is a pronounced Kidney-Yang deficiency. Herbal treatment
Pre scriptions
• JIN GUI SHEN QI WANGolden Chest Kidney-Qi Pill • CONG RONG TU SI ZI WANCistanche-Cuscuta Pill • GU YIN JIANConsolidating the Yin Decoction Three Treasures remedy
• STRENGTHEN THE ROOT
Women’s Treasure remedy
• UNICORN PEARL
Case history A 33-year-old woman sought treatment for possible secondary infertility: she had not had any tests or investigations but she had not been able to conceive after trying for 1 year (she already had two children aged 6 and 4). Her husband’s sperm had been checked and found to be normal. Her periods were consistently late with a cycle of about 6 weeks. The menstrual blood was rather pale and she suffered from slight pre-menstrual tension. Her bowels were usually loose and she complained of tiredness, backache, dizziness and occasionally tinnitus. Her tongue was Pale with a sticky, white coating and her pulse was Weak on the right Rear position. Diagnosis The underlying condition is clearly one of Kidney-Yang deficiency as evidenced by the Pale tongue, the Weak pulse on the right Kidney position, the infertility, the long cycle, the tiredness, backache, dizziness and tinnitus. In addition to this there was also some Spleen-Qi deficiency manifesting with loose stools, tiredness and a sticky coating on the tongue, the last symptom also pointing to some Dampness. Treatment principle She was treated with herbs and acupuncture. I prescribed a variation of the formula Gu Yin Jian Consolidating the Yin Decoction • Ren ShenRadix Ginseng 3 g
• Shu Di HuangRadix Rehmanniae preparata 9 g • Shan YaoRhizoma Dioscoreae 6 g • Shan Zhu YuFructus Corni 4.5 g • Yuan ZhiRadix Polygalae 3 g • Zhi Gan CaoRadix Glycyrrhizae preparata 3 g • Tu Si ZiSemen Cuscutae 6 g • Bai ZhuRhizoma Atractylodis macrocephalae 6 g • Du ZhongCortex Eucommiae 6 g • Xu DuanRadix Dipsaci 4 g • Zi Su YeFolium Perillae 4 g
Explanation The first seven herbs constitute the formula Gu Yin Jian (minus Wu Wei Zi) to tonify Qi and strengthen Kidney-Yang. • Bai Zhu was added to tonify Qi and resolve Dampness. • Du Zhong was added to tonify and warm Kidney-Yang. • Xu Duan was added to tonify Kidney-Yang and also to prevent miscarriage. When I treat women for infertility, I often add to my prescription herbs that prevent miscarriage so that, if the patient becomes pregnant while taking the prescription, some of its ingredients will help to maintain the pregnancy. • Zi Su Ye was added for the same reason as it is one of the herbs that ‘calm the fetus’, i.e. prevent miscarriages.
With acupuncture, I used points to tonify Qi and resolve Dampness such as: • Ren-12, Zhongwan and ST-36 Zusanli (with warm needle) to tonify Qi.
• SP-9 Yinlingquan and SP-6 Sanyinjiao to resolve Dampness.
I had been treating this woman for only 8 weeks when she became pregnant. This case is presented here as an example of Late Periods, although, given the very short duration, it is unlikely (but not impossible) that it was the treatment that helped her to conceive.
Liver-Qi stagnation
Clinical manifestations Late and scanty periods with clots, irritability, depression, abdominal and breast distension for a long time before the period comes. Tongue: normal coloured or slightly Red on the sides if the stagnation is pronounced. Pulse: Wiry. Treatment principle Pacify the Liver, move Qi, eliminate stagnation, invigorate Blood, regulate the periods. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), LIV-3 Taichong, LIV-14 Qimen, KI-14 Siman, T.B.-6 Zhigou, SP-6 Sanyinjiao, Ren-4 Guanyuan, Ren-6 Qihai, P-7 Daling. All with reducing or even method. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel, subdue rebellious Qi and invigorate Blood. – LIV-3, LIV-14 and T.B.-6 pacify the Liver, move Qi and eliminate stagnation. – KI-14, a point of the Penetrating Vessel, moves Qi and eliminates
stagnation in the Uterus and the Penetrating Vessel. – SP-6 invigorates Blood. – Ren-4 and Ren-6 can move Qi in the Lower Burner, eliminate stagnation and strengthen the Uterus. – P-7 calms the Mind and settles the Ethereal Soul. It is selected if there are pronounced emotional problems. Prescription from the Great Compendium of Acupuncture3
– G.B.-41 Zulinqi, SP-6 Sanyinjiao, Ren-3 Zhongji. Herbal treatment
a Prescription
– XIAO YAO SAN – Free and Easy Wanderer Powder Explanation This formula, already explained, pacifies the Liver, moves Qi, eliminates stagnation, nourishes Liver-Blood and tonifies the Spleen. It is particularly suitable if the stagnation of Liver-Qi is associated with or derives from LiverBlood deficiency: in such a case, the tongue is Pale and the pulse Fine or Choppy and only slightly Wiry on the left.
b Prescription
– CHAI HU SHU GAN TANG – Bupleurum Pacifying the Liver Decoction Explanation This formula, already explained, pacifies the Liver, moves Qi, eliminates stagnation and stops pain. It is therefore prescribed purely for stagnation of Qi (i.e. not associated with Liver-Blood deficiency as the previous one was). The tongue will be slightly Red on the sides (from long-term stagnation) and the pulse Wiry. This formula is particularly suitable if the woman experiences a long phase of distension and pain before the period arrives. c Prescription
– WU YAO TANG Variation – Linderia Decoction Variation Explanation This prescription pacifies the Liver, moves Qi, eliminates stagnation, stops pain and nourishes Liver-Blood. It is similar in action to the previous formula Chai Hu Shu Gan Tang but it differs from it in so far as it also nourishes Liver-Blood. It has also a somewhat stronger pain-reducing action. – Xiang Fu, Wu Yao, Mu Xiang, Sha Ren, Yan Hu Suo and Bing Lang pacify the Liver, move Qi, eliminate stagnation and stop pain.
– Gan Cao harmonizes and stops pain. – Dang Gui and Chuan Xiong nourish and invigorate Blood. d Prescription
– QI ZHI XIANG FU WAN – Seven Prepared Cyperus Pill Explanation This formula moves Qi and strongly invigorates Blood. It is therefore used when there are pronounced signs of Blood as well as Qi stasis, such as abdominal pain before the period arrives, dark clots, a Wiry pulse and a Purple tongue. The formula should be used with caution as it contains herbs that ‘break’ Blood such as E Zhu and San Leng: it may be advisable to reduce the dosage of these herbs to no more than 6 g each. – Xiang Fu, Wu Yao and Chai Hu move Qi, pacify the Liver and eliminate stagnation. – Dang Gui and Mu Dan Pi nourish and invigorate Blood. – E Zhu and San Leng ‘break’ Blood and eliminate stasis. – Ai Ye warms the Uterus. – Chuan Xiong, Yan Hu Suo and Hong Hua invigorate Blood and eliminate stasis. e Prescription
– DING JING TANG Variation – Settling the Menses Decoction Variation Explanation The original formula Ding Jing Tang is composed of the first eight herbs and comes from Fu Qing Zhu (1607–1684): its variation is proposed by Cong Chun Yu in Selection of Clinical Experiences in Chinese Gynaecology.4 This formula moves Qi, eliminates stagnation, pacifies the Liver, nourishes Blood and tonifies Kidney-Yang. It is essentially a variation of Xiao Yao San Free and Easy Wanderer Powder. Fu Qing Zhu recommends this formula both for Early and Late Periods. – Bai Shao and Dang Gui nourish Liver-Blood. – Tu Si Zi, Shu Di Huang and Yin Yang Huo tonify Kidney-Yang. Shu Di Huang – also nourishes Blood. – Chai Hu, and Xiang Fu move Qi, eliminate stagnation and pacify the Liver. – Shan Yao and Fu Ling tonify the Spleen and resolve Dampness. – Jing Jie stops bleeding. Although this should make it unsuitable for Late Periods, it can be used for them when combined with the other herbs. Modifications
• If there is Empty-Heat, add Di Gu Pi Cortex Lycii. • If the periods are heavy, remove Dang Gui and replace it with E Jiao Colla Corii asini. Table 9.4 compares and contrasts the above five formulae. Table 9.4 Comparison of formulae Xiao Yao San, Chai Hu Shu Gan Tang, Wu Yao Tang, Qi Zhi Xiang Fu Wan and Ding Jing Tang for Late Periods from Qi stagnation
Women’s Treasure remedy
– FREEING THE MOON This remedy is a variation of Xiao Yao San: it moves Qi, pacifies the Liver, eliminates stagnation, nourishes Liver-Blood and tonifies the Spleen. Compared with Xiao Yao San, it has a stronger Blood-nourishing action and a more pronounced Mind-calming action. Summary Liver-Qi stagnation
Clinical manifestations
Late and scanty periods with clots, irritability, depression, abdominal and breast distension for a long time before the period comes. Tongue: normal coloured or slightly Red on the sides if the stagnation is pronounced. Pulse: Wiry. Treatment principle
Pacify the Liver, move Qi, eliminate stagnation, invigorate Blood, regulate the periods. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), LIV-3 Taichong, LIV-14 Qimen, KI-14 Siman, T.B.-6 Zhigou, SP-6 Sanyinjiao, Ren-4 Guanyuan, Ren-6 Qihai, P-7 Daling. All with reducing or even method. Herbal treatment
Pre scriptions
• XIAO YAO SANFree and Easy Wanderer Powder • CHAI HU SHU GAN TANGBupleurum Pacifying the Liver Decoction • WU YAO TANG Variation Linderia Decoction Variation • QI ZHI XIANG FU WANSeven Prepared Cyperus Pill • DING JING TANG Variation Settling the Menses Decoction Variation Women’s Treasure remedy
• FREEING THE MOON
Prognosis and prevention Acupuncture and/or herbal therapy are effective in treating the problem of Late Periods. Perhaps the herbal treatment is slightly more effective, particularly for the Empty patterns. The most difficult pattern to treat is that of Kidney deficiency which will therefore take the longest. An important consideration when treating Late Periods is the contraceptive pill: if a woman stops taking the contraceptive pill after using it for years, it is very common for the periods to become late. From this point of view, it therefore seems to induce a deficiency of Blood and a Kidney deficiency. When the periods are reluctant to come on time after years of contraceptive pill use, the treatment is more difficult and will take much longer: the patient should be encouraged to persevere as it may take several months or even a year to bring the periods back to a normal cycle. A patient suffering from Blood or a Kidney deficiency should make sure that she has an adequately nourishing diet and takes adequate rest. Those suffering from Cold in the Uterus should absolutely avoid cold-energy foods and ice-cold drinks. They should also drink a decoction of fresh ginger and brown sugar every day. End notes 1. Shen Jin Ao 1774 Jade Ruler of Gynaecology (Fu Ke Yu Chi), cited in Luo Yuan Kai 1986 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Shanghai Science and Technology Press, Shanghai, p. 43..
2.
Long Jiajun, Zhang Qi, Shen Kang, Lin Hongyang 1996 Dr Zhang Jian Zhai’s Experience in Treating Gynaecological Diseases (Zhang Jian Zhai Zhi Liao Fu Ke Bing Jing Yan), Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi
), China Academy of Traditional Chinese Medicine, Beijing, No. 1, p. 16..
3. Heilongjiang Province National Medical Research Group 1984 An Explanation of the Great Compendium of Acupuncture (Zhen Jiu Da Cheng Jiao Shi
), People’s Health Publishing House, Beijing, p. 1107. The Great Compendium of Acupuncture itself was published in 1601..
4. Cong Chun Yu 1989 Selection of Clinical Experiences in Chinese Gynaecology (Zhong Yi Fu Ke Lin Chuang Jing Yan Xuan
), Chinese Medicine and Pharmacology Publishing House, Beijing, p. 82..
CHAPTER 10 Irregular Periods
AETIOLOGY 225 PATHOLOGY 226 IDENTIFICATION OF PATTERNS AND TREATMENT 226 Liver-Qi stagnation 226 Kidney-Yang deficiency 227 Kidney-Yin deficiency 228 Ancient acupuncture prescriptions for Irregular Periods 230 PROGNOSIS AND PREVENTION 230 The term ‘Irregular Periods’ refers to periods that come with an irregular cycle, sometimes early, sometimes late. It is important to note that if the periods come consistently early or consistently late, they fall under the categories of Early Periods or Late Periods respectively: thus, it is only when they are sometimes late and sometimes early in an unpredictable manner that they constitute Irregular Periods. An irregularity of the cycle in the time preceding the menopause is normal; similarly for some months after the menarche. When questioning a woman patient, it is important to make sure that her particular problem does indeed fall into this category; many women refer to their periods as being ‘irregular’ when they are in fact consistently early or consistently late. Irregular Periods are called Yue Jing Xian Hou Wu Ding Qi which
means ‘an irregular cycle with periods that come early or late’. In the old literature the condition was also called Jing Luan which means ‘chaotic periods’. An irregularity of the cycle is always related to the Liver and Kidneys (and especially the latter) because it is the rhythmic ebb and flow of Blood and Essence that give rise to the periods. Thus, these two organs are responsible for the internal, biological clock that determines the menstrual cycle. In fact, Fu Qing Zhu says in Fu Qing Zhu’s Gynaecology: The menstrual flow originates from the Kidneys, the Liver is the Child of the Kidneys, when the Liver stagnates the Kidneys also stagnate. When the Kidneys stagnate their Qi does not diffuse, early periods, late periods, stoppage or continuation of the periods all relate to Kidney-Qi being free or obstructed . . . Whether Liver-Qi is free or obstructed affects whether Kidney-Qi goes or stays.1 This statement clearly stresses that the regularity of the menstrual cycle depends first and foremost on Liver and Kidneys: this is because the Liver stores Blood and the Kidneys are the origin of the Heavenly Gui. An interesting aspect of the above statement is Fu Qing Zhu’s reference to Kidney-Qi stagnation, a condition that is not usually mentioned as one of the patterns of disharmony but that does, nonetheless, exist.
Aetiology
Emotional stress Emotional stress such as anger, frustration or resentment may cause Liver-Qi to become stagnant and the Directing and Penetrating Vessels (Ren and Chong Mai) to become obstructed. When Qi stagnates for some time, Blood also stagnates so that the Sea of Blood (of the Penetrating Vessel) cannot fill the Uterus and the periods become irregular. The Complete Works of Jing Yue (1624) attributes great importance to emotional problems as a cause of irregular periods. It says: Unfulfilled longing and deep pensiveness cause the Qi of Heart and Spleen to stagnate, this injures the source of the Directing and Penetrating vessels, and Kidney-Qi declines: in mild cases the periods become irregular, in severe cases they may stop altogether.2
Overwork, too many children too close together Overwork or having too many children too close together lead to a Kidney deficiency: when the Kidneys are deficient, the Directing and Penetrating Vessels become depleted, the Sea of Blood of the Penetrating Vessel cannot fill the Uterus and the periods become irregular.
Pathology The pathology of Irregular Periods may be due to: • Liver-Qi stagnation • Kidney deficiency (Yang or Yin). The Liver and Kidneys are therefore the two organs at the root of this problem. This is understandable because it is these two organs that are most responsible for the cyclical recurrence of the periods. In fact, the Liver stores Blood and is closely related to the Penetrating Vessel and the Kidneys are the origin of the Heavenly Gui that crystallizes into menstrual blood. Irregular Periods from Kidney deficiency tend to occur in older women.
Identification of patterns and treatment
Liver-Qi stagnation
Clinical manifestations Irregular periods usually with scanty bleeding with some clots, abdominal and breast distension, pre-menstrual tension, depression, sighing, irritability. Tongue: normal coloured or, if the stagnation is longstanding, slightly Red sides. Pulse: Wiry. Treatment principle Pacify the Liver, move Qi, eliminate stagnation, regulate the periods. Acupuncture LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, LIV-14 Qimen, Ren-4 Guanyuan, Ren-6 Qihai, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left). All with reducing or even method. Explanation
– LIV-3, T.B.-6, and LIV-14 pacify the Liver, move Qi and eliminate stagnation. – P-6, related to the Liver channel through the Terminal Yin, moves LiverQi, calms the Mind and settles the Ethereal Soul. – Ren-4 and Ren-6 move Qi in the Lower Burner and strengthen the Uterus.
– SP-4 and P-6 regulate the Penetrating Vessel and subdue rebellious Qi. They are selected if there are clear symptoms of rebellious Qi of this vessel such as a feeling of distension of the abdomen that seems to transmit upwards to the chest, a feeling of oppression or tightness of the chest with sighing and a vague feeling of anxiety. Prescription from the Great Compendium of Acupuncture (1601)3
– Ren-6 Qihai, Ren-3 Zhongji, G.B.-26 Daimai, BL-23 Shenshu and SP6 Sanyinjiao. Herbal treatment
a Prescription
– XIAO YAO SAN – Free and Easy Wanderer Powder Explanation This formula, which has already been explained, pacifies the Liver, moves Qi, eliminates stagnation, nourishes Liver-Blood and tonifies Spleen-Qi. Modifications
• If there is abdominal pain, add Xiang Fu Rhizoma Cyperi and Yan Hu
Suo Rhizoma Corydalis. • If stagnant Liver-Qi turns into Fire, add Mu Dan Pi Cortex Moutan and Shan Zhi Zi Fructus Gardeniae. b Prescription
– DING JING TANG – Settling the Menses Decoction Explanation This formula, by Fu Qing Zhu, pacifies the Liver and tonifies the Kidneys. Since an underlying deficiency of the Kidneys nearly always accompanies Liver-Qi stagnation when the periods are irregular, this formula is well adapted to treat the type of patients we see. About irregular periods, Fu Qing Zhu says: When the child is ill the mother attends to it. When the Liver stagnates the Kidneys have compassion; opening or blockage of Liver-Qi implies going or staying of Kidney-Qi . . . One must pacify the Liver and open the stagnation of Kidney-Qi.4 – Tu Si Zi, Shu Di Huang and Shan Yao tonify the Kidneys. – Bai Shao and Dang Gui nourish Liver-Blood and pacify the Liver. – Fu Ling resolves Dampness. – Jing Jie stops bleeding.
– Chai Hu pacifies the Liver, moves Qi and eliminates stagnation. Women’s Treasure remedy
– FREEING THE MOON This remedy is a variation of Xiao Yao San Free and Easy Wanderer Powder, with more emphasis placed on nourishing Blood and calming the Mind. The tongue presentation appropriate to this remedy is a Pale body or a normal-coloured body with Pale sides. Summary Liver-Qi stagnation
Clinical manifestations
Irregular periods usually with scanty bleeding with some clots, abdominal and breast distension, pre-menstrual tension, depression, sighing, irritability. Tongue: normal coloured or, if the stagnation is longstanding, slightly Red sides. Pulse: Wiry. Treatment principle
Pacify the Liver, move Qi, eliminate stagnation, regulate the periods. Acupuncture
LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, LIV-14 Qimen, Ren-4 Guanyuan, Ren-6 Qihai, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left). All with reducing or even method.
Herbal treatment
Pre scriptions
• XIAO YAO SAN Free and Easy Wanderer Powder • DING JING TANG Settling the Menses Decoction Women’s Treasure remedy
• FREEING THE MOON
Kidney-Yang deficiency
Clinical manifestations Irregular periods that are scanty with pale menstrual blood, no clots, backache, dizziness, tinnitus, feeling cold, frequent, pale urination. Tongue: Pale and Swollen. Pulse: Weak, Deep. Treatment principle Tonify and warm the Kidneys, regulate the periods, consolidate the Penetrating and Directing Vessels. Acupuncture BL-23 Shenshu, Ren-4 Guanyuan, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), ST-36 Zusanli, SP-6 Sanyinjiao. All with reinforcing method, moxa must be used. Explanation
– BL-23, Ren-4 (with moxa cones) and KI-3 tonify the Kidneys. – LU-7 and KI-6 regulate the Directing Vessel, regulate the periods, strengthen the Uterus and tonify the Kidneys. – ST-36 and SP-6 tonify Qi and Blood in general. They are a very effective tonic treatment of Spleen and Kidneys especially when needled with warm needle.
Herbal treatment
a Prescription
– GU YIN JIAN – Consolidating the Yin Decoction Explanation This formula, already explained, tonifies Qi and Blood and strengthens Kidney-Yang. It is specific to regulate the period cycle. Modifications
• If the symptoms and signs of Yang deficiency are pronounced, add Rou Gui Cortex Cinnamomi and Bu Gu Zhi Fructus Psoraleae. b Prescription
– YI SHEN FU YANG TANG – Benefiting the Kidneys and Supporting the Yang Decoction Explanation
– Ren Shen tonifies Qi and strengthens the Original Qi. – Shu Di Huang, Shan Zhu Yu and Shan Yao tonify the Kidneys, Liver and Spleen. – Tu Si Zi and Bu Gu Zhi tonify Kidney-Yang. – Yuan Zhi calms the Mind. – Wu Wei Zi nourishes the Essence. – Zhi Gan Cao harmonizes. – Fu Zi and Rou Gui strongly tonify the Fire of the Gate of Life and expel Cold. This formula differs from the previous one in that it is much hotter in nature and strongly tonifies the Fire of the Gate of Life. It is therefore suitable only if the manifestations of Yang deficiency and internal Cold are pronounced. Three Treasures remedy
– STRENGTHEN THE ROOT This remedy is a variation of You Gui Wan Restoring the Right [Kidney] Pill which tonifies Kidney-Yang. Its Yang-tonifying effect lies between that of Jin Gui Shen Qi Wan and Wu Ji Bai Feng Wan mentioned above. It also nourishes Blood. The tongue presentation appropriate to this remedy is a Pale body. Women’s Treasure remedy
– Unicorn Pearl Summary Kidney-Yang deficiency
Clinical manifestations
Irregular periods that are scanty with pale menstrual blood, no clots, backache, dizziness, tinnitus, feeling cold, frequent, pale urination. Tongue: Pale and Swollen. Pulse: Weak, Deep. Treatment principle
Tonify and warm the Kidneys, regulate the periods, consolidate the Penetrating and Directing vessels. Acupuncture
BL-23 Shenshu, Ren-4 Guanyuan, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), ST-36 Zusanli, SP-6 Sanyinjiao. All with reinforcing method, moxa must be used. Herbal treatment
Pre scriptions
• GU YIN JIAN Consolidating the Yin Decoction • YI SHEN FU YANG TANG Benefiting the Kidneys and Supporting the Yang Decoction
Three Treasures remedy
• STRENGTHEN THE ROOT Women’s Treasure remedy
• UNICORN PEARL
This remedy tonifies Kidney-Yang and the Kidney-Essence. The tongue presentation appropriate to this remedy is a Pale and wet body. Kidney-Yin deficiency
Clinical manifestations
Irregular and scanty periods, dizziness, burred vision, night sweating, feeling of heat in the evening. Tongue: without coating; Red, if there is Empty-Heat. Pulse: Floating-Empty or Fine and Rapid. Treatment principle
Nourish Yin, tonify the Kidneys, consolidate the Directing and Penetrating Vessels. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-3 Taixi, SP-6 Sanyinjiao, Ren-7 Jinjiao. All with reinforcing method, no
moxa. Explanation
– LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and nourish the Kidneys. – Ren-4, SP-6 and KI-3 nourish the Kidneys. – Ren-7 nourishes the Yin and strengthens the Uterus. Herbal treatment
a Prescription
– LIU WEI DI HUANG WAN – Six-Ingredient Rehmannia Pill Explanation
This formula, already explained, nourishes Liver- and Kidney-Yin. b Prescription
– ZUO GUI WAN – Restoring the Left [Kidney] Pill Explanation
This prescription nourishes Liver- and Kidney-Yin and Blood. For gynecological problems I prefer it to the formula Liu Wei Di Huang Wan because it has a broader action: in fact it nourishes Blood with Gou Qi Zi and it specifically strengthens the Directing and Penetrating Vessels with Gui Ban Jiao. It also has the additional action of strengthening the back and knees (with Niu Xi and Lu Jiao). – Shu Di Huang, Shan Zhu Yu and Shan Yao nourish Liver and Kidneys. – Gou Qi Zi nourishes Yin and Blood. – Chuan Niu Xi nourishes the Kidneys and benefits the sinews and lower back. – Tu Si Zi and Lu Jiao tonify Kidney-Yang. Although the main thrust of the formula is to nourish Kidney-Yin, tonification of Kidney-Yang is necessary because, especially in women over 40, both Kidney-Yin and Kidney-Yang are often deficient. – Gui Ban Jiao nourishes Kidney-Yin, subdues Yang and strengthens the Directing and Penetrating Vessels. Modifications
• If there are pronounced symptoms and signs of Empty-Heat, add Zhi Mu Rhizoma Anemarrhenae and Di Gu Pi Cortex Lycii. Three Treasures remedy
– NOURISH THE ROOT This remedy, a variation of Zuo Gui Wan, nourishes Liver- and Kidney-
Yin and Blood and strengthens the Directing and Penetrating Vessels. Women’s Treasure remedy
– GROWING JADE Summary Kidney-Yin Deficiency
Clinical manife stations
Irregular and scanty periods, dizziness, blurred vision, night sweating, feeling of heat in the evening. Tongue: without coating; Red, if there is Empty-Heat. Pulse: Floating-Empty or Fine and Rapid. Tre atme nt principle
Nourish Yin, tonify the Kidneys, consolidate the Directing and Penetrating Vessels. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-3 Taixi, SP-6 Sanyinjiao, Ren-7 Jinjiao. All with reinforcing method, no moxa. He rbal tre atme nt
Prescriptions
• LIU WEI DI HUANG WAN Six-Ingredient Rehmannia Pill • ZUO GUI WAN Restoring the Left [Kidney] Pill
Three Treasures re me dy
• NOURISH THE ROOT Women’s Treasurere me dy
• GROWING JADE
This remedy nourishes Kidney-Yin and the Kidney-Essence. The appropriate tongue presentation is a Red body without coating. Ancient acupuncture prescriptions for Irregular Periods 5
1. Ren-6 Qihai, Ren-3 Zhongji, G.B.-26 Daimai (1 moxa cone), BL-23 Shenshu, SP-6 Sanyinjiao (Great Compendium of Acupuncture and Moxibustion, Zhen Jiu Da Cheng
, 1601). 2. Ren-6 Qihai, Ren-3 Zhongji and KI-6 Zhaohai for irregular periods from stasis of Blood (Illustrated Supplement to the Classic of Categories, Lei Jing Tu Yi
, 1624). 3. Ren-3 Zhongji, Ren-6 Qihai and BL-33 Zhongliao (Bian Que’s Jade Dragon Classic of Miraculously-Effective Acupuncture, Bian Que Shen Ying Zhen Yu Long Jing
, 1329). 4. Ren-4 Guanyuan for irregular period with a feeling of cold during the period (Great Compendium of Acupuncture, Zhen Jiu Da Cheng
, 1601). 5. L.I.-11 Quchi, T.B.-6 Zhigou, ST-36 Zusanli and SP-6 Sanyinjiao (Great Compendium of Acupuncture, Zhen Jiu Da Cheng
, 1601). 6. KI-8 Jiaoxin, SP-10 Xuehai and G.B.-26 Daimai (Experience of Acupuncture and Moxibustion Therapy, Zhen Jiu Zi Sheng Jing
, 1220). 7. Ren-4 Guanyuan, P-5 Jianshi, KI-6 Zhaohai, ST-25 Tianshu, Ren-5 Shimen (7 to 100 moxa cones) for irregular periods with Blood masses (Collection of Acupuncture and Moxibustion, Zhen Jiu Ji Cheng
, 1874).
Prognosis and prevention Irregular periods can be quite difficult to treat and the treatment may take a long time. The pattern of Kidney-Yin deficiency is the most difficult, that of Liver-Qi stagnation the least. Again, if the periods have become irregular because the patient has been using the contraceptive pill, it may take longer to treat. Although various patterns may cause the periods to become irregular, I always treat the Liver and Kidneys when there is an irregularity in the cycle. Thus, I would add one or two Kidney tonics to the formulae for Liver-Qi stagnation. The formulae for Kidney-Yang and Kidney-Yin deficiency do not need any modifications in this sense because they already contain Liver and Kidney tonics. Women suffering from irregular periods from Liver-Qi stagnation should pay attention to their emotional life and try to identify what factor in their life is causing Liver-Qi to stagnate. Apart from trying to help the patient to find out and deal with her emotional issues, it is often necessary to emphasize the emotional aspect of the treatment by using points such as P-7 Daling to settle the Ethereal Soul or BL-23 Shenshu, BL-52 Zhishi and BL-47 Hunmen to strengthen the Will Power and regulate the ‘coming and going’ of the Ethereal Soul: these points will help the patient when she feels disoriented, aimless and depressed. Those suffering from a Kidney deficiency, usually older women, should pay attention to having enough rest and should not overwork. End notes 1. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p. 17. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
2. Zhang Jing Yue 1624 The Complete Works of Jing Yue (Jing Yue Quan Shu) cited in Luo Yuan Kai 1986 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Shanghai Science and Technology Press, Shanghai, p. 45..
3. Heilongjiang Province National Medical Research Group, 1984, An Explanation of the Great Compendium of Acupuncture (Zhen Jiu Da Cheng Jiao Shi
), People’s Health Publishing House, Beijing, p. 1107. The Great Compendium of Acupuncture itself was published in 1601..
4. Fu Qing Zhu’s Gynaecology, p. 17..
5. Wang Xue Tai 1995 Great Treatise of Chinese Acupuncture (Zhong Guo Zhen Jiu Da Quan),
Henan Science and Technology Publishing House, p. 499..
CHAPTER 11 Heavy Periods
AETIOLOGY 231 PATHOLOGY 232 IDENTIFICATION OF PATTERNS AND TREATMENT 232 Qi deficiency 232 Blood-Heat 233 Blood stasis 235 PROGNOSIS AND PREVENTION 237 ‘Heavy Periods’ means periods that occur regularly and last the customary 5 days or thereabouts but are heavier than normal. As mentioned in Chapter 2 on physiology, the average blood loss during a menstrual cycle is 30–80 ml. Since the range of blood loss is quite broad, the definition of a ‘heavy’ period can be rather subjective and difficult to gauge. Generally speaking, a period may be called ‘heavy’ if it starts with a gush of blood, catching the woman unaware and necessitating an urgent resort to a tampon or sanitary towel (pad), or if the woman has to make very frequent changes of these protective devices. As a category of disease-symptom in Chinese medicine, Heavy Periods (called Yue Jing Guo Duo) should be differentiated from Flooding and Trickling (Beng Lou). The former consists of heavy bleeding which occurs at the proper time and within the proper span of the periods (approximately 5 days); the latter consists of very heavy bleeding that may both start before
the proper time and continue after it, and may also trickle on for a long time after the period should have ended. The distinction between these two conditions is not too important in terms of pathology and treatment, which are essentially the same, but it matters from a prognostic perspective: in fact, Flooding and Trickling is more difficult to treat than Heavy Periods. Table 11.1 illustrates the main differences between Heavy Periods and Flooding and Trickling; see also Fig. S-4.1 (p. 198). Table 11.1 Differentiation between heavy periods and flooding and trickling
Aetiology
Excessive physical work Excessive physical work, including exercise or sports, may injure the Spleen, so that deficient Spleen-Qi fails to hold Blood, the Directing and Penetrating Vessels are weakened and the period becomes heavy. Emotional stress, irregular diet, external heat Emotional stress leads to Qi stagnation and, if this continues for a long time, stagnant Qi may turn into Fire. Excessive consumption of hot, spicy foods and alcohol may also lead to Heat or Fire, which may derive from external Heat as well. Whatever the cause, if Heat enters the Blood portion and agitates the Blood so that it spills out of the blood vessels, this gives rise to heavy periods. Emotional stress, surgery, post-partum conditions Qi stagnation from emotional stress as described above may turn into Blood stasis rather than Fire. Abdominal surgery and post-partum conditions also frequently lead to Blood stasis. Whatever the cause, when Blood stagnates, the Directing and Penetrating Vessels become obstructed, new Blood cannot enter the channels (because they are blocked by stagnant Blood), bleeding occurs and heavy periods may develop.
Pathology The pathology of Heavy Periods consists of: • Qi deficiency • Blood-Heat • Blood stasis. In the first pattern, Blood leaks out because deficient Spleen-Qi fails to hold it in the vessels. In the second, it spills over because Heat agitates it and forces it out of the vessels. In the third, it leaks out because the vessels are obstructed by stagnant Blood and newly generated Blood has no place to go to. The pattern of Qi deficiency is therefore primarily related to the Spleen, but the Kidneys also play their part because Kidney-Qi also holds Blood in the vessels (especially the blood vessels of the Uterus). The patterns of Blood-Heat and Blood stasis are mostly related to the Liver.
Identification of patterns and treatment All the herbal prescriptions in this section are detailed in Appendix 1 on p. 937.
Qi deficiency
Clinical manifestations Heavy period, pale and dilute blood, pale complexion, tiredness. Spleen-Qi deficiency: loose stools, slight abdominal distension. Kidney-Qi deficiency: frequent urination, backache, dizziness. Tongue: Pale. Pulse: Weak. Treatment principle Tonify and raise Qi of Spleen and/or Kidneys, contain Blood, consolidate the Directing and Penetrating Vessels. Acupuncture Du-20 Baihui, Ren-12 Zhongwan, Ren-6 Qihai, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-23 Shenshu. All with reinforcing method; moxa should be used. Explanation
– Du-20 raises Qi. This point can be stimulated with a moxa stick. – Ren-12, ST-36, SP-6 and BL-20 tonify Spleen-Qi. – Ren-6 tonifies and raises Qi. It is very effective with direct moxa cones. – Ren-4 tonifies the Kidneys and consolidates Directing and Penetrating Vessels.
– BL-23 is used if there is also a Kidney deficiency. Herbal treatment
a Prescription
– JU YUAN JIAN – Raising the Original [Qi] Decoction Explanation This prescription, already explained, tonifies and raises Spleen-Qi: this will stop the bleeding from deficiency. b Prescription
– BU ZHONG YI QI TANG – Tonifying the Centre and Benefiting Qi Decoction Explanation This formula, already explained, tonifies and raises Spleen-Qi to stop bleeding. Very similar to the previous one, it is perhaps more suitable to stop bleeding because it contains Dang Gui to enter the Blood portion. c Prescription
– GUI PI TANG – Tonifying the Spleen Decoction Explanation This formula, already explained, tonifies Spleen-Qi and calms the Mind. It is suitable to stop bleeding because it also contains Dang Gui, which enters the Blood portion, and is particularly appropriate if the patient suffers from anxiety and depression. Modifications These modifications apply to all three previous formulae. – If the period is very heavy, add E Jiao Colla Corii asini, Wu Zei Gu Endoconcha Sepiae and Pao Jiang Rhizoma Zingiberis preparatum (fried). – If the period is long, add Pu Huang Pollen Typhae and Yi Mu Cao Herba Leonuri. – If there are symptoms of Kidney-Yang deficiency, add Xu Duan Radix Dipsaci and Ai Ye Folium Artemisiae argyi. d Prescription
– JIA JIAN SI WU TANG – Modified Four Substances Decoction
Explanation This formula, by Fu Qing Zhu, is for chronic conditions of heavy bleeding from Qi deficiency resulting in Blood deficiency as well. Although it may seem strange that heavy bleeding occurs when Blood is deficient, Fu Qing Zhu explains this by saying that, no matter how deficient Blood is, if it does not return to the vessels properly, menstruation will be heavy.1 – Shu Di Huang, Bai Shao, Dang Gui and Chuan Xiong nourish Blood. – Bai Zhu tonifies Qi which helps to nourish Blood. – Jing Jie stops bleeding. – Shan Zhu Yu and Xu Duan tonify the Liver and Kidneys, consolidate the Directing and Penetrating Vessels and stop bleeding. – Gan Cao harmonizes. Women’s Treasure remedy
– RESTRAIN THE FLOW This remedy is specific to stop uterine bleeding from Qi deficiency. The tongue presentation appropriate to this remedy is a Pale body. Three Treasures remedy
– TONIFY QI AND EASE THE MUSCLES This remedy is a variation of Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction: it tonifies and raises Spleen-Qi and
can stop bleeding. It also resolves Dampness and is therefore suitable if there are pronounced symptoms of this, which is a very common occurrence. The tongue presentation appropriate to this remedy is a Pale and Swollen body with a sticky coating. Summary Qi deficiency
Clinical manifestations
Heavy period, pale and dilute blood, pale complexion, tiredness. Spleen-Qi deficiency: loose stools, slight abdominal distension. Kidney-Qi deficiency: frequent urination, backache, dizziness. Tongue: Pale. Pulse: Weak. Treatment principle
Tonify and raise Qi of Spleen and/or Kidneys, contain Blood, consolidate the Directing and Penetrating Vessels. Acupuncture
Du-20 Baihui, Ren-12 Zhongwan, Ren-6 Qihai, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-23 Shenshu. All with reinforcing method; moxa should be used. Herbal treatment
Pre scriptions
• JU YUAN JIAN Raising the Original [Qi] Decoction
• BU ZHONG YI QI TANG Tonifying the Centre and Benefiting Qi Decoction • GUI PI TANG Tonifying the Spleen Decoction • JIA JIAN SI WU TANG Modified Four Substances Decoction Women’s Treasure remedy
• RESTRAIN THE FLOW Three Treasures remedy
• TONIFY QI AND EASE THE MUSCLES
Blood-Heat
Clinical manifestations Heavy period, bright red or dark red, dense blood, mental restlessness, anxiety, a feeling of heat, thirst, dark urine, headaches. Tongue: Red, redder sides. Pulse: Rapid, Overflowing. This pattern affects mostly the Liver and Heart. Treatment principle Clear Heat, cool Blood, stop bleeding. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, LIV-3 Taichong, SP-6 Sanyinjiao, BL-17 Geshu, SP-8 Diji. All with reducing method, no moxa. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel. This vessel is the Sea of Blood and is therefore closely involved in menstrual bleeding from BloodHeat. – L.I.-11, SP-10, SP-6 and BL-17 cool Blood. – KI-2 and LIV-3 in combination cool Blood. – SP-8, Accumulation point, stops uterine bleeding.
Herbal treatment
a Prescription
– BAO YIN JIAN Variation – Protecting Yin Decoction Variation Explanation The first eight herbs constitute the formula Bao Yin Jian which nourishes Yin and clears Heat. – Sheng Di Huang, Bai Shao and Shu Di Huang nourish Yin and Blood and cool Blood. – Shan Yao tonifies the Spleen and Kidneys. – Huang Qin and Huang Bo clear Heat. – Xu Duan tonifies the Kidneys. – Gan Cao harmonizes. – Di Yu and Huai Hua were added to cool Blood and stop bleeding. Modifications
• If the period is heavy and long, add Wu Zei Gu Endoconcha Sepiae, Qian Cao Gen Radix Rubiae, and Xian He Cao Herba Agrimoniae.
• If there is both Qi and Yin deficiency induced by the longstanding blood loss, use Liang Di Tang Two ‘Di’ Decoction and Sheng Mai San Generating the Pulse Powder in combination. b Prescription
– AN CHONG TANG – Calming the Penetrating Vessel Decoction Explanation This formula is used if longstanding bleeding has given rise to Yin and Qi deficiency with symptoms of Qi deficiency such as tiredness, palpitations and shortness of breath. – Bai Zhu and Huang Qi tonify and raise Qi. – Long Gu and Mu Li firm Qi, stop bleeding and nourish Yin. – Sheng Di Huang and Bai Shao nourish Yin and cool Blood. – Wu Zei Gu is astringent and stops bleeding. – Qian Cao Gen cools and invigorates Blood and stops bleeding. – Xu Duan tonifies the Kidneys and stops bleeding. c Prescription
– JIE DU SI WU TANG Variation
– Expelling Toxin Four Substances Decoction Variation Explanation This formula is used if external Heat penetrates the Interior and generates Toxic-Heat and Blood-Heat which lead to bleeding. The first eight herbs constitute the formula Jie Du Si Wu Tang. – Huang Lian, Huang Qin, Huang Bo and Shan Zhi Zi clear Heat and Dampness, and resolve Toxic-Heat. – Sheng Di Huang nourishes Yin, cools Blood and stops bleeding. – Dang Gui and Bai Shao nourish Blood and ‘calm’ Blood to stop bleeding. – Chuan Xiong, part of Si Wu Tang, invigorates Blood. – Bai Jiang Cao resolves Fire-poison and invigorates Blood. – Mu Dan Pi cools Blood and stops bleeding. Women’s Treasure remedy
– COOL THE MENSES This remedy is specific to reduce uterine bleeding occurring from Blood-Heat. The tongue presentation appropriate to this remedy is a Red body with a yellow coating. Summary Blood-Heat
Clinical manifestations
Heavy period, bright red or dark red, dense blood, mental restlessness, anxiety, a feeling of heat, thirst, dark urine, headaches. Tongue: Red, redder sides. Pulse: Rapid, Overflowing. Treatment principle
Clear Heat, cool Blood, stop bleeding. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, LIV-3 Taichong, SP-6 Sanyinjiao, BL-17 Geshu, SP-8 Diji. All with reducing method, no moxa. Herbal treatment
Pre scriptions
• BAO YIN JIAN Variation Protecting Yin Decoction Variation • AN CHONG TANG Calming the Penetrating Vessel Decoction • JIE DU SI WU TANG Variation Expelling Toxin Four Substances Decoction Variation Women’s Treasure remedy
• COOL THE MENSES
Blood stasis
Clinical manifestations Heavy period with dark, clotted blood, painful period, abdominal pain which is worse with pressure and better after passing menstrual clots. Tongue: Purple. Pulse: Wiry. Treatment principle Invigorate Blood, eliminate stasis, stop bleeding, regulate the periods. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, BL-17 Geshu, SP-8 Diji, SP-6 Sanyinjiao, Ren-6 Qihai, KI-14 Siman, ST29 Guilai, LIV-3 Taichong. All with reducing or even method. If the stasis of Blood derives from Cold, moxa can be used. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel and invigorate Blood as this vessel is the Sea of Blood. – BL-17 and SP-10 invigorate Blood. – SP-8 stops bleeding. – SP-6 invigorates Blood.
– Ren-6 moves Qi in the Lower Burner. – KI-14, a point of the Penetrating Vessel, eliminates stagnation in the Lower Burner and Uterus. – ST-29 invigorates Blood in the Uterus. – LIV-3 moves Liver-Qi and invigorates Liver-Blood. Herbal treatment
Prescription
– SI WU TANG and SHI XIAO SAN Variation – Four Substances Decoction and Breaking into a Smile Powder Variation Explanation The first four herbs constitute the formula Si Wu Tang which invigorates Blood. The herbs Pu Huang and Wu Ling Zhi make up the formula Shi Xiao San which invigorates Blood, stops bleeding and stops pain. – San Qi invigorates Blood and stops bleeding. – E Jiao stops bleeding and nourishes Blood. Women’s Treasure remedy
– INVIGORATE BLOOD AND STEM THE FLOW This remedy is specific to reduce uterine bleeding from Blood stasis. The tongue presentation appropriate to this remedy is a Purple body. Three Treasures remedy
– STIR FIELD OF ELIXIR This remedy invigorates Blood in the Lower Burner and stops bleeding. The tongue presentation appropriate to this remedy is a Purple body. Summary Blood Stasis
Clinical manifestations
Heavy period with dark, clotted blood, painful period, abdominal pain which is worse with pressure and better after passing menstrual clots. Tongue: Purple. Pulse: Wiry. Treatment principle
Invigorate Blood, eliminate stasis, stop bleeding, regulate the periods. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, BL-17 Geshu, SP-8 Diji, SP-6 Sanyinjiao, Ren-6 Qihai, KI-14 Siman, ST29 Guilai, LIV-3 Taichong. All with reducing or even method. If the stasis of Blood derives from Cold, moxa can be used.
Herbal treatment
Pre scription
• SI WU TANG and SHI XIAO SAN Variation Four Substances Decoction and Breaking into a Smile Powder Variation Women’s Treasure remedy
• INVIGORATE BLOOD AND STEM THE FLOW Three Treasures remedy
• STIR FIELD OF ELIXIR
Case history A 22-year-old woman had been suffering from very heavy periods ever since the menarche. Her cycle was up to 6 weeks long, her period lasted 6 days with heavy bleeding and was painful, and the menstrual blood was rather dark with clots. Her main reason for seeking treatment, however, was persistent acne for the previous 2 years. The acne manifested only on the face with red papules or pustules: some of the papules became purple and took a long time to go: the skin eruptions were worse before the period. She had been given a contraceptive pill to help the acne but this had actually made it worse. On questioning, it transpired that she also suffered from backache, slight dizziness, slight tinnitus and night sweating during the periods. She was also constipated. Her tongue was slightly Red and had a sticky coating. Her pulse was slightly Wiry and very Weak on the left Rear position.
Diagnosis The main cause of the heavy periods is stasis of Blood: the painful period and the dark menstrual blood with clots clearly indicate this. Stasis of Blood also accounts for the long cycle. It was obviously not severe since her tongue was not Purple. Besides this, she also suffered from Damp-Heat which was the cause of the acne: the Damp-Heat was also obvious from the tongue which was Red and had a sticky coating. The condition of Damp-Heat, however, was linked with her menstrual cycle and Blood because the acne clearly got worse before the period. Blood affects the state and lustre of the skin and, for this reason, a woman’s skin problems often become worse before the period if there is a stagnation of Qi or Blood; this deterioration is especially marked with acne. She also had a Kidney-Yin deficiency evidenced by the backache, slight dizziness, slight tinnitus, night sweating and very Weak pulse on the left Kidney position. If she suffered from a Kidney-Yin deficiency, why was her tongue not Red and peeled? The answer was her age: when young people suffer the beginning of Yin deficiency, the tongue often does not show it; very often, it shows other exuberant conditions which are due to the patient’s youth: in this case, her tongue showed only Damp-Heat. Thus, her condition was characterized by two Full conditions (stasis of Blood and Damp-Heat) and an Empty one (Kidney-Yin deficiency). Treatment principle I decided to tackle the Full conditions first, i.e. stasis of Blood and DampHeat, by adopting the treatment principle of harmonizing and invigorating Blood, eliminating stasis, regulating the periods and resolving Damp-Heat. Eliminating Blood stasis and resolving Damp-Heat in this case can be achieved by regulating the periods: thus, one herbal formula can help both the heavy periods and the acne. Only after the stasis of Blood and Damp-Heat had been eliminated, would I start to nourish Kidney-Yin. Acupuncture
With acupuncture, I concentrated on regulating the periods by using the Directing Vessel, resolving Damp-Heat and invigorating Blood. The points used over several treatments were chosen from the following: • LU-7 Lieque (on the right) and KI-6 (on the left) to regulate the Directing Vessel and the periods. • Ren-6 Qihai to move Qi in the Lower Burner in order to invigorate Blood. • KI-14 Siman, a point of the Penetrating Vessel, to invigorate Blood in the Uterus. • SP-6 Sanyinjiao to invigorate Blood and resolve Dampness. • SP-9 Yinlingquan and L.I.-11 to resolve Damp-Heat. • L.I.-4 Hegu to affect the face. Herbal treatment
I used a variation of Qin Jiao Si Wu Tang Gentiana macrophylla Four Substances Decoction: although this formula is a variation of Si Wu Tang for joint pain, it suited this patient because it regulates the period, invigorates Blood and resolves Damp-Heat. In fact, Qin Jiao expels Wind and Dampness and Yi Yi Ren resolves Damp-Heat and softens spots; in addition, Qin Jiao will also promote bowel movement. Can Sha was eliminated from the prescription. • Dang Gui Radix Angelicae sinensis 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Chi Shao Radix Paeoniae rubra 4 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Qin Jiao Radix Gentianae macrophyllae 6 g
• Yi Yi Ren Semen Coicis 6 g • Huang Qin Radix Scutellariae 4 g • Ze Xie Rhizoma Alismatis 4 g • Bai Xian Pi Cortex Dictamni 4 g • Gan Cao Radix Glycyrrhizae 3 g
Explanation The formula Qin Jiao Si Wu Tang was modified by substituting Chi Shao for Bai Shao in order to invigorate Blood. • Huang Qin and Bai Xian Pi were added to resolve Damp-Heat. • Ze Xie was added to drain Dampness and also clear the slight Empty-Heat deriving from Yin deficiency (night sweating).
After 3 months of treatment along these lines, this patient reported a good improvement in the periods: they were no longer painful and the menstrual blood was red without clots. The acne improved much more slowly and was still a problem, which did not surprise me since this particular skin condition is quite stubborn to treatment. The patient is still receiving treatment at the time of writing.
Prognosis and prevention Heavy Periods are amenable to treatment with acupuncture and/or Chinese herbs but the treatment may take several months to show results. The most difficult pattern to treat is that from Blood-Heat, the easiest that from Qi deficiency. A woman suffering from heavy periods because of Qi deficiency should have adequate rest, especially lying down, because with heavy menstrual bleeding from Qi deficiency there is always an element of Qi sinking, which would be aggravated by prolonged standing. Those suffering from BloodHeat should not have too many hot, spicy foods or alcohol, while those who suffer from Blood stasis should have adequate, moderate exercise to reduce the stagnation in the Lower Burner. End note 1. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, pp 23–24. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
CHAPTER 12 Scanty Periods
AETIOLOGY 239 PATHOLOGY 240 IDENTIFICATION OF PATTERNS AND TREATMENT 240 Blood deficiency 240 Kidney-Yang deficiency 241 Kidney-Yin deficiency 243 Stasis of Blood 244 Phlegm obstructing the Uterus 245 PROGNOSIS AND PREVENTION 246 The periods are defined as ‘Scanty Periods’ when the bleeding is very light (so as to necessitate few changes of sanitary towels/pads or tampons), or when the bleeding lasts only 2–3 days or is extremely scanty, like a small drip. It is important to ask women about the amount of bleeding in detail as most of them do not see scanty bleeding as a ‘problem’. Thus, if we ask only a general question, such as ‘Is the amount of bleeding normal?’, a woman might reply ‘Yes’ although her periods in fact last only 2 days. Because few women see scanty periods as a matter of concern, it is seldom the main presenting problem and is usually treated only when it accompanies other conditions. For example, a woman might complain of tiredness as her main problem; were this due to Blood deficiency, her periods might be scanty and therefore need treatment.
Aetiology
Chronic illness, haemorrhage, irregular diet A protracted, chronic illness easily leads to Blood deficiency. So does a serious haemorrhage, such as that might occur during labour and a slow, continuous bleeding in menorrhagia. A diet lacking in nourishment and Bloodforming foods also leads to Blood deficiency: this can happen when young girls embrace vegetarianism without paying attention to food combinations that properly replace the proteic value of meat. Whatever the cause, Blood deficiency is an obvious cause of scanty periods as the Sea of Blood becomes Empty, the Directing and Penetrating Vessels depleted and the period scanty. Please note that, since menstrual blood is Tian Gui which derives from the Kidneys, a ‘deficiency of Blood’ in gynecology is treated by tonifying both the Liver and the Kidneys. Overwork, hereditary weakness, too many children too close together Overwork in the sense of working long hours under stress without adequate rest may lead to Kidney-Yin deficiency. Having too many children is also often a cause of Kidney deficiency. When Kidney-Yin is deficient, Water is depleted, Kidney-Essence cannot be transformed into Heavenly Gui and the periods are or become scanty. Traumas, abdominal surgery, emotional stress, cold Traumas and abdominal surgery can easily lead to stasis of Blood in the Uterus, especially after repeated operations that result in the formation of adhesions. Emotional stress that affects the Liver causes Liver-Qi stagnation
and, after some time, this can result in Liver-Blood stasis. Internal Cold obstructs the circulation of Blood and may lead to Blood stasis in the Uterus. This is a common cause of scanty periods in young women or in school girls who have been playing sports in shorts and T-shirts on cold and damp days. Whatever the cause, when Blood stagnates in the Uterus, the period may become scanty. Irregular diet, physical overwork Excessive consumption of dairy foods and greasy, fried foods leads to the formation of Dampness and weakens the Spleen. This organ is also weakened by excessive exercise, physical work or sports. Phlegm obstructs the Uterus and the Directing and Penetrating Vessels and this results in scanty periods. Women suffering from this pattern are often overweight. Contraceptive pill A very common effect of the contraceptive pill is scanty periods. If a woman stops the contraceptive pill after taking it for some years, very often the periods are very scanty or completely absent. In my opinion, this is usually due to Blood deficiency.
Pathology The main pathological factors causing Scanty Periods are: • Blood deficiency (of the Liver) • Kidney deficiency (Yin or Yang deficiency) • stasis of Blood • Phlegm. Blood deficiency is more common in young women or girls and it is often a result of prolonged use of the contraceptive pill. A Kidney deficiency (especially of Kidney-Yin) can occur either in older women as a result of overwork or in young women as a consequence of a hereditary weakness. Phlegm as a cause of Scanty Periods is often seen in women suffering from polycystic ovary syndrome: these women tend to obesity. Some of the old Chinese gynecology books made a clear and interesting distinction between thin and overweight women, saying that scanty periods in thin women are due to Blood deficiency and in overweight women are due to Phlegm and Dampness.1 The Standards of Diagnosis and Treatment (1602) makes an interesting distinction between periods that are scanty and those that are ‘dry’ (the actual word literally means ‘puckering’ or ‘astringent’). ‘Scanty’ means that the amount of blood is scanty but the blood itself is normal, i.e. neither too dilute nor too thick. ‘Dry’ means that the menstrual blood is not only scanty but also rather thick and somewhat powdery, often described by women as a brownish discharge. Scanty bleeding calls for tonification and dry bleeding not only for tonification but also moistening.2
Identification of patterns and treatment
Blood deficiency
Clinical manifestations Scanty period with pale, dilute blood, may be only a drip, dizziness, blurred vision, tingling of limbs, insomnia, palpitations, poor memory, dull, pale complexion. Tongue: Pale and Thin. If, in addition to Blood deficiency, there is Qi deficiency and Dampness (a very common occurrence), the tongue might be Swollen. Pulse: Choppy or Fine. Treatment principle Nourish Blood, strengthen the Liver, tonify the Kidneys, fill the Directing and Penetrating Vessels (Ren and Chong Mai), regulate the periods. Acupuncture LU-7 Lieque on the right with KI-6 Zhaohai on the left (Ren Mai), Ren-4 Guanyuan, LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-23 Shenshu, BL-18 Ganshu. All with reinforcing method; moxa can be used. Explanation
– LU-7 and KI-6 regulate the Directing Vessel. – Ren-4 nourishes Blood and strengthens the Uterus; it is particularly effective with direct moxa cones.
– LIV-8, ST-36 and SP-6 nourish Blood and strengthen the Liver. They are particularly effective with warm needle on ST-36 and SP-6. – BL-20 and BL-23 nourish Blood. – BL-18, in conjunction with the previous two points, nourishes LiverBlood. Herbal treatment
a Prescription
– REN SHEN ZI XUE TANG – Ginseng Growing Blood Decoction Explanation
– Ren Shen, Shan Yao and Fu Ling tonify Qi in order to nourish Blood. – Shu Di Huang, Dang Gui and Bai Shao nourish Blood. – Chuan Xiong invigorates Blood. b Prescription
– BA ZHEN TANG – Eight Precious Decoction
Explanation This formula, which has already been explained, tonifies Qi and nourishes Blood. Modifications
• If there are some Empty-Heat signs from Blood deficiency such as slight hot flushes, add Sheng Di Huang Radix Rehmanniae and Mu Dan Pi Cortex Moutan. • If the patient has insomnia and palpitations, add Ye Jiao Teng Caulis Polygoni multiflori and Wu Wei Zi Fructus Schisandrae. • If there is Blood deficiency with Liver-Qi stagnation, add Chai Hu Radix Bupleuri, Chuan Lian Zi Fructus Toosendan and Xiang Fu Rhizoma Cyperi. Alternatively, use the formula Xiao Yao San Free and Easy Wanderer Powder. • If there is Essence deficiency, add Gou Qi Zi Fructus Lycii and Shan Zhu Yu Fructus Corni. • If there is Spleen-Qi deficiency with Dampness, add Sha Ren Fructus Amomi, Chen Pi Pericarpium Citri reticulatae and Bai Zhu Rhizoma Atractylodis macrocephalae. • If the menstrual blood is somewhat dry and powdery, like a brownish discharge, add Shou Wu Radix Polygoni multiflori preparata, Hei Zhi Ma Semen Sesami nigrum and Bei Sha Shen Radix Glehniae. Women’s Treasure remedy
– PRECIOUS SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Blood deficiency
Clinical manifestations
Scanty period with pale, dilute blood, may be only a drip, dizziness, blurred vision, tingling of limbs, insomnia, palpitations, poor memory, dull, pale complexion. Tongue: Pale and Thin. If, in addition to Blood deficiency, there is Qi deficiency and Dampness (a very common occurrence), the tongue might be Swollen. Pulse: Choppy or Fine. Treatment principle
Nourish Blood, strengthen the Liver, tonify the Kidneys, fill the Directing and Penetrating Vessels (Ren and Chong Mai), regulate the periods. Acupuncture
LU-7 Lieque on the right with KI-6 Zhaohai on the left (Ren Mai), Ren-4 Guanyuan, LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-23 Shenshu, BL-18 Ganshu. All with reinforcing method; moxa can be used. Herbal treatment
Pre scriptions
• REN SHEN ZI XUE TANGGinseng Growing Blood Decoction • BA ZHEN TANGEight Precious Decoction Women’s Treasure remedy
• PRECIOUS SEA
Kidney-Yang deficiency
Clinical manifestations Scanty period with pale blood, backache, knee ache, dizziness, tinnitus, frequent, pale urination. Tongue: Pale and Swollen. Pulse: Deep, Weak. Treatment principle Tonify Yang, strengthen the Kidneys, nourish Blood, regulate the periods. It is necessary to nourish Blood because, when Kidney-Yang deficiency causes scanty periods, there is always an element of Blood deficiency too. Acupuncture LU-7 Lieque on the right with KI-6 Zhaohai on the right, BL-23 Shenshu, Ren-4 Guanyuan, KI-13 Qixue, LIV-8 Ququan, KI-3 Taixi, SP-6 Sanyinjiao, ST-36 Zusanli, Du-4 Mingmen All with reinforcing method; moxa must be used. Explanation
– LU-7 and KI-6 regulate the Directing Vessel (Ren Mai). – BL-23 tonifies Kidney-Yang. – Ren-4, with direct moxa cones, tonifies Kidney-Yang and strengthens the Uterus. – KI-13, a point of the Penetrating Vessel, tonifies the Kidneys and
strengthens this vessel and the Sea of Blood. – LIV-8 nourishes Liver-Blood. – KI-3, SP-6 and ST-36 tonify the Kidneys. Warm needle can be used on KI-3. – Du-4, with direct moxa cones, would be used only if the deficiency of Yang is very pronounced and there are symptoms of internal Cold. Herbal treatment
a Prescription
– DANG GUI DI HUANG YIN – Angelica sinensis-Rehmannia Decoction Explanation This formula nourishes Blood and tonifies Kidney-Yang. – Dang Gui nourishes Blood and strengthens the Uterus. – Shu Di Huang, Shan Zhu Yu and Shan Yao, a nucleus of many formulae to strengthen the Kidneys, tonify the Kidneys. – Du Zhong tonifies and warms Kidney-Yang. – Huai Niu Xi nourishes the Kidneys and strengthens the back and knees.
– Gan Cao harmonizes. b Prescription
– GUI SHEN WAN – Restoring the Kidneys Pill Explanation This formula also nourishes Blood and tonifies Kidney-Yang. Its KidneyYang tonifying power is slightly stronger than the previous formula. It is therefore suitable when the symptoms of Yang deficiency and Cold are rather pronounced. – Tu Si Zi and Du Zhong tonify Kidney-Yang. – Gou Qi Zi and Dang Gui nourish Blood. – Shu Di Huang, Shan Zhu Yu and Shan Yao tonify the Kidneys. Shu Di Huang also tonifies Blood. – Fu Ling resolves Dampness and is added to counteract the cloying action of tonic herbs. Modifications
• If there is Essence deficiency, add (or increase) Tu Si Zi Semen Cuscutae and add Ba Ji Tian Radix Morindae officinalis. • If the symptoms of both Blood and Essence deficiency are pronounced,
add Gou Qi Zi Fructus Lycii, Gui Ban Jiao Colla Plastri testudinis and Zi He Che Placenta hominis. Women’s Treasure remedy
– EASE THE JOURNEY-YANG This remedy tonifies Kidney-Yang and nourishes Blood. As a secondary aim, it is designed to nourish Kidney-Yin also. The tongue presentation appropriate to this remedy is a Pale and Thin body. Women’s Treasure remedy
– FREE-FLOWING SEA This remedy nourishes Blood, tonifies Kidney-Yang and moves LiverQi. The tongue presentation appropriate to this remedy is a Pale body. Summary Kidney-Yang deficiency
Clinical manifestations
Scanty period with pale blood, backache, knee ache, dizziness, tinnitus, frequent, pale urination. Tongue: Pale and Swollen. Pulse: Deep, Weak. Treatment principle
Tonify Yang, strengthen the Kidneys, nourish Blood, regulate the periods. It
is necessary to nourish Blood because, when Kidney-Yang deficiency causes scanty periods, there is always an element of Blood deficiency too. Acupuncture
LU-7 Lieque on the right with KI-6 Zhaohai on the right, BL-23 Shenshu, Ren-4 Guanyuan, KI-13 Qixue, LIV-8 Ququan, KI-3 Taixi, SP-6 Sanyinjiao, ST-36 Zusanli, Du-4 Mingmen. All with reinforcing method; moxa must be used. Herbal treatment
Pre scriptions
• DANG GUI DI HUANG YINAngelica sinensis-Rehmannia Decoction • GUI SHEN WANRestoring the Kidneys Pill Women’s Treasure remedies
• EASE THE JOURNEY-YANG • FREE-FLOWING SEA
Kidney-Yin deficiency
Clinical manifestations Scanty periods, dizziness, tinnitus, a dry throat, night sweating. Tongue: without coating (also Red if there is Empty-Heat). Pulse: Floating-Empty or Fine-Rapid. Treatment principle Nourish Kidney-Yin, nourish Blood and Essence, regulate the periods. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, SP-6 Sanyinjiao, Ren-4 Guanyuan, ST-36 Zusanli. All with reinforcing method. Moxa can be used as a warm needle on SP-6 and KI-3 unless there are pronounced signs of Empty-Heat and the tongue is very Red. Explanation
– LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and nourish Yin. – KI-3, SP-6 and ST-36 nourish Yin and strengthen the Kidneys. – Ren-4 nourishes the Kidneys and strengthens the Uterus. Herbal treatment
Prescription
– ZUO GUI WAN – Restoring the Left [Kidney] Pill Explanation This prescription nourishes Kidney-Yin and Blood and strengthens the Directing, Penetrating and Governing Vessels: for this reason, it is suitable to treat Scanty Periods. It is quite balanced to treat primarily Kidney-Yin but also Kidney-Yang. – Shu Di Huang, Shan Zhu Yu and Shan Yao tonify the Kidneys. Shu Di Huang also nourishes Blood. – Gou Qi Zi tonifies the Liver and Kidneys and nourishes Yin, Essence and Blood. – Chuan Niu Xi nourishes the Kidneys and strengthens the lower back. – Tu Si Zi tonifies Kidney-Yang. – Lu Jiao tonifies Kidney-Yang and strengthens the Governing Vessel. – Gui Ban Jiao nourishes Kidney-Yin and strengthens the Directing and Penetrating Vessels. Women’s Treasure remedy
– GROWING JADE This remedy nourishes Kidney-Yin and Blood. The tongue presentation appropriate to this remedy is a Red body without coating. Three Treasures remedy
– NOURISH THE ROOT This remedy is a variation of Zuo Gui Wan Restoring the Left [Kidney] Pill: it nourishes Kidney-Yin and the Essence and Blood and strengthens the Directing, Penetrating and Governing Vessels. The tongue presentation appropriate to this remedy is a Red tongue without coating. Summary Kidney-Yin deficiency
Clinical manifestations
Scanty periods, dizziness, tinnitus, a dry throat, night sweating. Tongue: without coating (also Red if there is Empty-Heat). Pulse: Floating-Empty or Fine-Rapid. Treatment principle
Nourish Kidney-Yin, nourish Blood and Essence, regulate the periods. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, SP-6 Sanyinjiao, Ren-4 Guanyuan, ST-36 Zusanli. All with reinforcing method.
Moxa can be used as a warm needle on SP-6 and KI-3 unless there are pronounced signs of Empty-Heat and the tongue is very Red. Herbal treatment
Pre scription
• ZUO GUI WANRestoring the Left [Kidney] Pill Women’s Treasure remedy
• GROWING JADE Three Treasures remedy
• NOURISH THE ROOT
Stasis of Blood
Clinical manifestations Scanty period with dark blood and clots, painful periods, abdominal pain which is better after passing clots. Tongue: Purple. Pulse: Wiry. Treatment principle Invigorate Blood, eliminate stasis, regulate the periods. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, BL-17 Geshu, SP-6 Sanyinjiao, KI-14 Siman, Ren-6 Qihai, Ren-4 Guanyuan, ST-29 Guilai. All with reducing or even method: moxa can be used if the tongue is Bluish-Purple. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel and invigorate Blood as this vessel is the Sea of Blood. – SP-10, BL-17 and SP-6 invigorate Blood. – KI-14, a point of the Penetrating Vessel, invigorates Blood and moves Qi in the lower abdomen. – Ren-6 moves Qi in the lower abdomen.
– Ren-4 invigorates Blood and strengthens the Uterus. – ST-29 invigorates Blood in the lower abdomen. Herbal treatment
a Prescription
– TAO HONG SI WU TANG – Persica-Carthamus Four Substances Decoction Explanation This formula invigorates Blood. – Shu Di Huang, Dang Gui, Bai Shao and Chuan Xiong invigorate Blood and eliminate stasis. – Tao Ren and Hong Hua invigorate Blood and eliminate stasis. Modifications
• If there are pronounced signs of Qi stagnation, especially a feeling of distension, add Xiang Fu Rhizoma Cyperi and Wu Yao Radix Linderae. b Prescription
– GE XIA ZHU YU TANG – Eliminating Stasis below the Diaphragm Decoction Explanation This formula invigorates Blood and eliminates stasis in the abdomen. It is stronger in effect than the previous one. It also stops pain. – Dang Gui, Chi Shao, Chuan Xiong, Tao Ren and Hong Hua are a modified version of the previous formula Tao Hong Si Wu Tang, with Chi Shao in place of Bai Shao (to invigorate Blood) and the removal of Shu Di Huang. – Wu Ling Zhi, Yan Hu Suo and Mu Dan Pi invigorate Blood, eliminate stasis and stop pain. – Xiang Fu, Zhi Ke and Wu Yao move Qi in order to invigorate Blood. – Gan Cao harmonizes. Modifications
• If there are Cold signs and the abdominal pain is relieved by the application of heat, add Gui Zhi Ramulus Cinnamomi and Wu Zhu Yu Fructus Evodiae. c Prescription
– SHAO FU ZHU YU TANG Variation
– Lower Abdomen Eliminating Stasis Decoction Variation Explanation This formula is used if the stasis of Blood derives from internal Cold and the tongue is Bluish-Purple. Pu Huang has been removed because besides invigorating Blood it also stops bleeding. – Xiao Hui Xiang, Gan Jiang and Rou Gui warm the Yang and expel internal Cold. In particular, Xiao Hui Xiang affects the lateral sides of the lower abdomen. – Yan Hu Suo, Mo Yao, Wu Ling Zhi, Dang Gui, Chuan Xiong and Chi Shao Yao all invigorate Blood and eliminate stasis. Table 12.1 compares and contrasts the above three prescriptions. Table 12.1 Comparison of Tao Hong Si Wu Tang, Ge Xia Zhu Yu Tang and Shao Fu Zhu Yu Tang
Women’s Treasure remedy
– STIR FIELD OF ELIXIR This remedy is a variation of Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction and it invigorates Blood, eliminates stasis and stops pain. The tongue presentation appropriate to this remedy is a Reddish-Purple body. Summary Stasis of Blood
Clinical manifestations
Scanty period with dark blood and clots, painful periods, abdominal pain which is better after passing clots. Tongue: Purple. Pulse: Wiry. Treatment principle
Invigorate Blood, eliminate stasis, regulate the periods. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, BL-17 Geshu, SP-6 Sanyinjiao, KI-14 Siman, Ren-6 Qihai, Ren-4 Guanyuan, ST-29 Guilai. All with reducing or even method: moxa can be used if the tongue is Bluish-Purple. Herbal treatment
Pre scriptions
• TAO HONG SI WU TANGPersica-Carthamus Four Substances Decoction • GE XIA ZHU YU TANGEliminating Stasis below the Diaphragm Decoction • SHAO FU ZHU YU TANG Variation Lower Abdomen Eliminating Stasis Decoction Variation Women’s Treasure remedy
• STIR FIELD OF ELIXIR
Phlegm obstructing the Uterus
Clinical manifestations Scanty period with a brownish discharge, obesity, a feeling of oppression of the chest, excessive vaginal discharge, period stops and starts, tiredness, a feeling of heaviness. Tongue: Swollen. Pulse: Slippery. Treatment principle Resolve Phlegm, dry Dampness, tonify the Spleen, regulate the periods. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-6 Qihai, ST28 Shuidao, Ren-9 Shuifen, BL-22 Sanjiaoshu, BL-32 Ciliao, SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, Ren-4 Guanyuan. All with reducing or even method except for the last three points which should be reinforced. If there are Cold signs, moxa can be used. Explanation
– LU-7 and KI-6 regulate the Directing Vessel and strengthen the Uterus. – Ren-6 moves Qi in the lower abdomen: moving Qi helps to resolve Dampness and Phlegm. – ST-28, Ren-9 and BL-22 promote the transformation and excretion of fluids by the Triple Burner.
– BL-32 also promotes the transformation of fluids and affects the Uterus. – SP-9 and SP-6 resolve Dampness. – Ren-12 and BL-20 tonify the Spleen. – Ren-4 strengthens the Uterus. Herbal treatment
Prescription
– CANG FU DAO TAN WAN – Atractylodes-Cyperus Conducting Phlegm Pill Explanation
– Fu Ling, Chen Pi and Dan Nan Xing resolve Phlegm and Dampness. – Xiang Fu and Zhi Ke move Qi: this helps to resolve Dampness and Phlegm. – Shen Qu resolves Food accumulation, which helps to resolve Phlegm. – Gan Cao and Sheng Jiang harmonize. Modifications
• If there are pronounced symptoms of Spleen deficiency, add Bai Zhu Rhizoma Atractylodis macrocephalae. • If there are symptoms of Damp-Heat, add Huang Bo Cortex Phellodendri and Yi Yi Ren Semen Coicis. • If there are symptoms of Kidney-Yang deficiency, add Tu Si Zi Semen Cuscutae and Du Zhong Cortex Eucommiae. • If there are ovarian cysts, add Huang Bo Cortex Phellodendri, Lu Lu Tong Fructus Liquidambaris and Yi Yi Ren Semen Coicis. • If the symptoms of Phlegm are pronounced, add Ban Xia Rhizoma Pinelliae preparatum and Gua Lou Fructus Trichosanthis. Summary Phlegm obstructing the Uterus
Clinical manife stations
Scanty period with a brownish discharge, obesity, a feeling of oppression of the chest, excessive vaginal discharge, period stops and starts, tiredness, a feeling of heaviness. Tongue: Swollen. Pulse: Slippery. Tre atme nt principle
Resolve Phlegm, dry Dampness, tonify the Spleen, regulate the periods. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-6 Qihai, ST28 Shuidao, Ren-9 Shuifen, BL-22 Sanjiaoshu, BL-32 Ciliao, SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, Ren-4 Guanyuan. All with reducing or even method except for the last three points
which should be reinforced. If there are Cold signs, moxa can be used. He rbal tre atme nt
Prescription
• CANG FU DAO TAN WANAtractylodes-Cyperus Conducting Phlegm Pill
Prognosis and prevention Scanty Periods can be difficult to treat and it may take several months to get results. The pattern of Phlegm obstructing the Uterus is the most difficult to treat and even more so when it is due to polycystic ovarian syndrome, an abnormality of gonadal function usually associated with anovulation (lack of ovulation), increase in luteinizing hormone, ovarian cysts and an increased production of androgens. Clinically, the patient tends to be obese (although not necessarily) and to suffer from hirsutism (excessive body hair): it may also lead to amenorrhoea. This is a very difficult condition and the treatment may take years. See Chapter 66 for a detailed discussion of polycystic ovary syndrome. The pattern of Blood deficiency is the easiest to treat, unless it has been brought on by use of the contraceptive pill for some years: in this case, it may take several months and even up to a year to restore the period to normal. Women suffering from Blood deficiency should make sure they have adequate nourishment and eat Blood-nourishing foods such as meat, eggs, spinach, carrots and wood-ear mushrooms. Those suffering from Kidney deficiency should avoid overwork and take adequate rest. Those suffering from Blood stasis should have regular, gentle exercise to move Qi and Blood. Those suffering from Phlegm should avoid eating dairy foods and greasy foods which tend to increase Dampness and Phlegm and should also make sure that they have regular exercise. End notes 1. Luo Yuan Kai 1986 Gynaecology in Chinese Medicine(Zhong Yi Fu Ke Xue
), Shanghai Science and Technology Press, Shanghai, p. 51..
2. Ibid., p. 51..
CHAPTER 13 Long Periods
AETIOLOGY 249 PATHOLOGY 249 IDENTIFICATION OF PATTERNS AND TREATMENT 249 Qi deficiency 249 Blood-Heat 251 Liver-Qi and Liver-Blood stasis 252 Kidney-Yin deficiency with Empty-Heat 253 PROGNOSIS AND PREVENTION 254 Long Periods are characterized by prolonged bleeding which may last 7–10 days; the cycle is regular and the amount of bleeding itself is not excessive. Thus, they differ from Heavy Periods, in which the amount of bleeding is excessive, and from Flooding and Trickling, in which the cycle is somewhat irregular because bleeding can occur before the right time.
Aetiology
Emotional stress Emotional stress, such as that deriving from anger, worry and guilt, affecting the Liver leads to Liver-Qi stagnation which, after some years, may lead to Liver-Blood stasis. The Directing and Penetrating Vessels become obstructed, the blood vessels are blocked by stagnant Blood, new Blood has nowhere to go and so the period lasts a long time. Overwork, too many children too close together Overwork or having too many children too close together may cause Kidney-Yin deficiency. When Yin is deficient for a long time, Empty-Heat develops: this agitates the Blood in the Penetrating Vessel and the period lasts a long time. Excessive physical work or irregular diet Excessive physical work and irregular diet may lead to Qi deficiency of the Spleen and/or Kidneys. Emotional stress and irregular diet Emotional stress leading to Heat and Fire of the Liver and Heart may cause Blood-Heat: this causes the blood to spill out of the vessels so that the periods are long. Heat or Fire may also derive from the excessive consumption of hot foods and alcohol.
Pathology The main pathological factors in Long Periods are: • Qi deficiency • Blood-Heat • Liver-Qi and Liver-Blood stasis • Kidney-Yin deficiency with Empty-Heat.
Identification of patterns and treatment
Qi deficiency
Clinical manifestations Periods lasting a long time, tapering off with a trickle, tiredness, poor appetite, slight abdominal distension, backache, dizziness, frequent, pale urination. Tongue: Pale. Pulse: Deep-Weak. This is deficiency of Qi of both Spleen and Kidneys. Treatment principle Tonify and raise Qi, strengthen the Spleen and Kidneys, consolidate the Penetrating and Directing Vessels (Chong and Ren Mai). Acupuncture LU-7 Lieque on the right with KI-6 Zhaohai on the left, Ren-12 Zhongwan, Ren-6 Qihai, Ren-4 Guanyuan, KI-13 Qixue, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-23 Shenshu. All with reinforcing method; moxa can be used. Explanation
– LU-7 and KI-6 regulate the Directing Vessel. – Ren-12, ST-36, SP-6 and BL-20 strengthen the Spleen. – Ren-4 and BL-23 strengthen the Kidneys. – KI-13 tonifies the Kidneys and consolidates the Penetrating and
Directing Vessels. – Ren-6 tonifies and raises Qi. Herbal treatment
a Prescription
– JU YUAN JIAN – Raising the Original [Qi] Decoction Explanation This prescription, already explained, tonifies and raises Spleen-Qi: this will stop the bleeding from Deficiency. b. Prescription
– BU ZHONG YI QI TANG – Tonifying the Centre and Benefiting Qi Decoction Explanation This formula, already explained, tonifies and raises Spleen-Qi to stop bleeding. Very similar to the previous one, it is perhaps more suitable to stop bleeding because it contains Dang Gui to enter the Blood portion.
c. Prescription
– GUI PI TANG – Tonifying the Spleen Decoction Explanation This formula, already explained, tonifies Spleen-Qi and calms the Mind. It is suitable to stop bleeding because it also contains Dang Gui, which enters the Blood portion, and is particularly appropriate if the patient suffers from anxiety and depression. Modifications These modifications apply to all three previous formulae. – If the period is very heavy, add E Jiao Colla Corii asini, Wu Zei Gu Endoconcha Sepiae and Pao Jiang Rhizoma Zingiberis preparatum (fried). – If the period is very long, add Pu Huang Pollen Typhae and Yi Mu Cao Herba Leonuri. – If there are symptoms of Kidney-Yang deficiency, add Xu Duan Radix Dipsaci and Ai Ye Folium Artemisiae argyi. Women’s Treasure remedy
– RESTRAIN THE FLOW
This remedy is specific to stop uterine bleeding from Qi deficiency. The tongue presentation appropriate to this remedy is a Pale body. Summary Qi deficiency
Clinical manifestations
Periods lasting a long time, tapering off with a trickle, tiredness, poor appetite, slight abdominal distension, backache, dizziness, frequent, pale urination. Tongue: Pale. Pulse: Deep-Weak. Treatment principle
Tonify and raise Qi, strengthen the Spleen and Kidneys, consolidate the Penetrating and Directing Vessels (Chong and Ren Mai). Acupuncture
LU-7 Lieque on the right with KI-6 Zhaohai on the left, Ren-12 Zhongwan, Ren-6 Qihai, Ren-4 Guanyuan, KI-13 Qixue, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-23 Shenshu. All with reinforcing method; moxa can be used. Herbal treatment
Pre scriptions
• JU YUAN JIAN Raising the Original [Qi] Decoction
• BU ZHONG YI QI TANG Tonifying the Centre and Benefiting Qi Decoction • GUI PI TANG Tonifying the Spleen Decoction Women’s Treasure remedy
• RESTRAIN THE FLOW
Blood-Heat
Clinical manifestations Long periods that tend also to be heavy, dark blood, irritability, thirst, red face, feeling of heat. Tongue: Red with yellow coating. Pulse: Firm or Overflowing. Treatment principle Clear Heat and cool Blood, clear the Liver and Heart, regulate the Penetrating Vessel. Acupuncture SP-4 Gongsun on the right with P-6 Neiguan on the left, KI-14 Siman, L.I.-11 Quchi, SP-10 Xuehai, LIV-3 Taichong, KI-2 Rangu. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel. – KI-14 cools Blood in the Uterus. – L.I.-11 and SP-10 in combination cool Blood. – LIV-3 and KI-2 cool Blood. Herbal treatment
a Prescription
– BAO YIN JIAN Variation – Protecting Yin Decoction Variation Explanation The first eight herbs constitute the formula Bao Yin Jian which nourishes Yin and clears Heat. – Sheng Di Huang, Bai Shao and Shu Di Huang nourish Yin and Blood and cool Blood. – Shan Yao tonifies the Spleen and Kidneys. – Huang Qin and Huang Bo clear Heat. – Xu Duan tonifies the Kidneys. – Gan Cao harmonizes. – Di Yu and Huai Hua were added to cool Blood and stop bleeding. Modifications
• If the period is heavy and long, add Wu Zei Gu Endoconcha Sepiae, Qian Cao Gen Radix Rubiae, and Xian He Cao Herba Agrimoniae. • If there is both Qi and Yin deficiency induced by the longstanding blood
loss, use Liang Di Tang Two ‘Di’ Decoction and Sheng Mai San Generating the Pulse Powder in combination. b. Prescription
– AN CHONG TANG – Calming the Penetrating Vessel Decoction Explanation This formula is used if longstanding bleeding has given rise to Yin and Qi deficiency with symptoms of Qi deficiency such as tiredness, palpitations and shortness of breath. – Bai Zhu and Huang Qi tonify and raise Qi. – Long Gu and Mu Li firm Qi, stop bleeding and nourish Yin. – Sheng Di Huang and Bai Shao nourish Yin and cool Blood. – Wu Zei Gu is astringent and stops bleeding. – Qian Cao Gen cools and invigorates Blood and stops bleeding. – Xu Duan tonifies the Kidneys and stops bleeding. c. Prescription
– JIE DU SI WU TANG Variation
– Expelling Toxin Four Substances Decoction Variation Explanation This formula is used if external Heat penetrates the Interior and generates Toxic-Heat and Blood-Heat which lead to bleeding. The first eight herbs constitute the formula Jie Du Si Wu Tang. – Huang Lian, Huang Qin, Huang Bo and Shan Zhi Zi clear Heat and Dampness, and resolve Toxic-Heat. – Sheng Di Huang nourishes Yin, cools Blood and stops bleeding. – Dang Gui and Bai Shao nourish Blood and ‘calm’ Blood to stop bleeding. – Chuan Xiong, part of Si Wu Tang, invigorates Blood. – Bai Jiang Cao resolves Fire-poison and invigorates Blood. – Mu Dan Pi cools Blood and stops bleeding. Women’s Treasure remedy
– COOL THE MENSES This remedy is specific to reduce uterine bleeding occurring from Blood-Heat. The tongue presentation appropriate to this remedy is a Red body with a yellow coating. Summary Blood Heat
Clinical manifestations
Long periods that tend also to be heavy, dark blood, irritability, thirst, red face, feeling of heat. Tongue: Red with yellow coating. Pulse: Firm or Overflowing. Treatment principle
Clear Heat and cool Blood, clear the Liver and Heart, regulate the Penetrating Vessel. Acupuncture
SP-4 Gongsun on the right with P-6 Neiguan on the left, KI-14 Siman, L.I.-11 Quchi, SP-10 Xuehai, LIV-3 Taichong, KI-2 Rangu. All with reducing or even method. Herbal treatment
Pre scriptions
• BAO YIN JIAN Variation Protecting Yin Decoction Variation • AN CHONG TANG Calming the Penetrating Vessel Decoction • JIE DU SI WU TANG Variation Expelling Toxin Four Substances Decoction Variation Women’s Treasure remedy
• COOL THE MENSES
Liver-Qi and Liver-Blood stasis
Clinical manifestations Long periods that are scanty with dark blood and clots, depression, irritability, abdominal pain and distension. Tongue: Purple. Pulse: Wiry. Treatment principle Move Qi, invigorate Blood, eliminate stagnation, regulate the periods. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, BL-17 Geshu, SP-8 Diji, SP-6 Sanyinjiao, Ren-6 Qihai, KI-14 Siman, ST29 Guilai, LIV-3 Taichong. All with reducing or even method. If the stasis of Blood derives from Cold, moxa can be used. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel and invigorate Blood as this vessel is the Sea of Blood. – BL-17 and SP-10 invigorate Blood. – SP-8 stops bleeding. – SP-6 invigorates Blood. – Ren-6 moves Qi in the Lower Burner.
– KI-14, a point of the Penetrating Vessel, eliminates stagnation in the Lower Burner and Uterus. – ST-29 invigorates Blood in the Uterus. – LIV-3 Taichong moves Liver-Qi and invigorates Liver-Blood. Herbal treatment
a. Prescription
– SI WU TANG and JIN LING ZI SAN – Four Substances Decoction and Toosendan Powder Explanation The formula Si Wu Tang invigorates Blood and regulates the periods. – Jin Ling Zi moves Liver-Qi. – Yan Hu Suo moves Qi, invigorates Blood and stops pain. Modifications
– If Blood stasis is very pronounced and the tongue very Purple, add Tao Ren Semen Persicae, Hong Hua Flos Carthami and Qian Cao Gen Radix Rubiae. – If bleeding goes on for a long time, add Pu Huang Pollen Typhae and
San Qi Radix Notoginseng. – If there is abdominal pain, add Wu Ling Zhi Faeces Trogopteri. b. Prescription
– GUO QI YIN – Beyond Phase Decoction Explanation This formula, from the Golden Mirror of Medicine (1742), is specific for Long Periods from stagnation of Qi and Blood with an underlying Cold condition. It is therefore suitable if the tongue is Pale-Purplish. The first six herbs constitute the formula Tao Hong Si Wu Tang Persica-Carthamus Four Substances Decoction which nourishes and invigorates Blood. – Xiang Fu and Mu Xiang move Qi and eliminate stasis. – E Zhu invigorates Blood. – Rou Gui expels internal Cold. – Mu Tong removes obstructions from the Connecting channels. Please note that the use of this herb is illegal: it can be replaced with Tong Cao Medulla Tetrapanacis. – Gan Cao harmonizes. Women’s Treasure remedy
– STIR FIELD OF ELIXIR This remedy invigorates Blood in the Lower Burner and stops bleeding. The tongue presentation appropriate to this remedy is a Purple body. Summary Liver-Qi and Liver-Blood stasis
Clinical manifestations
Long periods that are scanty with dark blood and clots, depression, irritability, abdominal pain and distension. Tongue: Purple. Pulse: Wiry. Treatment principle
Move Qi, invigorate Blood, eliminate stagnation, regulate the periods. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, BL-17 Geshu, SP-8 Diji, SP-6 Sanyinjiao, Ren-6 Qihai, KI-14 Siman, ST29 Guilai, LIV-3 Taichong. All with reducing or even method. If the stasis of Blood derives from Cold, moxa can be used. Herbal treatment
Pre scriptions
• SI WU TANG and JIN LING ZI SAN Four Substances Decoction and
Toosendan Powder • GUO QI YIN Beyond Phase Decoction Women’s Treasure remedy
• STIR FIELD OF ELIXIR
Kidney-Yin deficiency with Empty-Heat
Clinical manifestations Long periods with scanty blood, a dry throat, malar flush, night sweating, dry stools. Tongue: Red without coating. Pulse: Floating-Empty. Treatment principle Nourish Yin, strengthen the Kidneys, clear Empty-Heat, stop bleeding, regulate the periods. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-3 Taixi, SP-6 Sanyinjiao, KI-2 Rangu, SP-8 Diji. All with reinforcing method except for KI-2 and SP-8 which should be needled with even method. No moxa. Explanation
– LU-7 and KI-6 regulate the Directing Vessel, nourish Yin and strengthen the Uterus. – Ren-4, KI-3 and SP-6 nourish the Kidneys and strengthen the Uterus. – SP-8 stops uterine bleeding. – KI-2 clears Empty-Heat.
Herbal treatment
Prescription
– LIANG DI TANG and ER ZHI WAN – Two ‘Di’ Decoction and Two Solstices Pill Explanation The formula Liang Di Tang, already explained, nourishes Kidney-Yin and Blood, clears Empty-Heat, stops bleeding and regulates the periods. – Nu Zhen Zi and Han Lian Cao nourish Kidney-Yin, clear Empty Heat, stop bleeding and treat night-sweating. Modifications
• If bleeding is very prolonged, add Wu Zei Gu Endoconcha Sepiae and Qian Cao Gen Radix Rubiae. These two herbs are frequently combined in gynecological bleeding syndromes because the former is astringent and the latter is moving (as well as stopping bleeding): thus, in combination, these two herbs invigorate Blood, stop bleeding without causing stasis and consolidate the Lower Burner. Women’s Treasure remedy
– EASE THE JOURNEY-YIN This remedy nourishes Kidney-Yin, strengthens the Directing and Penetrating Vessels, stops bleeding and regulates the periods. Summary Kidney-Yin Deficiency with Empty-Heat
Clinical manifestations
Long periods with scanty blood, a dry throat, malar flush, night sweating, dry stools. Tongue: Red without coating. Pulse: Floating-Empty. Treatment principle
Nourish Yin, strengthen the Kidneys, clear Empty-Heat, stop bleeding, regulate the periods. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-3 Taixi, SP-6 Sanyinjiao, KI-2 Rangu, SP-8 Diji. All with reinforcing method except for KI-2 and SP-8 which should be needled with even method. No moxa. Herbal treatment
Pre scription
• LIANG DI TANG and ER ZHI WAN Two ‘Di’ Decoction and Two Solstices Pill
Women’s Treasure remedy
• EASE THE JOURNEY-YIN
Prognosis and prevention Long Periods are relatively easily treated by acupuncture and/or Chinese herbs. The pattern from Kidney-Yin deficiency is more difficult to treat. Women suffering from Yin deficiency should not overwork and should have adequate rest. Those suffering from stagnation of Liver-Qi should pay some attention to their emotional life and, if necessary, enlist the help of a counsellor or psychotherapist.
CHAPTER 14 Painful Periods
AETIOLOGY 256 PATHOLOGY 256 DIAGNOSIS 257 TREATMENT PRINCIPLES 258 IDENTIFICATION OF PATTERNS AND TREATMENT 259 FULL CONDITIONS 259 Stagnation of Qi 259 Stasis of Blood 261 Stagnation of Cold 264 Damp-Heat 268 Stagnant Liver-Qi turning into Fire 269 EMPTY CONDITIONS 270 Qi and Blood deficiency 270 Yang and Blood deficiency 271 Kidney- and Liver-Yin deficiency 273 Ancient acupuncture prescriptions for Painful Periods 274 PROGNOSIS AND PREVENTION 275 WESTERN VIEW 275
CLINICAL TRIALS 276 Acupuncture 276 Herbal treatment 281 Painful Periods indicates menstrual pain that occurs before, during or after menstruation. The pain may occur in the lower abdomen or sacral region and sometimes extend to the legs. In severe cases, there may be nausea and vomiting or even fainting. The Liver, Penetrating Vessel and Directing Vessel are responsible for the physiology of menstruation. For a normal period to occur, Blood must be abundant and move adequately. Proper movement of Blood relies on the free flow of Liver-Qi and of the Qi of the Penetrating Vessel. As we have seen in Chapter 2 on physiology, four different phases may be identified in each menstrual cycle. During the pre-menstrual phase, Yang rises and Liver-Qi moves in preparation for moving Blood during the period. Thus, a proper movement of Liver-Qi and Liver-Blood is essential for a pain-free period. If Liver-Qi stagnates, it may cause pain, especially before the period, while if Liver-Blood stagnates, it causes pain during the period. Stagnation is therefore the most important pathological condition causing painful periods: even in deficiency conditions when the pain is mild, it is some element of stagnation that causes it. The earliest mention of Painful Periods is probably in the Synopsis of Prescriptions of the Golden Cabinet which says: “If a woman has irregular periods with abdominal pain and fullness, and the periods are irregular, use Tu Gua Gen Powder”.1 Another passage in the same book appears to describe an episode of severe dysmenorrhoea from Cold: When Cold invades the Lower Burner the menses may become scanty and painful with a dragging pain in the vagina and a feeling of cold in the abdomen … there is an acute pain on Qichong [ST-30] … there may be sudden vertigo and the woman may pass out … this is a gynaecological problem and is not due to an attack of evil spirits
…2
Aetiology
Emotional strain Emotional strain is a very important aetiological factor in painful periods. Anger, frustration, resentment, worry and guilt all may lead to Liver-Qi stagnation. In women, Liver-Qi stagnation causes Blood to stagnate in the Uterus leading to painful periods. In some cases, stagnant Liver-Qi may turn into Liver-Fire and this, in turn, may lead to Blood-Heat. Blood-Heat often combines with Damp-Heat in the Uterus. External Cold and Dampness Excessive exposure to Cold and Dampness, especially during the puberty years, may cause Cold to invade the Uterus. Cold contracts and causes stasis of Blood in the Uterus and therefore painful periods. In cold and damp countries where young girls dressed in shorts play school sports and games, this is a very common cause of painful periods. During puberty, the body is in a vulnerable state because it is undergoing profound changes, and it is therefore very likely to be affected by pathogenic factors. Invasion of Cold in the Uterus is the most common cause of painful periods in adolescent girls. Women are also prone to invasion of Cold in the Uterus during and soon after the period when the Uterus and Blood are in a relatively weakened state. At this time, therefore, they should take particular care not to be exposed to cold and dampness. Fu Qing Zhu says: The Liver pertains to Wood, it stores Blood and it hates wind and cold most of all. During menstruation the space between skin and muscles (cou li) is wide open, when this is invaded by wind and cold Liver-Qi stagnates and the passages of the menses become obstructed.3
Women with a pre-existing condition of Yang deficiency are obviously more prone to invasion of external Cold. Overwork, chronic illness Physical overwork or a chronic illness leads to deficiency of Qi and Blood, especially of Stomach and Spleen. Deficiency of Blood leads to malnourishment of the Penetrating and Directing Vessels so that the Blood has no force to move properly thus causing stagnation and pain. Excessive sexual activity, childbirth The Liver and Kidneys are weakened by excessive sexual activity (which affects women somewhat less than men), too many childbirths too close together, and sexual activity starting too early. A deficiency of Liver and Kidneys induces Emptiness of the Penetrating and Directing Vessels so that they cannot move Qi and Blood properly, thus causing painful periods.
Pathology Thus, stagnation of Qi and/or Blood, which may arise by itself or be caused by Cold in the Uterus, is the most important factor in painful periods. Even deficiency types of painful periods, caused by Blood or Liver/Kidney deficiency, involve an element of stagnation as the deficient Blood fails to move properly. The main patterns causing Painful Periods are therefore: • stagnation of Qi • stasis of Blood • stagnation of Cold (of the Empty or Full type) • Damp-Heat (with Blood-Heat) • stagnant Liver-Qi turning into Fire • Qi and Blood deficiency • Yang and Blood deficiency • Kidney- and Liver-Yin deficiency. Stagnation of Qi and stasis of Blood are very common patterns occurring in Painful Periods. They very often accompany other patterns. For example, a deficiency of Qi and Blood may occur in combination with some stagnation of Qi and/or Blood. Similarly, Cold obstructing the Uterus obviously leads to stasis of Blood. In gynecology, stagnation of Qi and of Blood is always related to the Liver and the Penetrating Vessel. A free-flowing Liver-Qi is essential to move Blood before and during the period; if Liver-Qi stagnates, Blood does not move properly and pain results. The Penetrating Vessel is also usually involved in painful periods from stagnation as it is the Sea of Blood and it flows through the Uterus: for this
reason, stasis of Blood in the Uterus is often due to stagnation in this vessel. Of all the extraordinary vessels, the Penetrating Vessel is the most important one in the pathology of Painful Periods. When the periods are painful from stagnation of Qi, the pain is accompanied by a pronounced feeling of distension of the abdomen, typically occurring especially before the periods. Other symptoms may include premenstrual tension, irritability, depression and a Wiry pulse. Many books list a Purple tongue as a sign of Qi stagnation: I tend to disagree as the tonguebody colour reflects more the state of Blood than Qi so that, if it is Purple, I relate that to Blood rather than Qi stagnation. In Qi stagnation, the tonguebody colour may be normal, except in severe and longstanding cases when it may be Red on the sides. Stagnation of Liver-Qi is often secondary to or accompanied by LiverBlood stasis (as discussed at length in Chapter 3 on pathology): when this is the case, the pulse may not be Wiry at all but Fine or Choppy (and perhaps slightly Wiry on one side) and the tongue may be Pale (from Blood deficiency). When stasis of Blood is predominant, the pain is more intense, is stabbing in character and is typically relieved by the passing of dark clots. A dark menstrual blood with clots is an essential and sufficient symptom to diagnose stasis of Blood, i.e. by itself it validates a diagnosis of Blood stasis, even if there are no other indications. Another important sign is a Purple colour of the tongue body although, if the stasis of Blood is fairly recent and not too severe, the tongue may not show this sign. Another symptom of Blood stasis is that the period may be hesitant, i.e. it may start and stop. Stagnation of Cold is a common cause of Painful Periods especially in young girls living in cold and damp countries. With stagnation of Cold, there is always stasis of Blood as Cold obstructs the Uterus and the vessels preventing a proper flow of blood. It is for this reason that with Cold, too, there are clots in the menstrual blood: however, if Cold is the cause, the menstrual blood is typically red and the clots are dark and rather small or stringy, whereas if stasis of Blood is the cause, the blood itself is dark and the clots are rather large. The pain from stagnation of Cold is very intense and
cramping in character and typically alleviated by the application of heat. Blood-Heat does not usually cause intense menstrual pain; often associated with Damp-Heat (for this reason these two pathogenic factors will be discussed together), it tends to make the periods heavy. Other symptoms include a feeling of heat, thirst, a Red tongue and a Rapid pulse. If DampHeat is present, there will also be a feeling of heaviness, an excessive vaginal discharge, a bearing-down sensation, a sticky-yellow coating on the tongue and a Slippery pulse. Deficiency of Qi and Blood and Liver and Kidneys usually causes only mild menstrual pain. The latter pattern is seen more in older women. As mentioned before, even in Empty conditions there is some element of stagnation as deficient Qi and Blood fail to move Blood properly and this leads to some stagnation. In fact, Zhang Jing Yue in the Complete Works of Jing Yue (1624) says: In women with painful periods, in many cases there is an intrinsic Deficiency and purely Excess types are few … when Qi and Blood are deficient Blood does not move … Qi is deficient and Blood stagnates.4
Diagnosis
Time of onset Pain before and during the period is usually of the Full type, while pain after the period is of the Empty type. Pressure If the pain is made worse by pressure, it indicates Fullness, while if the patient gets relief from pressing the lower abdomen, it indicates Emptiness. Patients are not sure how to answer this question if it is not asked in a sensible way. Thus, instead of enquiring whether the “pain is better with pressure or not”, we should ask the patient whether she perhaps likes to hold her abdomen or whether she dislikes to be touched on the abdomen at that time. Women often find that a hot-water bottle on the abdomen relieves the pain, but sometimes they like the pressure rather than the heat of the bottle. Heat-Cold If the pain is relieved by the application of heat (such as a hot-water bottle), it indicates either a Cold condition or stasis of Blood from Cold. It should be kept in mind, however, that this sign is not always indicative of Cold, as other conditions, such as stagnation of Qi or Blood, may also be alleviated by the application of a hot-water bottle. Furthermore, a sensation of heat is often comforting in itself without really indicating that the pain is due to Cold. If the pain is aggravated by heat, it indicates Blood-Heat. Character of pain
• Pain better after passing clots: stasis of Blood. • Pain with a pronounced feeling of distension: stagnation of Qi. • Burning pain: Blood-Heat. • Cramping pain: Cold in the Uterus. • Stabbing pain, not moving: stasis of Blood. • Pulling pain: stasis of Blood. • Bearing-down pain before the period: stasis of Blood. • Bearing-down pain after the period: Kidney deficiency. Location of pain
• Pain on both sides of lower abdomen: Liver channel. • Pain in lower abdomen, central: Kidney channel and Penetrating Vessel. • Pain on sacrum: Kidney channel, deficiency. Cycle If the cycle is long (i.e. the periods come consistently late) and the menstrual blood is dark and clotted, it indicates stasis of Blood. If the menstrual blood is red with small dark clots, it indicates Cold in the Uterus. If the cycle is short, the period heavy and the blood bright red, it indicates Blood-Heat.
Treatment principles From the point of view of Manifestation (Biao) the central pathology of Painful Periods is a disharmony of the Penetrating Vessel and Sea of Blood. Hence the main principle of treatment for the Manifestation is to regulate the Qi and Blood of the Penetrating Vessel. As discussed in Chapter 3 on pathology, the Penetrating Vessel is the Sea of Blood. It arises from the Uterus and is therefore always involved in Painful Periods. This vessel is particularly prone to stagnation of Qi and Blood in the abdomen and many of its points (especially KI-14 Siman) eliminate stagnation. The Qi of the Penetrating Vessel is prone to rebel upwards from the abdomen towards the chest giving rise to a feeling of oppression of the chest. Since this vessel is also closely related to the Bright-Yang channels via the important point ST-30 Qichong, a stagnation in the Penetrating Vessel often causes Qi to rebel in the Bright Yang: this explains the nausea and vomiting experienced by some women suffering from painful periods. To treat stasis of Blood in the Penetrating Vessel, I often use the vessel’s opening points, i.e. SP-4 Gongsun on the right and P-6 Neiguan on the left together with other points on the vessel such as KI-14 Siman, KI-12 Dahe or KI-16 Huangshu. Other points related to the Penetrating Vessel in treating painful periods are LIV-3 Taichong, ST-42 Chongyang and ST-30 Qichong. LIV-3 Taichong is the most important one to affect the Penetrating Vessel: by moving LiverQi, it regulates the Penetrating Vessel, subdues its rebellious Qi and invigorates Blood. The association between this point and the Penetrating Vessel is so close that sometimes the old classics call this vessel Taichong. In fact, the very first chapter of the Simple Questions, in describing the 7-year cycles of women, says: “At 14, the Heavenly Gui arrives [i.e. the menses], the Directing Vessel is open and the Taichong vessel is flourishing.”5 The ‘Taichong vessel’ is the Penetrating Vessel. ST-42 Chongyang also regulates Blood within the Penetrating Vessel and eliminates stasis due to the relationship between this vessel and the Bright Yang. ST-30 Qichong is one
of the most important points on the Penetrating Vessel and strongly moves Qi and Blood in the abdomen. Its other name, Qijie, means ‘avenues of Qi’, referring to the channels and vessels of the abdomen which the Penetrating Vessel influences. To treat the Root in Painful Periods, one must differentiate clearly between Heat, Cold, deficiency and excess. First identify the prevailing pattern, then treat it in order to treat the Root: this may involve moving Qi, invigorating Blood, expelling Cold, resolving Dampness, clearing Heat, tonifying Qi and Blood or strengthening Liver and Kidneys. The most important differentiation is that between Full and Empty types of painful periods. Full types are much more common than Empty, and clinically are more important as they are characterized by more intense pain. Moreover, even in Empty types of painful periods there is an element of stasis of Blood as deficient Blood fails to move properly. For this reason, even for Empty types of painful periods, some Blood-moving herbs are added to the prescription used. The treatment principle is often changed according to the time of the menstrual cycle. During the period one concentrates on treating the Manifestation, i.e. invigorate Blood and stop pain. At other points in the cycle one treats the Root, i.e. according to the main pattern. A deficiency, in particular, is best treated during the 2 weeks, or thereabouts, that follow the period.
Identification of patterns and treatment
Full conditions
Stagnation of Qi
Clinical manifestations
Lower abdominal pain during the period, or 1 to 2 days before the period, a pronounced feeling of distension of the abdomen and breasts, hesitant start to the period, menstrual blood dark without clots, pre-menstrual tension and irritability. Tongue: Normal coloured or slightly Red on the sides. If there is deficiency of Blood, the tongue may be Pale. Pulse: Wiry. The pulse may be Choppy if Liver-Blood deficiency predominates. Treatment principle
Move Qi and Blood, eliminate stagnation, stop pain. Acupuncture
LIV-3 Taichong, Ren-6 Qihai, G.B.-34 Yanglingquan, SP-8 Diji, ST-29 Guilai, SP-10 Xuehai, SP-6 Sanyinjiao, SP-4 Gongsun and P-6 Neiguan, SP-14 Fujie. Reducing or even method. Explanation
– LIV-3 moves Qi and Blood and stops pain.
– Ren-6 moves Qi in the lower abdomen. – G.B.-34, in combination with Ren-6, moves Qi in the lower abdomen. – SP-8 regulates Blood in the Uterus and stops pain. – ST-29 regulates Blood in the Uterus. – SP-10 invigorates Blood. – SP-6 helps to invigorate Blood and stop pain. – SP-4 (on the right) and P-6 (on the left) regulate the Penetrating Vessel and regulate Blood in the Uterus. – SP-14 moves Qi and Blood in the lower abdomen. Herbal treatment
Prescription
– XIAO YAO SAN Variation – Free and Easy Wanderer Powder Variation Explanation
The first eight herbs constitute the Xiao Yao San which moves Qi and is specific for menstrual problems, especially from emotional strain. – Wu Yao, Xiang Fu, Zhi Ke and Yan Hu Suo move Qi more strongly and stop pain.
Women’s Treasure remedy
– FREE FLOW This remedy is a variation of the formula Xiao Yao San Free and Easy Wanderer Powder which pacifies the Liver, moves Qi, eliminates stagnation, nourishes Liver-Blood and tonifies Spleen-Qi. The formula has been adapted with the addition of herbs that move Qi and stop pain. The tongue presentation appropriate to this remedy is a normal-coloured body or slightly Pale on the sides; if the stagnation of Qi is severe, it could be slightly Red on the sides. Summary Stagnation of Qi
Clinical manife stations
Lower abdominal pain during the period, or 1 to 2 days before the period, a pronounced feeling of distension of the abdomen and breasts, hesitant start to the period, menstrual blood dark without clots, pre-menstrual tension and irritability. Tongue: Normal coloured or slightly Red on the sides. If there is deficiency of Blood, the tongue may be Pale. Pulse: Wiry. The pulse may be Choppy if Liver-Blood deficiency predominates. Tre atme nt principle
Move Qi and Blood, eliminate stagnation, stop pain. Acupuncture
LIV-3 Taichong, Ren-6 Qihai, G.B.-34 Yanglingquan, SP-8 Diji, ST-29 Guilai, SP-10 Xuehai, SP-6 Sanyinjiao, SP-4 Gongsun and P-6 Neiguan, SP-14 Fujie. Reducing or even method.
He rbal tre atme nt
Prescription
• XIAO YAO SAN Variation Free and Easy Wanderer Powder Variation Women’s Treasure re me dy
• FREE FLOW
Case history A 32-year-old woman had been suffering from painful periods for 2 years. The pain occurred during the period in the hypogastrium, lateral abdomen and sacrum. It was dull in character and associated with a bearingdown sensation. Her periods were regular and the menstrual blood was slightly dark with a few clots. She also suffered from pre-menstrual tension with a pronounced distension of breast and abdomen and irritability. She had been on the contraceptive pill for 10 years and the periods became painful when she stopped taking it. She had been given a progesterone pill but this had not helped the dysmenorrhoea at all. Apart from the menstrual problems, she also suffered from the so-called irritable bowel syndrome causing her a spastic pain in the abdomen and alternation of constipation and diarrhoea: she had had this problem for 10 years. On interrogation, it transpired that her vision was sometimes blurred, she was occasionally dizzy and experienced tingling of the limbs. Her tongue was slightly orangey on the sides, and her pulse was Fine on the right side and Fine but also slightly Wiry on the left. Diagnosis
This is a very clear example of stagnation of Liver-Qi associated with (or caused by) Liver-Blood deficiency. The symptoms of Liver-Qi stagnation are very obvious: pre-menstrual tension with distension and irritability, painful
periods, Wiry pulse on the left, abdominal pain with constipation and diarrhoea. The symptoms of Liver-Blood deficiency are also equally clear: the dull character of the menstrual pain, the blurred vision, the tingling and dizziness, the orangey colour of the sides of the tongue and the Fine pulse. I am inclined to think that, in this case, stagnation of Liver-Qi derived from Liver-Blood deficiency and this was, in turn, probably caused by the contraceptive pill. Treatment principle
This patient was treated with acupuncture and herbal remedies. The acupuncture points used were selected from the following: • LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to regulate the Directing Vessel and strengthen the Uterus. • L.I.-4 Hegu, in combination with LIV-3 Taichong, to regulate the ascending and descending of Qi and calm the Mind. • LIV-3 Taichong to pacify the Liver, move Qi, eliminate stagnation, calm the Mind and settle the Ethereal Soul. • ST-36 Zusanli and SP-6 Sanyinjiao with warm needle to tonify Qi and Blood. • Ren-4 Guanyuan to nourish Blood and strengthen the Uterus. • ST-29 Guilai to move Qi and Blood and stop pain.
An example of a point combination in one treatment would be: LU-7 (on the right) and KI-6 (on the left), L.I.-4 on the left, LIV-3 on the right, Ren-4, ST-36 and SP-6 bilaterally; the last three points with reinforcing method, the others with even method. The herbal remedies used were the Three Treasures’s Brighten the Eyes to nourish Liver-Blood and Freeing the Moon to pacify the Liver and eliminate stagnation. The latter remedy (a variation of Xiao Yao San Free and Easy Wanderer Powder) also nourishes Liver-Blood, and, in addition, pacifies Liver-Qi and tonifies Spleen-Qi. The patient took Brighten the Eyes
for 2 weeks after the period and Freeing the Moon from then until the beginning of the next period. This patient reacted exceedingly well to the treatment, improving even after the first session. After only three acupuncture sessions (over a period of 1 month) and use of the remedies, she reported experiencing no menstrual pain with her last period and no abdominal bowel pain, and feeling very much better in herself. Such a quick reaction is rather unusual as it normally takes at least 3 monthly cycles to affect a menstrual irregularity. Stasis of Blood
Clinical manifestations
Intense, stabbing pain before or during the period, dark menstrual blood with large clots, mental restlessness, pain relieved after passing clots. Tongue: Purple. Pulse: Wiry. Treatment principle
Invigorate Blood, eliminate stasis, stop pain. Acupuncture
LIV-3 Taichong, Ren-6 Qihai, G.B.-34 Yanglingquan, SP-8 Diji, ST-29 Guilai, SP-10 Xuehai, SP-6 Sanyinjiao, SP-4 Gongsun and P-6 Neiguan, BL-17 Geshu, KI-14 Siman, ST-25 Tianshu. All with reducing or even method. Explanation
– LIV-3 moves Qi and Blood, stops pain and regulates the Sea of Blood of the Penetrating Vessel. – Ren-6 moves Qi in the lower abdomen. – G.B.-34, in combination with Ren-6, moves Qi in the lower abdomen. – SP-8 regulates Blood in the Uterus and stops pain. – ST-29 regulates Blood in the Uterus. – SP-10 and BL-17 invigorate Blood. – SP-6 helps to invigorate Blood and stop pain. – SP-4 (on the right) and P-6 (on the left) regulate the Penetrating Vessel and regulate Blood in the Uterus. – KI-14, a point of the Penetrating Vessel, moves Qi and Blood in the abdomen and eliminates stasis from this vessel. – ST-25, Front-Collecting point of the Stomach, invigorates Blood in the Penetrating Vessel. The Bright Yang is full of Qi and Blood and, because of its relationship with the Penetrating Vessel, can invigorate Blood. The ABC of Acupuncture (AD 259) by Huang Fu Mi says: “For women with pain in the uterus and periods that do not stop, use ST-25 Tianshu.”6 Herbal treatment
a . Prescription
– TAO HONG SI WU TANG Variation – Persica-Carthamus Four Substances Decoction Variation Explanation
The first six herbs constitute the Tao Hong Si Wu Tang which invigorates Blood. – Yan Hu Suo, Xiang Fu and Niu Xi move Qi and Blood in the lower abdomen and stop pain. b Prescription
– GE XIA ZHU YU TANG – Eliminating Stasis below the Diaphragm Decoction Explanation
This formula, which has already been explained, is specific to invigorate Blood in the lower abdomen. It is stronger than the previous one and is therefore selected when pain is more intense. c Prescription
– TONG JING YIN – Painful Menses Decoction Explanation
This formula is used if, together with stasis of Blood, there is some Cold. – Dang Gui and Bai Shao nourish and invigorate Blood. – Chuan Lian Zi, and Wu Yao move Qi and eliminate stagnation. – Yan Huo Suo, Chuan Xiong and Yi Mu Cao invigorate Blood and eliminate stasis. – Xiao Hui Xiang expels Cold. – Gan Cao harmonizes. Modifications
• If there is pain before the periods, add Qing Pi Pericarpium Citri reticulatae viride. • If there are pronounced symptoms of Cold, add Pao Jiang Rhizoma Zingiberis preparatum (fried). • If there is pain after the period, add Shu Di Huang Radix Rehmanniae preparata. d Prescription
– NEI YI FANG7 – Endometriosis Formula Explanation
– Dang Gui nourishes and invigorates Blood. – Dan Shen, Chi Shao, Xue Jie, Chuan Niu Xi, and E Zhu invigorate Blood and eliminate stasis. – Xiang Fu moves Qi, which helps to invigorate Blood. – Gui Zhi warms the blood vessels and thus helps to invigorate Blood. – Hai Zao dissolves swellings. This formula has a stronger Blood-invigorating action and is suitable to treat endometriosis. e Prescription
– HUA YU DING TONG TANG8 – Eliminating Stasis and Stopping Pain Decoction Explanation
– Dang Gui and Chuan Xiong nourish and invigorate Blood and, given their pungent taste, scatter and remove obstructions. – Dan Shen invigorates Blood and generates new Blood. – Chuan Niu Xi invigorates Blood. – Chi Shao cools and invigorates Blood. – Xue Jie, Mo Yao and Yan Hu Suo invigorate Blood, eliminate stasis and
stop pain. – Xiang Fu and Su Mu move Qi to help to invigorate Blood. – Wu Ling Zhi and Pu Huang form the prescription Shi Xiao San Breaking into a Smile Powder which invigorates Blood and stops bleeding. This formula is specific for endometriosis. Modifications
• If there is abdominal pain and pain in the anus, the author of this formula, Dr Cai Xiao Sun, recommends adding insect substances such as Di Bie Chong Eupolyphaga or Jiang Can Bombyx batryticatus. Women’s Treasure remedy
– STIR FIELD OF ELIXIR This remedy is a variation of Ge Xia Zhu Yu Tang and it invigorates Blood in the Uterus and Lower Burner. The tongue presentation appropriate to this remedy is a Purple body. Summary Stasis of Blood
Clinical manife stations
Intense, stabbing pain before or during the period, dark menstrual blood with large clots, mental restlessness, pain relieved after passing clots. Tongue: Purple. Pulse: Wiry.
Tre atme nt principle
Invigorate Blood, eliminate stasis, stop pain. Acupuncture
LIV-3 Taichong, Ren-6 Qihai, G.B.-34 Yanglingquan, SP-8 Diji, ST-29 Guilai, SP-10 Xuehai, SP-6 Sanyinjiao, SP-4 Gongsun and P-6 Neiguan, BL-17 Geshu, KI-14 Siman, ST-25 Tianshu. All with reducing or even method. He rbal tre atme nt
Prescriptions
• TAO HONG SI WU TANG Variation Persica-Carthamus Four Substances Decoction Variation • GE XIA ZHU YU TANG Eliminating Stasis below the Diaphragm Decoction • TONG JING YIN Painful Menses Decoction • NEI YI FANG Endometriosis Formula • HUA YU DING TONG TANG Eliminating Stasis and Stopping Pain Decoction Women’s Treasure re me dy
STIR FIELD OF ELIXIR
Case history A 29-year-old woman had been suffering from painful periods ever since the menarche. The pain occurred during the period and the menstrual blood was dark with some clots. The period started hesitantly and there was not much distension. The pain was alleviated by the application of a hot-
water bottle. She also suffered from thrush with itching of the vagina and a white, sticky discharge. She felt generally tired and her stools were loose. She had a lower backache, her memory was poor and she felt always cold. Her tongue was Pale and her pulse was Weak on the Liver and right Kidney positions and slightly Slow (68). Diagnosis
My diagnosis was painful periods from mild stasis of Blood occurring against a background of Liver and Kidney deficiency (the tiredness, cold feeling, backache, poor memory and tongue and pulse all pointed to the latter). Besides this, she also suffered from Spleen deficiency (loose stools) and Dampness in the Lower Burner (vaginal itching and discharge). Treatment principle
This case is given here as an example of adopting the wrong principle of treatment. As I came to the conclusion that the main aspect of the condition was a deficiency (of Liver, Kidneys and Spleen) with only a mild and secondary excess (stasis of Blood and Dampness in the Lower Burner), I adopted the principle of tonifying and warming the Kidneys and nourishing the Liver. He rbal tre atme nt
I therefore chose a variation of the formula You Gui Wan Restoring the Right [Kidney] Pill: • Shu Di HuangRadix Rehmanniae preparata 9 g • Shan YaoRhizoma Dioscoreae 6 g • Shan Zhu YuFructus Corni 3 g • Tu Si ZiSemen Cuscutae 6 g
• Gou Qi ZiFructus Lycii 6 g • Du ZhongCortex Eucommiae 4 g • Dang GuiRadix Angelicae sinensis 6 g • Lu Jiao JiaoColla Cornu Cervi 6 g • Bai ZhuRhizoma Atractylodis macrocephalae 6 g • Fu LingPoria 6 g • Xiang FuRhizoma Cyperi 4 g • Yi Mu CaoHerba Leonuri 4 g • Zhi Gan CaoRadix Glycyrrhizae preparata 3 g Explanation
The first eight herbs constitute a variation of You Gui Wan to tonify and warm the Kidneys and nourish the Liver. • Bai Zhu and Fu Ling were added to tonify the Spleen. • Xiang Fu and Yi Mu Cao were added to move Qi and Blood and stop pain. • Zhi Gan Cao harmonizes.
After 10 packets of this decoction, she was no better at all. I therefore reassessed the diagnosis and principle of treatment and came to the conclusion that, although there was a pronounced deficiency, it would be better to eliminate pathogenic factors first. I did this by giving her first 10 packets of a decoction to resolve Dampness, and then 10 packets of a further decoction to invigorate Blood and eliminate stasis. The first decoction was a variation of Si Miao San Four Wonderful Powder: • Cang ZhuRhizoma Atractylodis 4 g • Huang BoCortex Phellodendri 4 g
• Niu XiRadix Achyranthis bidentatae seu Cyathulae 4 g • Yi Yi RenSemen Coicis 9 g • Dang GuiRadix Angelicae sinensis 6 g • Bai ZhuRhizoma Atractylodis macrocephalae 6 g • Fu LingPoria 6 g • Hong HuaFlos Carthami 4 g • Tao RenSemen Persicae 6 g • Tu Si ZiSemen Cuscutae 4 g Explanation
The first four herbs represent the Si Miao San. • Dang Gui and Tu Si Zi were added to nourish Liver and Kidneys. • Bai Zhu and Fu Ling were added to tonify the Spleen. • Hong Hua and Tao Ren were added to invigorate Blood, eliminate stasis and stop pain.
She improved considerably after this decoction which was then followed by a variation of Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction to invigorate Blood and eliminate stasis: • Wu Ling ZhiFaeces Trogopteri 4 g • Dang GuiRadix Angelicae sinensis 6 g • Chuan XiongRadix Chuanxiong 4 g • Tao RenSemen Persicae 4 g • Hong HuaFlos Carthami 4 g
• Chi ShaoRadix Paeoniae rubra 4 g • Wu YaoRadix Linderae 4 g • Yan Hu SuoRhizoma Corydalis 4 g • Xiang FuRhizoma Cyperi 4 g • Gan CaoRadix Glycyrrhizae 3 g • Zhi KeFructus Aurantii 4 g • Bai ZhuRhizoma Atractylodis macrocephalae 6 g • Tu Si ZiSemen Cuscutae 6 g
This is a variation of Ge Xia Zhu Yu Tang with the addition of Bai Zhu to tonify the Spleen and Tu Si Zi to tonify the Kidneys and the removal of Mu Dan Pi Cortex Moutan, too cooling for her condition. After 20 packets of this decoction, she was much better and her periods were painless. Even though neither of the above two formulae is tonifying, she had more energy. After 20 packets of this last decoction, the treatment principle reverted to the original one of tonifying Kidneys and Liver with You Gui Wan. This time, she felt well on it. This case history is given to illustrate the importance of adopting a correct principle of treatment: even if the diagnosis is correct, adoption of the wrong principle of treatment will not yield results. This case also shows the importance, in mixed excess and deficiency conditions, of eliminating pathogenic factors before tonifying: this approach is particularly important when herbs are used, less so if only acupuncture is used. Stagnation of Cold
Clinical manifestations
Lower abdominal pain before or after the period, pain central, pain relieved by the application of heat, menstrual blood rather scanty and bright red with small, dark clots, feeling cold, sore back. Tongue: Pale-Bluish or BluishPurple. Pulse: Deep and Choppy or Deep and Wiry. Treatment principle
Warm the Uterus, expel Cold, invigorate Blood. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-6 Qihai, ST-29 Guilai, KI-14 Siman, SP-8 Diji, SP-6 Sanyinjiao, ST-36 Zusanli, ST-28 Shuidao. Reducing method except on ST-36 which should be reinforced. Moxa must be used. Explanation
– LU-7 and KI-6 regulate the Directing Vessel and strengthen the Uterus. – Ren-4, with moxa, warms the Uterus. – Ren-6, with moxa, moves Qi and expels Cold from the lower abdomen. – ST-29 and KI-14 invigorate Blood. – SP-8 and SP-6 invigorate Blood and stop pain. – ST-36 tonifies Qi and helps to scatter Cold. – ST-28, with moxa cones, expels Cold from the Uterus. The ABC of
Acupuncture says: “For fullness, distension and pain of the hypogastrium radiating to the genitals, ache in the lower back during menstruation, accumulations and Cold in the Uterus … use ST-28 Shuidao.”9 Herbal treatment
Empty-Cold
a Prescription
– WEN JING TANG – Warming the Menses Decoction Explanation
This is a famous formula from the Synopsis of Prescriptions from the Golden Cabinet by Zhang Zhong Jing (AD 220), which is primarily for Cold obstructing the Uterus. The rationale behind it is as follows. When Cold obstructs the Uterus, it makes Blood stagnate. When Blood stagnates, new Blood has nowhere to go and it cannot be contained in the Uterus: this induces a deficiency of Blood. A longstanding Blood deficiency may give rise to some Empty-Heat signs, which may mistakenly be interpreted as Heat signs; but the Pale-Purple colour of the tongue clearly indicates that this is not so. In fact, the original text refers to a parched mouth and lips as the symptoms of Empty-Heat from Blood deficiency.10 When used for its proper pattern of longstanding internal Cold occurring against a background of deficiency and leading to stasis of Blood, this formula is very effective. An essential sign for its use is that the tongue-body colour be Pale or Bluish-
Purple. – Wu Zhu Yu, Gui Zhi and Sheng Jiang warm the Uterus and expel Cold. – Dang Gui, Chuan Xiong and Bai Shao nourish and invigorate Blood, which is necessary because the obstruction of the Uterus by Cold prevents new Blood from taking its proper place there. – Dang Shen tonifies Qi to nourish Blood. – Mai Men Dong and E Jiao nourish Blood and Yin. – Mu Dan Pi clears any Empty-Heat which might arise from Blood deficiency. – Ban Xia harmonizes the Uterus via the Stomach channel to which it is connected through the Penetrating Vessel. – Gan Cao harmonizes. b Prescription
– AI FU NUAN GONG WAN – Artemisia-Cyperus Warming the Uterus Pill Explanation
– Ai Ye, Wu Zhu Yu and Rou Gui warm the Uterus and expel Cold. – Xiang Fu moves Qi in the lower abdomen. – Dang Gui, Chuan Xiong and Bai Shao nourish and invigorate Blood.
– Huang Qi tonifies Qi in order to help to produce more Blood. – Sheng Di Huang nourishes Blood and Yin. – Xu Duan tonifies the Kidneys to help to nourish Blood. Compared with the previous formula, this is more warming and more tonifying. It is therefore suitable if there is a more pronounced Kidney-Yang deficiency, while the former is better if there is a Blood deficiency. The two formulae are similar in action. The main difference between them is that the former, Wen Jing Tang, which addresses the situation when the deficiency of Blood is a consequence of Cold obstructing the Uterus, is applicable for a deficiency of Blood and Yin with some symptoms of Empty-Heat such as a malar flush and a feeling of heat; the latter, Ai Fu Nuan Gong Wan, is used when a deficiency of Kidney-Yang and Blood leads to internal Cold. Modifications
These variations apply to both formulae. • If symptoms of Cold are very pronounced, add (or increase if already in the formula) Fu Zi Radix Aconiti lateralis preparata and Ai Ye Folium Artemisiae argyi. • If there is Dampness as well as Cold add, Cang Zhu Rhizoma Atractylodis and Fu Ling Poria. c Prescription
– WEN QI HUA SHI TANG – Warming the Umbilicus and Resolving Dampness Decoction Explanation
This prescription is from Fu Qing Zhu’s Gynaecology. It is for long-term
retention of Cold and Dampness in the Uterus leading to deficiency of Qi and Yang and painful periods. Fu Qing Zhu says: Some women have pain below the umbilicus 3–5 days before the period, the pain is stabbing and the period is like black-bean juice … who would say that this is due to Cold and Dampness in the Lower Burner! … The Directing and Penetrating Vessels are in the Lower Burner, the Penetrating Vessel is the Sea of Blood and the Directing Vessel controls the Uterus and is the Blood Chamber … the menses spring from these two vessels, when these are obstructed by Cold and Dampness a struggle between these two causes pain; the pathogenic factors are victorious and the Upright Qi declines. Cold generates turbidity and, because of this, the menstrual blood looks like black-bean juice. The treatment must be aimed at resolving Dampness and expelling Cold [with warm herbs] to eliminate the pathogenic factors from the Directing and Penetrating Vessels.11 – Bai Zhu benefits the Qi of the back and umbilicus. – Fu Ling resolves Dampness. – Ba Ji Tian and Bai Guo remove obstructions from the Directing Vessel. – Bian Dou, Shan Yao and Lian Zi protect the Penetrating Vessel. d Prescription
– WEN SHEN FU YANG TANG – Warming the Kidneys and Supporting Yang Decoction Explanation
– Ren Shen, Bai Zhu and Shan Yao tonify the Spleen and the Original Qi.
– Shu Di Huang and Shan Zhu Yu tonify Liver and Kidneys. – Wu Zhu Yu, Rou Gui and Fu Zi warm the Uterus and expel Cold. – Tu Si Zi and Bu Gu Zhi tonify Kidney-Yang. This formula is the most tonifying of the four for painful periods from Empty-Cold. The four formulae are compared and contrasted in Table 14.1. Table 14.1 Comparison of four formulae for Painful Periods from Empty-Cold
Women’s Treasure remedy
– WARM THE MENSES This remedy is a variation of the formula Wen Jing Tang Warming the Menses Decoction which expels Cold, warms the Uterus and nourishes
Blood. The tongue presentation appropriate to this remedy is a Pale or Bluish-Purple body. Full-Cold
Prescription
– SHAO FU ZHU YU TANG – Lower Abdomen Eliminating Stasis Decoction Explanation
– Xiao Hui Xiang, Gan Jiang and Rou Gui warm the Uterus and expel Cold. – Yan Hu Suo, Mo Yao, Pu Huang and Wu Ling Zhi invigorate Blood and stop pain. – Dang Gui, Chuan Xiong and Chi Shao nourish and invigorate Blood. Modifications
• If there is Dampness, add Cang Zhu Rhizoma Atractylodis and Fu Ling Poria. Summary Stagnation of cold
Clinical manifestations
Lower abdominal pain before or after the period, pain central, pain relieved by the application of heat, menstrual blood rather scanty and bright red with small, dark clots, feeling cold, sore back. Tongue: Pale-Bluish or BluishPurple. Pulse: Deep and Choppy or Deep and Wiry. Treatment principle
Warm the Uterus, expel Cold, invigorate Blood. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-6 Qihai, ST-29 Guilai, KI-14 Siman, SP-8 Diji, SP-6 Sanyinjiao, ST-36 Zusanli, ST-28 Shuidao. Reducing method except on ST-36 which should be reinforced. Moxa must be used. Herbal treatment
Empty-cold Prescriptions • WEN JING TANGWarming the Menses Decoction • AI FU NUAN GONG WANArtemisia-Cyperus Warming the Uterus Pill • WEN QI HUA SHI TANGWarming the Umbilicus and Resolving Dampness Decoction • WEN SHEN FU YANG TANGWarming the Kidneys and Supporting Yang Decoction Women’s Treasure remedy
• WARM THE MENSES Full-Cold
Prescription • SHAO FU ZHU YU TANGLower Abdomen Eliminating Stasis Decoction
Case history A 42-year-old woman had been suffering from painful periods for 15 years. Her cycle was short, with a period coming every 21–25 days. She experienced severe pain during the period and the blood was red with small dark clots. She felt cold in general, but especially so during the period. She also suffered from backache and dizziness. Her tongue was Pale and slightly Swollen. Her pulse was very Slow (52), Choppy, Weak on the left Rear position and had no wave. Diagnosis
The painful periods themselves are due to Cold obstructing the Uterus. This is Cold of the Empty type as is clearly shown by the Weak and Choppy pulse. Besides this, there is an underlying deficiency of Kidney-Yang as shown by the Slow and Weak pulse on the left Rear position, Pale and Swollen tongue, dizziness, cold feeling and backache, and some deficiency of Qi and Blood as evidenced by the Choppy pulse. Tre atme nt principle
The treatment principle adopted was to tonify and warm Kidney-Yang, scatter internal Cold, nourish Blood and stop pain. She was treated with both acupuncture and herbs. Acupuncture
The acupuncture points, used with even method to scatter Cold and reinforcing method to tonify the Kidneys and nourish Blood, were selected from the following:
• LU-7 Lieque and KI-6 Zhaohai to open the Directing Vessel, regulate Qi and Blood in the Uterus and stop pain. • ST-29 Guilai, with moxa, to invigorate Blood, scatter Cold and stop pain. • Ren-6 Qihai and Ren-4 Guanyuan, with moxa, to tonify Qi and Blood and strengthen Kidney-Yang. • BL-23 Shenshu, with needle and moxa, to tonify and warm Kidney-Yang. • SP-6 Sanyinjiao and ST-36 Zusanli to tonify Qi and Blood. Herbal treatment
The formula used was a variation of Ai Fu Nuan Gong Wan ArtemisiaCyperus Warming the Uterus Pill: • Ai YeFolium Artemisiae argyi 9 g • Wu Zhu YuFructus Evodiae 4.5 g • Rou GuiCortex Cinnamomi 3 g • Xiang FuRhizoma Cyperi 6 g • Dang GuiRadix Angelicae sinensis 9 g • Chuan XiongRhizoma Chuanxiong 6 g • Bai ShaoRadix Paeoniae alba 9 g • Huang QiRadix Astragali 6 g • Sheng Di HuangRadix Rehmanniae 9 g • Xu DuanRadix Dipsaci 6 g • Wu YaoRadix Linderae 6 g • Yan Hu SuoRhizoma Corydalis 6 g Explanation
The first 10 herbs constitute the root formula which scatters Cold, warms the Uterus, tonifies Qi and Blood and tonifies and warms Kidney-Yang. • Wu Yao and Yan Hu Suo move Qi and Blood and stop pain.
This patient was treated with acupuncture every 2 weeks and took the above decoction, with slight variations, for 6 months. After this time, her cycle became regular and the menstrual pain was reduced by about 80%. Case history A 35-year-old woman had been suffering from painful periods from the age of 14 which were now getting worse. The pain was central in the lower abdomen and occurred mostly on the first day: severe and cramping, it was relieved by the application of a hot-water bottle. When she had the pain, she liked to curl up and she felt cold and turned pale. The menstrual cycle was 30 days long, the period lasted 5 days and the blood was dark with small clots. Her complexion was pale, her tongue was slightly Pale with a white coating and her pulse was very slightly Tight on the left and Weak on both Rear positions. Diagnosis
This is a clear example of painful periods from Empty-Cold. The Cold is evident from the severe, cramping nature of the pain, its alleviation with heat, the cold feeling and pale complexion during the period, the small, dark clots and the Tight pulse. That the Cold is of a deficient nature is evident from the desire to curl up, from the Weak pulse on both Rear positions and from the fact that the pulse is only very slightly Tight on the left. Apart from the EmptyCold, there is a deficiency of Kidney-Yang as shown by the Weak pulse on both Kidney positions. As for the cause of this problem, as a schoolgirl in Yorkshire (a county in the North of England with a cold and damp climate) she played lots of sports
and did cross-country running. This had obviously led to the invasion of external Cold in the Uterus; as explained in Chapter 4 on aetiology, the genital system in young girls is particularly vulnerable and prone to invasion of external Cold. Tre atme nt principle
This patient was treated only with herbs as she lived quite a long way away. I selected a variation of Wen Jing Tang Warming the Menses Decoction, using the whole original decoction plus: • Xiang Fu Rhizoma Cyperi and Yan Hu Suo Rhizoma Corydalis to move Qi and invigorate Blood.
The results in this case exceeded every expectation as, after only seven packets of the above decoction, her next period was totally pain free and, at the time of writing (4 months later), her periods are still so. In subsequent decoctions, I added Du Zhong Cortex Eucommiae to tonify Kidney-Yang. Damp-Heat
Clinical manifestations
Hypogastric pain before the period and sometimes on mid-cycle, burning sensation extending to the sacrum, feeling of heat, menstrual blood red with small clots, vaginal discharge, scanty, dark urine, thirst, mental restlessness. Tongue: Red, sticky-yellow tongue coating. Pulse: Slippery. Treatment principle
Clear Heat, resolve Dampness, eliminate stasis.
Acupuncture
SP-9 Yinlingquan, SP-6 Sanyinjiao, LU-7 Lieque on the right and KI-6 Zhaohai on the left, Ren-3 Zhongji, ST-28 Shuidao, BL-32 Ciliao, BL-22 Sanjiaoshu, Ren-9 Shuifen, L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, LIV3 Taichong. Reducing or even method. Explanation
– SP-9 and SP-6 resolve Dampness in the Lower Burner. SP-6 also moves Blood. – LU-7 and KI-6 open the Directing Vessel and regulate the Uterus. – Ren-3 and ST-28 resolve Dampness from the Lower Burner and Uterus. – BL-32 resolves Dampness in the Uterus. – BL-22 promotes the transformation of fluids and resolves Dampness from the Lower Burner. – Ren-9 promotes the transformation of fluids. – L.I.-11 and SP-10 cool Blood. – KI-2 and LIV-3 in combination, cool Blood. LIV-3 also invigorates Blood. Herbal treatment
a Prescription
– QING RE TIAO XUE TANG – Clearing Heat and Regulating Blood Decoction Explanation
– Dan Pi and Sheng Di clear Heat and cool Blood. – Huang Lian resolves Damp-Heat. – Dang Gui and Bai Shao harmonize Blood. – Chuan Xiong, Hong Hua, Tao Ren and E Zhu invigorate Blood. – Xiang Fu and Yan Hu Suo move Qi and stop pain. Yan Hu Suo also invigorates Blood. b Prescription
– EMPIRICAL PRESCRIPTION Explanation
Compared with the previous formula, the present prescription aims more at resolving Damp-Heat, the former more at clearing Heat and cooling Blood. – Qu Mai, Bian Xu, Mu Tong and Che Qian Zi drain Dampness via urination. – Huang Qin resolves Damp-Heat.
– Chi Shao and Di Gu Pi clear Heat and cool Blood. – Chuan Lian Zi and Yan Hu Suo move Qi and stop pain. – Gan Cao harmonizes. c Prescription
– ER MIAO SAN Variation – Two Wonderful Powder Variation Explanation
– Cang Zhu and Huang Bo form the Er Miao San which resolves DampHeat from the Lower Burner. – Bai Jiang Cao resolves Fire-poison, invigorates Blood and stops pain. – Yan Hu Suo invigorates Blood and stops pain. Women’s Treasure remedy
– DRAIN REDNESS This remedy is a variation of the formula Qing Re Tiao Xue Tang Clearing Heat and Regulating Blood Decoction which clears Heat, cools Blood, resolves Dampness and stops pain. The tongue presentation appropriate to this remedy is a Red body with sticky-yellow coating. Summary
Damp-Heat
Clinical manife stations
Hypogastric pain before the period and sometimes on mid-cycle, burning sensation extending to the sacrum, feeling of heat, menstrual blood red with small clots, vaginal discharge, scanty, dark urine, thirst, mental restlessness. Tongue: Red, sticky-yellow tongue coating. Pulse: Slippery. Tre atme nt principle
Clear Heat, resolve Dampness, eliminate stasis. Acupuncture
SP-9 Yinlingquan, SP-6 Sanyinjiao, LU-7 Lieque on the right and KI-6 Zhaohai on the left, Ren-3 Zhongji, ST-28 Shuidao, BL-32 Ciliao, BL-22 Sanjiaoshu, Ren-9 Shuifen, L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, LIV3 Taichong. Reducing or even method. He rbal tre atme nt
Prescriptions
• QING RE TIAO XUE TANGClearing Heat and Regulating Blood Decoction • EMPIRICAL PRESCRIPTION • ER MIAO SAN Variation Two Wonderful Powder Variation Women’s Treasure re me dy
• DRAIN REDNESS
Stagnant Liver-Qi turning into Fire
Clinical manifestations
Abdominal pain before or during the period, dark menstrual blood, heavy period, irritability, propensity to outbursts of anger, thirst, feeling of heat, dry stools. Tongue: Red with yellow coating, redder on the sides. Pulse: Rapid, Wiry. This is Liver-Fire deriving from long-term stagnation of Liver-Qi. It is treated not by draining Fire with bitter-cold herbs but by clearing Heat through eliminating stagnation. Treatment principle
Clear Heat, pacify the Liver, eliminate stagnation, stop pain. Acupuncture
LIV-3 Taichong, LIV-2 Xingjian, LIV-14 Qimen, Ren-6 Qihai, Ren-4 Guanyuan, KI-14 Siman, SP-10 Xuehai, L.I.-11 Quchi, T.B.-6 Zhigou, G.B.-34 Yanglingquan. All with reducing or even method. No moxa. Explanation
– LIV-3 pacifies the Liver and eliminates stagnation. It also harmonizes the Qi of the Penetrating Vessel and stops pain. – LIV-2 clears Liver-Fire. – LIV-14, T.B.-6 and G.B.-34 pacify the Liver, move Qi and eliminate stagnation.
– Ren-6 moves Qi in the lower abdomen. – Ren-4 invigorates Blood and strengthens the Uterus. – KI-14 moves Qi and Blood and harmonizes the Qi of the Penetrating Vessel. – SP-10 invigorates Blood and stops pain. – L.I.-11 clears Heat. Herbal treatment
a Prescription
– XUAN YU TONG JING TANG – Dispersing Stagnation and Penetrating the Menses Decoction Explanation
This formula is from Fu Qing Zhu’s Gynaecology. He explains that it is for abdominal pain before the period with dark, clotted blood, due to stagnant Liver-Qi turning into Fire. He says that to treat this, it is important to eliminate the stagnation; to clear Heat without eliminating the stagnation that creates it is like lopping off a branch (the Heat) but not the root (the stagnation).12 Unfortunately, Fu Qing Zhu does not explain the reason for the interesting inclusion of Bai Jie Zi in the formula: in fact, this herb expels Cold, warms the Lungs and resolves Cold-Phlegm from the Lungs. One possible explanation is that Bai Jie Zi is used to regulate Qi in the diaphragm, thus
helping to pacify Liver-Qi; another, that this very pungent herb is coordinated with the bitter herbs, such as Huang Qin, according to the principle of using ‘the pungent taste to open the passages, and the bitter taste to make Qi descend’: this sounds good but it is a method that is actually used to resolve Dampness, not to pacify the Liver! – Bai Shao and Dang Gui pacify the Liver. – Mu Dan Pi, Shan Zhi Zi and Huang Qin clear Liver-Heat. – Bai Jie Zi: see above. – Chai Hu, Xiang Fu and Yu Jin pacify the Liver, move Qi and eliminate stasis. – Gan Cao harmonizes. b Prescription
– DAN ZHI XIAO YAO SAN – Moutan-Gardenia Free and Easy Wanderer Powder Explanation
This formula, already explained, is specific to clear Liver-Heat when it derives from stagnation of Liver-Qi. It is milder than the previous prescription and is therefore suitable when the symptoms of Heat are not pronounced and those of stagnation predominate. Summary Stagnant Live r-Q i turning into Fire
Clinical manifestations
Abdominal pain before or during the period, dark menstrual blood, heavy period, irritability, propensity to outbursts of anger, thirst, feeling of heat, dry stools. Tongue: Red with yellow coating, redder on the sides. Pulse: Rapid, Wiry. Treatment principle
Clear Heat, pacify the Liver, eliminate stagnation, stop pain. Acupuncture
LIV-3 Taichong, LIV-2 Xingjian, LIV-14 Qimen, Ren-6 Qihai, Ren-4 Guanyuan, KI-14 Siman, SP-10 Xuehai, L.I.-11 Quchi, T.B.-6 Zhigou, G.B.-34 Yanglingquan. All with reducing or even method. No moxa. Herbal treatment
Prescriptions • XUAN YU TONG JING TANGDispersing Stagnation and Penetrating the Menses Decoction • DAN ZHI XIAO YAO SAN Moutan-Gardenia Free and Easy Wanderer Powder
Empty conditions
Qi and Blood deficiency
Clinical manifestations
Dull hypogastric pain towards the end of or after the period, dragging sensation in the lower abdomen, pain relieved by pressure and massage, scanty bleeding, pale complexion, tiredness, slight dizziness, loose stools. Tongue: Pale. Pulse: Choppy. Treatment principle
Tonify Qi, strengthen the Spleen, nourish Blood. Acupuncture
Ren-4 Guanyuan, Ren-6 Qihai, ST-36 Zusanli, SP-6 Sanyinjiao, SP-8 Diji, BL-20 Pishu, SP-10 Xuehai, BL-54 Zhibian, BL-32 Ciliao. All with reinforcing method except for SP-10, BL-54 and BL-32 which should be needled with even method. Moxa is applicable. Explanation
– Ren-4 nourishes Blood and the Uterus. – Ren-6 tonifies and moves Qi in the lower abdomen.
– ST-36 and SP-6 tonify Qi, strengthen the Spleen and nourish Blood. – SP-8 stops pain. – BL-20 strengthens the Spleen and nourishes Blood. – SP-10 invigorates Blood and stops pain. – BL-54 and BL-32 invigorate Blood and affect the lower genital system. They are indicated when the period pain occurs in the sacrum area. Herbal treatment
a Prescription
– SHENG YU TANG – Sage-like Healing Decoction Explanation
– Ren Shen and Huang Qi tonify Qi. – Dang Gui, Chuan Xiong, Shu Di and Bai Shao nourish and invigorate Blood. b Prescription
– BA ZHEN YI MU TANG
– Eight Precious Leonorus Decoction Explanation
This is the Ba Zhen Tang Eight Precious Decoction, which has already been explained, with the addition of Yi Mu Cao Herba Leonori to invigorate Blood and stop pain. c Prescription
– SHI QUAN DA BU TANG – Ten Complete Great Tonification Decoction Explanation
This formula is used if there are symptoms of Cold. Modifications
Even in painful periods of a deficiency type, there is always an element of stagnation, so in order to move Qi and Blood and stop pain, add Xiang Fu Rhizoma Cyperi and Yan Hu Suo Rhizoma Corydalis. Women’s Treasure remedy
– PRECIOUS SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. The tongue presentation appropriate to this remedy is a Pale and Thin body.
Summary Qi and Blood deficiency
Clinical manife stations
Dull hypogastric pain towards the end of or after the period, dragging sensation in the lower abdomen, pain relieved by pressure and massage, scanty bleeding, pale complexion, tiredness, slight dizziness, loose stools. Tongue: Pale. Pulse: Choppy. Tre atme nt principle
Tonify Qi, strengthen the Spleen, nourish Blood. Acupuncture
Ren-4 Guanyuan, Ren-6 Qihai, ST-36 Zusanli, SP-6 Sanyinjiao, SP-8 Diji, BL-20 Pishu, SP-10 Xuehai, BL-54 Zhibian, BL-32 Ciliao. All with reinforcing method except for SP-10, BL-54 and BL-32 which should be needled with even method. Moxa is applicable. He rbal tre atme nt
Prescriptions
• SHENG YU TANGSage-like Healing Decoction • BA ZHEN YI MU TANGEight Precious Leonorus Decoction • SHI QUAN DA BU TANGTen Complete Great Tonification Decoction Women’s Treasure re me dy
• PRECIOUS SEA
Yang and Blood deficiency
Clinical manifestations
Dull abdominal pain after the periods, scanty with pale blood, no clots, abdominal pain relieved by pressure and application of heat, dull headache, blurred vision, feeling cold, depression, dizziness. Tongue: Pale and Swollen. Pulse: Fine and Deep. This is due to a deficiency of Spleen-Yang and deficiency of Liver-Blood. Treatment principle
Warm the Yang, nourish Blood, strengthen the Centre and stop pain. Acupuncture
BL-20 Pishu, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, LIV-8 Ququan. LU-7 Lieque (on the right) and KI-6 Zhaohai (on the right), BL-54 Zhibian, BL-32 Ciliao. All with reinforcing method, except for BL-54 and BL-32 which should be needled with even method; moxa should be used. Explanation
– BL-20, Ren-12, ST-36 and SP-6, with moxa, nourish Blood, tonify the Spleen and warm the Yang.
– Ren-4 and LIV-8 nourish Blood. – LU-7 and KI-6 regulate the Directing Vessel and strengthen the Uterus. – BL-54 and BL-32 invigorate Blood and affect the lower genital system. They are indicated when the period pain occurs in the sacrum area. Herbal treatment
a Prescription
– DANG GUI JIAN ZHONG TANG – Angelica Strengthening the Centre Decoction Explanation
This is a variation of the formula Xiao Jian Zhong Tang Small Strengthening the Centre Decoction. – Dang Gui and Bai Shao nourish Blood. – Yi Tang and Da Zao tonify Qi. – Gui Zhi and Sheng Jiang warm the channels and expel Cold. – Zhi Gan Cao harmonizes. Modifications
• If symptoms of Cold are pronounced, add Rou Gui Cortex
Cinnamomi. • If there is a deficiency of Kidney-Yang, add Ba Ji Tian Radix Morindae officinalis and Tu Si Zi Semen Cuscutae. • If the deficiency of Blood is pronounced, add Shou Wu Radix Polygoni multiflori preparata and Shu Di Huang Radix Rehmanniae preparata. • If menstrual pain is severe, add Yan Hu Suo Rhizoma Corydalis. • If bleeding is profuse, add Ai Ye Folium Artemisiae argyi. • If the deficiency of Spleen-Yang is pronounced, add Bai Zhu Rhizoma Atractylodis macrocephalae and Gan Jiang Rhizoma Zingiberis. b Prescription
– YI SHEN TONG JING TANG – Benefiting the Kidneys and Penetrating the Menses Decoction Explanation
– Shan Yao tonifies the Kidneys and Spleen. – Ba Ji Tian tonifies and warms Kidney-Yang. – Dang Gui, Shu Di Huang and Bai Shao nourish Blood. – Xiang Fu and Chai Hu pacify the Liver, move Qi and eliminate stagnation. – Yu Jin and Dan Shen invigorate Blood and eliminate stasis.
Compared with the previous formula, this formula has a stronger Blood-invigorating effect and is therefore suitable when pain is more intense. c Prescription
– YU SHEN HUA YU TANG13 – Generating the Kidneys and Transforming Stasis Decoction Explanation
– Ba Ji Tian, Yin Yang Huo, Xu Duan and Tu Si Zi tonify and warm Kidney-Yang. – Dang Shen and Dang Gui tonify Qi and Blood. – Mu Dan Pi, Tao Ren, Hong Hua, Pu Huang and Chi Shao invigorate Blood and eliminate stasis. – Xiang Fu moves Qi, which helps to invigorate Blood. Women’s Treasure remedy
– WARM THE PALACE This remedy is a variation of the formula Dang Gui Jian Zhong Tang Angelica Strengthening the Centre Decoction which tonifies Kidney-Yang and nourishes Blood. The tongue presentation appropriate to this remedy is a Pale body. Summary
Yang and Blood deficiency
Clinical manife stations
Dull abdominal pain after the periods, scanty with pale blood, no clots, abdominal pain relieved by pressure and application of heat, dull headache, blurred vision, feeling cold, depression, dizziness. Tongue: Pale and Swollen. Pulse: Fine and Deep. Tre atme nt principle
Warm the Yang, nourish Blood, strengthen the Centre and stop pain. Acupuncture
BL-20 Pishu, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, LIV-8 Ququan. LU-7 Lieque (on the right) and KI-6 Zhaohai (on the right), BL-54 Zhibian, BL-32 Ciliao. All with reinforcing method, except for BL-54 and BL-32 which should be needled with even method; moxa should be used. He rbal tre atme nt
Prescriptions
• DANG GUI JIAN ZHONG TANGAngelica Strengthening the Centre Decoction • YI SHEN TONG JING TANGBenefiting the Kidneys and Penetrating the Menses Decoction • YU SHEN HUA YU TANGGenerating the Kidneys and Transforming Stasis Decoction Women’s Treasure re me dy
• WARM THE PALACE
Kidney- and Liver-Yin deficiency
Clinical manifestations
Dull hypogastric pain towards the end of or after the period, sore back, dizziness, scanty bleeding, pain relieved by pressure and massage, tinnitus, blurred vision, exhaustion. Tongue: without coating; Red if there is EmptyHeat. Pulse: Floating-Empty. Treatment principle
Nourish Yin, benefit the Kidneys, nourish the Liver. Acupuncture
BL-23 Shenshu, BL-18 Ganshu, Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-3 Taixi, ST-36 Zusanli, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), BL-54 Zhibian, BL-32 Ciliao. Reinforcing method, except for BL-54 and BL-32 which should be needled with even method. A small amount of moxa may be used if the tongue is not too Red. Explanation
– BL-23 and BL-18 tonify Kidneys and Liver. – Ren-4 nourishes Yin and tonifies the Kidneys and the Uterus.
– SP-6 and KI-3 nourish the Kidneys and Liver and regulate Blood. – ST-36 tonifies Qi and Blood and regulates the Uterus Connecting channel. – LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and nourish Yin. – BL-54 and BL-32 invigorate Blood and affect the lower genital system. They are indicated when the period pain occurs in the sacrum area. Herbal treatment
a Prescription
– TIAO GAN TANG – Regulating the Liver Decoction Explanation
– Dang Gui and Bai Shao nourish and move Blood. – Shan Yao tonifies Stomach and Kidneys. – E Jiao nourishes Blood. – Shan Zhu Yu nourishes Liver-Yin. – Ba Ji Tian tonifies Kidney-Yang and Kidney-Essence.
– Gan Cao harmonizes. Modifications
• If there is Damp-Heat, remove E Jiao and Ba Ji Tian and add Yi Yi Ren Semen Coicis, Ze Xie Rhizoma Alismatis and Bai Jiang Cao Herba Patriniae. • If there is stasis of Blood, add Yan Hu Suo Rhizoma Corydalis and Chi Shao Radix Paeoniae rubra. b Prescription
– GUI SHAO DI HUANG TANG – Angelica-Paeonia-Rehmannia Decoction Explanation
This formula nourishes Blood as well as Yin and it is therefore used when there is deficiency of Blood as well as of Yin. It is a variation of Liu Wei Di Huang Tang Six-Ingredient Rehmannia Decoction. – The first six herbs constitute the Liu Wei Di Huang Tang which nourishes Liver- and Kidney-Yin. – Bai Shao and Dang Gui nourish Blood. Summary Kidne y- and Live r-Yin De ficie ncy
Clinical manifestations
Dull hypogastric pain towards the end of or after the period, sore back, dizziness, scanty bleeding, pain relieved by pressure and massage, tinnitus, blurred vision, exhaustion. Tongue: without coating; Red if there is EmptyHeat. Pulse: Floating-Empty. Treatment principle
Nourish Yin, benefit the Kidneys, nourish the Liver. Acupuncture
BL-23 Shenshu, BL-18 Ganshu, Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-3 Taixi, ST-36 Zusanli, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), BL-54 Zhibian, BL-32 Ciliao. Reinforcing method, except for BL-54 and BL-32 which should be needled with even method. A small amount of moxa may be used if the tongue is not too Red. Herbal treatment
Prescriptions • TIAO GAN TANGRegulating the Liver Decoction • GUI SHAO DI HUANG TANGAngelica-Paeonia-Rehmannia Decoction
Case history A 33-year-old woman had been suffering from painful periods for 10 years. The pain occurred during the period and the blood was bright red and rather scanty. She felt cold in general and colder during the period. She had had four miscarriages. She also suffered from backache, dizziness, tinnitus, poor memory, a dry mouth at night and night sweating. Her urination was frequent and occasionally it dribbled. She felt always very tired and her knees ached. Her tongue was of a normal colour but without spirit on the root. Her pulse was generally Weak and, on the left side, very Fine and
Empty at the deep level. Diagnosis
This is a complicated condition characterized by a deficiency of both Kidney-Yin and Kidney-Yang. The symptoms of Kidney-Yin deficiency are: dizziness, tinnitus, dry mouth at night, night sweating, poor memory, tongue root without spirit and pulse Empty at the deep level. The symptoms of Kidney-Yang deficiency are: feeling cold, achy knees and frequent and dribbling urination. The miscarriages were due to the Kidney deficiency. Thus, this is a deficiency type of painful periods. Tre atme nt principle
The treatment principle adopted was to nourish Kidney-Yin and warm and tonify Kidney-Yang. The emphasis was put on nourishing Kidney-Yin as when both Yin and Yang are deficient, it is important to nourish the substance first (Kidney-Yin) rather than the function (Kidney-Yang). The very Fine pulse which is also Empty at the deep level also indicates the importance of nourishing the Yin primarily. However, secondary tonification of Kidney-Yang should not be overlooked. Herbal treatment
The formula used was a variation of Tiao Gan Tang Regulating the Liver Decoction: • Dang GuiRadix Angelicae sinensis 9 g • Bai ShaoRadix Paeoniae alba 9 g • Shan YaoRhizoma Dioscoreae 6 g • E JiaoColla Corii asini 6 g • Shan Zhu YuFructus Corni 6 g • Ba Ji TianRadix Morindae officinalis 4 g
• Zhi Gan CaoRadix Glycyrrhizae preparata 3 g • Chi ShaoRadix Paeoniae rubra 6 g • Yi Mu CaoHerba Leonuri 6 g • Gou JiRhizoma Cibotii 4 g • Gou Qi ZiFructus Lycii 9 g • Sheng Di HuangRadix Rehmanniae 12 g Explanation
The first seven herbs constitute the Tiao Gan Tang which nourishes Liver and Kidneys. • Chi Shao and Yi Mu Cao move Blood and stop pain. • Gou Ji was added to tonify Kidney-Yang and strengthen the back and knees. • Gou Qi Zi was added to nourish Liver-Yin. • Sheng Di Huang was added to nourish Kidney-Yin.
This patient was treated with this decoction (with slight variations) for 6 months, producing a cure in the painful periods. After a further 6 months of treatment with the same decoction taken on alternate weeks, she conceived and delivered a healthy baby. Ancient acupuncture prescriptions for Painful Periods 14
1. Ren-4 Guanyuan for Cold in the Penetrating Vessel (Simple Questions, Huang Di Nei Jing Su Wen, Ch. 39). 2. ST-28 Shuidao for distension, fullness and pain in the lower abdomen, lumbosacral pain during menstruation, palpable masses and Cold in the
Uterus with pain radiating to the thighs (ABC of Acupuncture, Zhen Jiu Jia Yi Jing, AD 259). 3. KI-6 Zhaohai, SP-6 Sanyinjiao, ST-44 Neiting and L.I.-4 Hegu for dizziness and pain on the lateral sides of the abdomen during the period; or KI-6 Zhaohai, G.B.-35 Yangjiao, ST-44 Neiting and L.I.-4 Hegu (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601). 4. ST-28 Shuidao and ST-27 Daju (Thousand Golden Ducat Prescriptions, Qian Jin Yao Fang, AD 652).15 5. ST-25 Tianshu and P-5 Jianshi (Experience of Acupuncture and Moxibustion, Zhen Jiu Zi Sheng Jing, 1220).
Prognosis and prevention Both acupuncture and Chinese herbs either singly or in combination give excellent results in painful periods and the overwhelming majority of cases can be cured. The Empty types are easier to treat than the Full types. Of the Full types, the one from Damp-Heat is the most difficult to treat while the one from stagnation of Qi and Blood is the easiest. Of course, in many patients there is a mixed condition of deficiency and excess, in which case one concentrates on treating the stagnation in the 2 weeks before the periods and the deficiency in the 2 weeks after. In some cases, it is better to eliminate pathogenic factors before tonifying: see case history above. In any menstrual problem, it takes a minimum of three menstrual cycles to regulate Blood and the Directing and Penetrating Vessels. Three months is therefore the shortest possible time for the treatment to be successful. If dysmenorrhoea is due to endometriosis (see below), the treatment will take considerably longer than for functional painful periods. Dr Su Xin Ming, my acupuncture teacher in Nanjing, used to say that acupuncture should give very good results in painful periods: if it does not, it probably means the woman has endometriosis.
Western view Western medicine differentiates primary from secondary dysmenorrhoea. Primary dysmenorrhoea starts during adolescence and is not associated with any organic disorder. From the Chinese point of view, this is often due to invasion of Cold in the Uterus when young girls are exposed to cold during puberty either because they often play outdoor games during cold and wet winters, or because they have been engaged in physical work (such as farming) outdoors. Secondary dysmenorrhoea starts later in life and may be associated (although not necessarily) with organic diseases such as endometriosis, pelvic inflammatory disease or myomas. Studies show that primary dysmenorrhoea is associated with uterine hypercontractility: during contractions, endometrial blood flow is reduced and there is a correlation between minimal blood flow and maximal colicky pain, favouring the idea that ischaemia due to hypercontractility causes primary dysmenorrhoea.16 This ties in well with the Chinese idea that stagnation of Qi and Blood is a factor in most types of dysmenorrhoea: indeed, one of the many actions of Blood-invigorating herbs is to improve circulation of blood and relieve ischaemia. Endometriosis
In endometriosis, ectopic endometrium is implanted in adjacent pelvic organs such as ovaries, Fallopian tubes, pelvic ligaments, vagina, sigmoid colon, rectum, ureters or bladder. The most common symptom associated with endometriosis is pelvic pain which usually starts 1–2 days before the period and lasts throughout it. There may also be rectal pressure, pain on defaecation, lower backache radiating to the anterior thigh and dyspareunia (pain on intercourse). However, there is no direct correlation between the severity of the pain and the extent of endometriosis: in fact, some women with severe endometriosis may have no symptoms and, vice versa, women
with very slight endometriosis may suffer severe pain. The differential diagnosis of endometriosis is very difficult because many other diseases present with symptoms very similar to those of endometriosis: these include primary dysmenorrhoea, pelvic inflammatory disease, ovarian tumours, uterine myomas and gastrointestinal disorders such as irritable bowel syndrome. The diagnosis of endometriosis is also fraught with difficulties and is affected by subjectivity. Although a laparoscopy may seem an objective and conclusive diagnostic technique, it suffers from inherent faults: the main one, that it relies entirely on the visual and very subjective assessment of the pelvis by the operator and consequently is prone to misinterpretation and subjectivity; often microscopic disease is not detected. Laparoscopy is also associated with significant morbidity.17 Endometriosis is on the increase and it has become the commonest cause of secondary dysmenorrhoea. It is also a major cause of infertility: 30–70% of women investigated for infertility are found to have endometriosis in varying degrees of severity. However, as it occurs in other cases, this association does not necessarily prove that there is a causal link between endometriosis and infertility, except in cases of gross disease of the pelvis. Endometriosis may cause lack of ovulation, the luteinized unruptured follicle syndrome (i.e. the follicle responds to the luteinizing hormone surge but fails to rupture) and luteal phase deficiency: each of these conditions may cause infertility. The treatment for endometriosis in women over 40 is radical surgery, i.e. hysterectomy, bilateral salpingo-oophorectomy and resection of all residual disease. In women under 40, danazol is usually prescribed: this is a derivative of 17α ethinyl testosterone that acts on ovarian steroidogenesis and with an antigonadotropic effect. The side effects of danazol are largely androgenic and they include weight gain, reduction in breast size, mood changes, depression, acne, decreased libido, headaches, muscle cramps, hot flushes, oily skin, oedema, hirsutism, nausea and a deep voice. This last change is often permanent and irreversible when the medication is discontinued. From a Chinese perspective, this disease falls under the category of
‘Painful Periods’ or ‘Abdominal Masses’. Endometriosis is discussed in detail in Chapter 65. Myoma
Myomas do not usually cause pain. However, if there is torsion they may cause dysmenorrhoea. Dysmenorrhoea due to myomas may be helped even if they cannot be dissolved. Invigorating Blood and eliminating stasis will ease the dysmenorrhoea and in general make the abdomen feel more comfortable in spite of the myomas. Very small myomas (up to about 2 cm in diameter) may be dissolved with acupuncture and Chinese herbs. If the diagnosis of myomas is definitely confirmed, then the formulae used should include strong herbs which ‘break’ Blood such as E Zhu Rhizoma Curcumae, Ze Lan Herba Lycopi and San Leng Rhizoma Sparganii. A particularly good formula for myomas from stasis of Blood is Gui Zhi Fu Ling Tang Ramulus Cinnamomi-Poria Decoction which contains Gui Zhi Ramulus Cinnamomi, Fu Ling Poria, Tao Ren Semen Persicae, Chi Shao Radix Paeoniae rubra and Mu Dan Pi Cortex Moutan. The treatment of myomas is discussed in detail in Chapter 67. Mittelschmerz
Mittelschmerz consists of pain in mid-cycle. It is probably due to the rupture of a follicular cyst. The pain occurs in either lateral region of the lower abdomen and does not usually last more than 24 hours. From the Chinese point of view, it is often due to Dampness.
Clinical trials
Acupuncture
The effects of auricular acupressure and nitric oxide on menstrual symptoms for women with primary dysmenorrhoea
– Journal of Alternative and Complementary Medicine 2009 15(3): 235– 242. – Wang M C, Hsu M C, Chien L W, Kao C H, Liu C F. – Department of Nursing, National Taipei College of Nursing, Taipei, Taiwan. Objective The aim of this study was to evaluate the effects of auricular acupressure on relieving menstrual symptoms and decreasing nitric oxide (NO) for women with primary dysmenorrhoea. Methods This was a randomized clinical trial comparing the effects of auricular acupressure by seed-pressure method and placebo adhesive patch. The trials took place at colleges in northern and central Taiwan. A total of 71 college women took part with a diagnosis of primary dysmenorrhoea confirmed by the presence of serum CA125 testing. Thirty-six women were randomly
allocated to the acupressure group and 35 to the control group. The acupressure group received auricular acupressure by seed-pressure method on the Liver, Kidney and Endocrine points. The control group had a plain adhesive patch placed on the same points with no seed attached. The protocol included massaging each point 15 times, three times a day, for a total of 20 days. Outcomes measures were: a primary short-form Menstrual Distress Questionnaire (MDQ), and secondary NO blood samples. Assessments of both were performed at baseline and within the first 2 days of the next menstrual cycles (after completion of 20 days of acupressure). Results In the acupressure group, the overall menstrual symptoms and the two subscales, menstrual pain and negative affects, revealed that menstrual symptoms decreased significantly after auricular acupressure by the seedpressure method (P < 0.05). NO level increased in the acupressure group, although this difference did not achieve statistical significance (P > 0.05). Conclusion This study supports the effects of auricular acupressure by seed-pressure method in improving menstrual symptoms, and offers a non-invasive complementary therapy for women with primary dysmenorrhoea. The influence of ginger-partitioned moxibustion on serum nitric oxide (NO) and plasma endothelin-1 levels in patients with primary dysmenorrhoea due to Cold-Damp stagnation
– Zhen Ci Yan Jiu, Acupuncture Research 2008 33(6): 409–412. – Yang J J, Sun L H, She Y F, Ge J J, Li X H, Zhang R J.
– College of Chinese Medicine, Hebei Medical University, Shijiazhuang, China. Objective To explore the mechanism of ginger-partitioned moxibustion in the treatment of cold-damp stagnation primary dysmenorrhoea (PD) patients. Methods A total of 209 PD outpatients with a diagnosis of cold-damp stagnation from three hospitals were randomized into two groups. The moxibustion group (n = 105) was treated with ginger-partitioned moxibustion, and the control group (n = 104) was given Yueyueshu Tang (Menstruation Calming Decoction). Ginger-partitioned moxibustion was applied to Ren-8 Shenque and Ren-4 Guanyuan from the start of the menstrual period onwards for the first course and 3 days before the start for the second and third course. At baseline and after the treatment, plasma endothelin-1 (ET-1) and serum nitric oxide (NO) levels were compared with those of women (n = 20) experiencing a normal menstrual period and were determined by radioimmunoassay and nitrate reductase methods. Results After treatment, of the 105 and 104 cases in the moxibustion and control groups, 58 and 32 were cured, 37 and 33 saw markedly effective results, 5 and 24 saw effective results, and 5 and 15 failed, with the effective rates being 95.24% and 85.58% respectively. The therapeutic effect of the moxibustion group was significantly better than that of control group (P < 0.05). At baseline, in comparison with the normal group, plasma ET-1 contents in both the moxibustion and control groups were significantly higher (P < 0.01), while serum NO contents in these two groups were markedly
lower (P < 0.01). After the treatment, comparison of both the moxibustion and control groups showed that plasma ET-1 decreased significantly and serum NO levels increased considerably (P < 0.05, P < 0.01), and the therapeutic effect of the moxibustion group was markedly superior to that of the control group in lowering plasma ET-1 (P < 0.01). Conclusion Ginger-partitioned moxibustion is effective in relieving the pain of PD. This may be closely associated with the actions of the moxibustion in lowering plasma ET-1 level and raising serum NO contents. The acupuncture treatment of dysmenorrhoea which is resistant to conventional medical treatment
– Evidence Based Complementary and Alternative Medicine 2008 5(2): 227–230. – Iorno V, Burani R, Bianchini B, Minelli E, Martinelli F, Ciatto S. Objective To evaluate the effect of acupuncture on non-steroidal anti-inflammatory drug (NSAID)-resistant dysmenorrhoea-related pain. Methods Fifteen patients received 8 weekly acupuncture treatments at KI-3 Taixi, LIV-3 Taichong, SP-4 Gongsun, ST-36 Zusanli, ST-25 Tianshu, ST-29 Guilai, ST-30 Qichong, Ren-4 Guanyuan, Ren-6 Qihai, BL-62 Shenmai, HE-7 Shenmen, L.I.-4 Hegu, P-6 Neiguan and Zigong. The patients were
allowed to continue taking painkillers. Pain was measured according to the visual analogue scale (VAS) and was measured at baseline (T1), midtreatment (T2), end of the treatment (T3) and 3 months (T4) and 6 months (T5) after the end of the treatment. Results Pain levels and NSAID use were substantially reduced in 13 out of 15 patients (87%). The pain intensity was significantly reduced with respect to baseline (average VAS = 8.5), by 64%, 72%, 60% and 53% at T2, T3, T4 and T5 respectively. A greater reduction of pain was observed for primary as compared with secondary dysmenorrhoea. The average pain duration at baseline (2.6 days) was significantly reduced by 62%, 69%, 54% and 54% at T2, T3, T4 and T5 respectively. The average NSAID use was significantly reduced by 63%, 74%, 58% and 58% at T2, T3, T4 and T5 respectively, and ceased completely in 7 patients, who were still asymptomatic 6 months after the treatment. Conclusion The findings suggest that acupuncture may be indicated to treat dysmenorrhoea-related pain, particularly for patients who refuse or have contraindications for NSAIDs or oral contraceptives. A clinical observation of the treatment of primary dysmenorrhoea with acupuncture and massage
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2008 28(5): 418–420. – Lin L L, Liu C Z, Huang B Y.
– Acupuncture College of Beijing University of Chinese Medicine, Beijing, China. Objective To observe the clinical therapeutic effect of acupuncture massage for primary dysmenorrhoea and the influence of acupuncture on prostaglandin F2α level in menstrual fluid. Methods Ninety women with primary dysmenorrhoea were assigned to an acupuncture group (n = 30), a massage group (n = 30) and a control group (n = 30) which was given Somiton tablet orally. The treatment course was three menstrual cycles. The pain-relieving effect was evaluated using a numerical rating scale (NRS) at baseline and after treatment and change of PGF2α content in menstrual fluid was tested. Results After treatment, the NRS score and the PGF2α level in the acupuncture group and the massage group were significantly lower than that in the control group (both P < 0.01), but without significant difference between the acupuncture and massage group (P > 0.05) Conclusion Acupuncture and massage have a reliable therapeutic effect on primary dysmenorrhoea, which is superior to that of Somiton. The mechanism might be due to regulation of the PGF2α level in menstrual fluid. Acupuncture at the Siguan (4 gates) points for the treatment of
primary dysmenorrhoea
– Zhongguo Zhen Jiu, Chinese Acupuncture and Moxibustion 2008 28(3): 187–190. – Li C H, Wang Y Z, Guo X Y. – Luohe High Medical Training School, Henan, China. Objective To observe the therapeutic effect of acupuncture, using the Qinglong Baiwei (Green Dragon Swaying its Tail) method at the Siguan points, on primary dysmenorrhoea (PD). Methods One-hundred and eighty women with PD were randomly divided into group A, group B and group C, with 60 cases in each group. Group A was treated by acupuncture at L.I.-4 Hegu and LIV-3 Taichong using the Qinglong Baiwei method; group B was treated by routine acupuncture with SP-6 Sanyinjiao and BL-32 Ciliao as the main points; and group C was treated by oral administration of Yueyueshu Tang (Menstruation Calming Decoction). After 3 months of treatment, the therapeutic effects were analysed, and changes of haemorrheologic indices and the prostaglandin level were observed. Results The cured rate and the total effective rates were 75% and 100% in group A, 60% and 95% in group B, and 25% and 90% in group C respectively, group
A and B being significantly better than group C (P < 0.01). The analgesic effects within 30 minutes of treatment in both groups A and B were significantly better than that in group C (P < 0.01), and that in group A was significantly better than that in group B (P < 0.01). Conclusion Acupuncture at the four gates using the Qinglong Baiwei method has a significant therapeutic effect on primary dysmenorrhoea. It is suggested that the points work by relieving pain by improving blood circulation and inhibiting production of prostaglandin. Acupuncture in patients with dysmenorrhoea: a randomized study on clinical effectiveness and cost-effectiveness in usual care
– American Journal of Obstetrics and Gynaecology 2008 198(2): 166.e1– 8. – Witt C M, Reinhold T, Brinkhaus B, Roll S, Jena S, Willich S N. – Institute for Social Medicine, Epidemiology, and Health Economics, Charité University Medical Centre, Berlin, Germany. Objective To investigate the clinical effectiveness and cost-effectiveness of acupuncture in patients with dysmenorrhoea. Methods In this randomized controlled trial plus non-randomized cohort, 201 patients
with dysmenorrhoea were randomized to receive acupuncture (15 sessions over 3 months) or to a control group (no acupuncture). A total of 649 women participated (mean age 36.1 ± 7.1 years) of whom 201 were randomized. Patients who declined randomization received acupuncture treatment. All subjects were allowed to receive usual medical care. Results After 3 months, the average pain intensity on a scale of 0–10 was lower in the acupuncture compared to the control group: 3.1 vs. 5.4 which was a significant difference (P < 0.001). The acupuncture group had better quality of life scores. Conclusion Additional acupuncture in patients with dysmenorrhoea was associated with improvements in pain and quality of life as compared to treatment with usual care alone. Although acupuncture treatment in addition to usual care incurs additional costs, the improvement to a patient’s quality of life can be considered as cost-effective. An observation on retained seeds at auricular acupuncture points for the treatment of primary dysmenorrhoea
– Zhongguo Zhen Jiu, Chinese Acupuncture and Moxibustion 2007 27(11) 815–817. – Wu R D, Zhang H D, Lin L F. – Rehabilitation Section, Yongchun Hospital of Quanzhou City, Fujian, China.
Objective To observe the therapeutic effect and prognosis of using ear seeds for primary dysmenorrhoea. Methods One-hundred and fourteen women were randomly divided into an ear seed group (n = 60) and a Western medication group (n = 54). The ear seed group was treated at the points: Shenmen, Uterus, Endocrine, Subcortex, Sympathetic and Kidney using Vaccaria seeds which were retained with an adhesive plaster. The Western medication group was treated orally with Indomeixin enteric tablets. (Enteric tablets use a special coating which prevents release and absorption of the active ingredients until the tablets reach the intestines.) The therapeutic effects were assessed after treatment of three menstrual cycles. Results The total effective rate was 91.7% in the ear seed group and 77.8% in the Western medication group with a significant difference between the two group (P < 0.05); and the long-term therapeutic effect in the ear seed group was better than that in the Western medication group. Conclusion Using ear seeds has significant therapeutic effect on primary dysmenorrhoea. A randomized controlled study on the analgesic effect of superficial needling plus electrostimulation of SP-6 Sanyinjiao for primary dysmenorrhoea
– Zhen Ci Yan Jiu, Acupuncture Research 2007 32(5): 342–346. – Zhi L X. – Eye-Ear-Nose-Throat Hospital of Jiaozuo Coal Corporation, Jiaozuo, China. Objective To evaluate the analgesic and therapeutic effects of superficial acupuncture followed by electrostimulation (ESA) of SP-6 Sanyinjiao for treating primary dysmenorrhoea (PD). Methods One-hundred and seventy-one patients were randomly divided into ESA (n = 57), superficial acupuncture (SA; n = 57) and medication (n = 57) groups. Patients in the SA group were needled bilaterally at SP-6 Sanyinjiao and patients in the ESA group were needled at SP-6 Sanyinjiao bilaterally before electric stimulation of 60 Hz (2–3 V) was applied for 30 minutes. Patients in the medication group took Brufen sustained-release capsules 0.3 mg, b.i.d., for 3 days, then again 3 days before the start of menstruation for 5 days. The cumulative score of clinical symptoms was evaluated before and after the treatment. Results Comparison among the three groups showed that there was a significant difference from baseline scores to post-treatment scores in both the ESA and SA groups and these were significantly larger than that of the medication group (P < 0.001). In the ESA group, during the first menstrual cycle, the
number of patients who saw complete relief from their symptoms after 30 minutes of stimulation was significantly more than those of the SA group (P < 0.05). Results of intention-to-treat (ITT) analysis showed that out of the ESA, SA and medication groups, the cured cases were 40, 38 and 10, the markedly effective were 9, 10 and 27, the effective were 5, 4 and 7, and the failed were 3, 5 and 13 respectively with the total effective rates being 94.74%, 91.23% and 77.19% respectively. The effective rates of ESA and SA groups were significantly higher than that of medication group (P < 0.01), and the results of per-protocol analysis were similar to those of ITT analysis. Conclusion The analgesic effect of both ESA and SA at SP-6 Sanyinjiao for PD patients is significantly better than that of oral administration of Brufen. Ascertaining the efficacy of acupuncture for the treatment of primary dysmenorrhoea
– Gynakologisch Geburtshilfliche Rundschau, Gynaecologic and Obstetric Review 2003 43(4): 250–253. – Habek D, Cerkez Habek J, Bobi-Vukovi M, Vuji B. – Clinical Department of Gynaecology and Obstetrics, Clinical Hospital, Osijek, Croatia. Objective The aim of this study was to evaluate the effect of acupuncture in the treatment of primary dysmenorrhoea (PD). Methods
This clinical prospective, placebo-controlled trial included 57 women with primary dysmenorrhoea. Of these, 30 were treated with real acupuncture at the points Du-20 Baihui, bilateral L.I-4 Hegu, Ren-3 Zhongji, Ren-4 Guanyuan, Ren-6 Qihai, bilateral G.B-34 Yanglingquan, bilateral BL-23 Shenshu, bilateral SP-6 Sanyinjao and auricular acupuncture at Shenmen; 27 women were treated with placebo acupuncture. Acupuncture treatments were considered successful if PD did not occur any more, medication for PD became unnecessary or if PD symptoms did not occur for 2 years after the acupuncture treatment. Results Women in the real acupuncture group had a significant decrease in medication compared with the placebo group (P < 0.0001). After 1 year, the success rate for the treatment of PD symptoms was 93.3% in the real acupuncture group vs. 3.7% in the placebo group. Conclusion Real acupuncture was proved effective in the treatment of the symptoms of primary dysmenorrhoea and this effect lasted until at least 1 year following the treatment. Herbal treatment
The therapeutic effects of Chiljeh Yangbuh Wan on primary dysmenorrhoea: a randomized, double blind, placebo-controlled study
– Complementary Therapies in Medicine 2009 17(3): 123–130.
– Jang J B, Yoon Y J, Park J H, Jeong H G, Cho J H, Ko S G et al. – Department of Korean Oriental Gynaecology, Kyung Hee University, Hoegi dong,Dongdaemun-gu, Seoul, Republic of Korea. Objective This clinical study was conducted to investigate the efficacy and safety of Chiljeh Yangbuh Wan (CYW), a herbal medicine native to Korea, in treating primary dysmenorrhoea. Methods One-hundred patients with primary dysmenorrhoea who visited Kyung Hee University Korean Oriental Medicine Hospital between 19 July 2004 and 27 August 2004 were recruited. Secondary or drug-related dysmenorrhoea was screened out through interviews and examination. The patients were randomized to receive either CYW or a placebo formula for one menstrual period in a double-blind model. Visual analogue scale (VAS), Verbal rating scale (VRS), and multidimensional verbal rating scale (MVRS) were used to evaluate the severity of the dysmenorrhoea. A total of 71 patients who passed the screening test was divided into either the placebo or CYW group. These two groups were further split into smaller subsets (indication, nonindication, and unspecified group) according to Korean Oriental medical diagnosis. Results In the non-indication group, the placebo and CYW group did not show significant difference in VAS, VRS and MVRS scores at baseline (first VAS, first VRS, first MVRS), or after medication (second VAS, second VRS, second MVRS). In the indication group, the placebo and CYW group showed significant difference in change in VAS and MVRS scores. No
evidence of toxicity could be found, and no serious adverse reactions to CYW were reported. Conclusion The results suggest that Chiljeh Yangbuh Wan is effective and safe in treating primary dysmenorrhoea when prescribed appropriately under Korean Oriental medical diagnosis. The clinical efficacy of Kampo medicine (Japanese traditional herbal medicine) in the treatment of primary dysmenorrhoea
– Journal of Obstetrics and Gynaecology Research 2008 34(5): 898–908. – Oya A, Oikawa T, Nakai A, Takeshita T, Hanawa T. – Department of Obstetrics and Gynaecology, Nippon Medical School, Kitasato University, Yama, Tokyo, Japan. Objective To evaluate the clinical efficacy of Kampo medicine in treating primary dysmenorrhoea. Methods A retrospective evaluation of Kampo treatment in 176 subjects with dysmenorrhoea during the previous 12 years was performed. In order to minimize the subjective discretion of the severity of symptoms, classification of the severity level of abdominal pain during menstruation was applied by considering the requirement for non-steroidal anti-inflammatory drugs
(NSAIDs) and disturbance of daily activities. Severity levels at baseline and after Kampo treatment were defined in 108 patients. The following severity levels were used: no abdominal pain (level 0), abdominal pain with no requirement of NSAIDs (level 1), abdominal pain with no daily activity disturbances with use of NSAIDs (level 2), and painful menstruation which required absenteeism even with use of NSAIDs (level 3). Results The numbers of cases in levels 0, 1, 2 and 3 changed from 0 (0%), 0 (0%), 47 (43.5%) and 61 (56.5%) to 5 (4.6%), 42 (38.9%), 51 (47.2%) and 10 (9.3%) respectively (P < 0.0001). There were 25 kinds of Kampo formulae prescribed in effective cases. Conclusion Kampo medicine prescribed according to Kampo diagnosis reduced the severity of primary dysmenorrhoea and is therefore suggested to be beneficial in improving quality of life. A traditional Chinese herbal medicine used to treat dysmenorrhoea among Taiwanese women
– Journal of Clinical Nursing 2008 17(19): 2588–2595. – Cheng J F, Lu Z Y, Su Y C, Chiang L C, Wang R Y. – Department of Nursing, China Medical University and China Medical University Hospital, Tai-Chung, Taiwan. Objective
The purposes of this study were two-fold: first, to ascertain the relative effectiveness of the Chinese herbal formula Si Wu Tang Four Substances Decoction (SWT) for dysmenorrhoea, and second, to compare two different timings for consumption of SWT in terms of menstrual pain. Methods A total of 49 participants was alternately assigned into two study groups. The experimental group was administered 15 g of SWT daily for 7 consecutive days, following the cessation of menstrual bleeding, for two consecutive menstrual cycles. The comparison group was provided with a similar intervention as soon as menstrual bleeding was noted. The degree of menstrual pain was recorded daily using a visual analogue scale and the duration of pain was also recorded during menstrual bleeding for five consecutive menstrual cycles. Results The results indicated that the decrease in menstrual pain levels and the duration of pain between the experimental group and the comparison group was not significant. However, the decrease in menstrual pain and the duration of pain over the five menstrual cycles within the experimental group (from 2.07 to 1.42; 2.71 to 1.21; P < 0.05) and within the comparison group (from 1.94 to 1.23; 2.66 to 1.68; P < 0.05) were significant (P < 0.05). Conclusion Si Wu Tang has been continuously standardized for effective use as part of menstrual health and can be integrated as a complementary therapy within Western medicine. Chinese herbal medicine for primary dysmenorrhoea
– Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD005288. DOI: 10.1002/14651858.CD005288.pub3. – Zhu X, Proctor M, Bensoussan A, Wu E, Smith CA. – Chinese Medicine Program, University of Western Sydney, Centre for Complementary Medicine Research, Bankstown Campus, Sydney, New South Wales, Australia. Objective To determine the efficacy and safety of Chinese herbal medicine for primary dysmenorrhoea when compared with placebo, no treatment and other treatment. Search strategy The following databases were searched: • The Cochrane Menstrual Disorders and Subfertility Group Trials Register (to 2006), MEDLINE (1950 to January 2007). • EMBASE (1980 to January 2007). • CINAHL (1982 to January 2007). • AMED (1985 to January 2007). • CENTRAL (The Cochrane Library Issue 4, 2006). • China National Knowledge Infrastructure (CNKI, 1990 to January 2007).
• Traditional Chinese Medicine Database System (TCMDS, 1990 to December 2006). • The Chinese BioMedicine Database (CBM, 1990 to December 2006). Citation lists of included trials were also reviewed. Selection criteria Any randomised controlled trials involving Chinese herbal medicine versus placebo, no treatment, conventional therapy, heat compression, another type of Chinese herbal medicine, acupuncture or massage were assessed. Exclusion criteria were identifiable pelvic pathology and dysmenorrhoea resulting from the use of an intra-uterine contraceptive device. Data collection and analysis Quality assessment, data extraction and data translation were performed independently by two review authors. Attempts were made to contact study authors for additional information and data. Results Thirty-nine randomized controlled trials (RCTs) involving a total of 3475 women were included in the review. A number of the trials were of small sample size and poor methodological quality. Results for Chinese herbal medicine compared to placebo were unclear in three RCTs. Chinese herbal medicine resulted in significant improvements in pain relief in 14 RCTs, improvement in overall symptoms in six RCTs and use of additional medication in two RCTs when compared to use of pharmaceutical drugs. Self-designed Chinese herbal formulae resulted in significant improvements in pain relief in 18 RCTs, in overall symptoms in 14 RCTs and use of additional medication in five RCTs after up to 3 months of follow-up when compared to commonly used Chinese herbal health products. Chinese herbal medicine
also resulted in better pain relief than acupuncture in two RCTs and heat compression in one RCT. Conclusion The review found promising evidence supporting the use of Chinese herbal medicine for primary dysmenorrhoea; however, results are limited by the poor methodological quality of the included trials. The effect of Tong Jing Ning Dysmenorrhoea pill on primary dysmenorrhoea
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2005 25(7): 608–611. – Song Z M, Xing S L, Lou M Y, Sun S, Ha X, Zhu L. – Research Centre of Traditional Chinese Medicine, Tianjin College of Traditional Chinese Medicine, Tianjin, China. Objective To study the effect of Tong Jing Ning (TJN) on primary dysmenorrhoea. Methods One-hundred and twenty primary dysmenorrhoea patients were treated with TJN and 40 patients were treated with aspirin as controls. The levels of serum oestrogen (E2) and progestin (P) content in the luteal metaphase and anaphase (MI/AI) as well as endothelin (ET) and calcitonin gene related peptide (CGRP) in the metaphase and menstrual stage before and after
treatment were determined. Results The therapeutic effect, and the curative markedly effective rate and improvement rate of the main accompanying symptoms of severe and moderate primary dysmenorrhoea patients in the treated group were superior to those in the control group (P < 0.01). The level of E2 and ET were significantly decreased, and the content of P and CGRP respectively were significantly increased in the treated group after treatment (P < 0.01). Conclusion In patients with primary dysmenorrhoea, Tong Jing Ning pill may not only regulate ovarian hormone, ET and CGRP, but improve the mental–emotional state, and improve homoeostasis thus consolidating the therapeutic effect. A novel anti-dysmenorrhoea therapy with cyclic administration of 2 Japanese-Chinese herbal medicines
– Clinical and Experimental Obstetrics and Gynaecology 2003 30(2–3): 95–98. – Tanaka T. – Department of Obstetrics and Gynaecology, Wakayama Medical University, Kimi-idera, Wakayama, Japan. Objective To evaluate the effect of two Japanese–Chinese herbal medicines on the
treatment of dysmenorrhoea. Methods Seventeen patients were administered Shakuyakukanzoto (SK) (Shao Yao Gan Cao Tang Peony and Licorice Decoction) and Tokishakuyakusan (TS) (Dang Gui Shao Yao San Angelica Paeonia Powder) alternately within the menstrual cycle (SK/TS cyclic therapy). Results All of the 17 patients suffering from dysmenorrhoea (including recurrent endometriotic and adenomyotic patients following treatment with gonadotropin-releasing hormone agonists or Danazol) obtained complete relief within 3 months when treated with the SK/TS cyclic therapy. Nine of 12 patients treated with the SK/TS cyclic therapy ovulated as determined by biphasic changes in basal body temperature patterns. All the three secondary amenorrhoea patients with moderate levels of serum oestradiol, but not the three secondary amenorrhoea patients with little serum oestradiol, ovulated during the SK/TS cyclic therapy. One of the treated patients, who had a history of 10 repetitive spontaneous abortions, carried the eleventh pregnancy to term resulting in a healthy newborn. Conclusion The SK/TS cyclic therapy can be a conservative anti-dysmenorrhoea therapy for endometriotic and adenomyotic patients who desire pregnancy. End notes 1. He Ren 1981 A New Explanation of the Synopsis of Prescriptions from the Golden Cabinet (Jin Gui Yao Lue Xin Jie
), Zhejiang Science Publishing House, p. 188. The Synopsis of Prescriptions from the Golden Cabinet was written by Zhang Zhong Jing c. AD 200..
2. Ibid., p. 187..
3. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p.19. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
4. Zhang Jing Yue 1986 The Complete Works of Jing Yue (Jing Yue Quan Shu
), Shanghai Science and Technology Press, Shanghai, p. 641. First published in 1624..
5. 1979 The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen
), People’s Health Publishing House, Beijing, p. 4. First published c. 100 BC..
6. Shandong College of Traditional Chinese Medicine 1980 An Explanation of the ABC of Acupuncture (Zhen Jiu Jia Yi Jing Jiao Shi
), People’s Health Publishing House, Beijing, p. 1476. The ABC of Acupuncture was written by Huang Fu Mi c. AD 259..
7. Hu Xi Ming 1990 Great Treatise of Secret Formulae in Chinese Medicine (Zhong Guo Zhong Yi Mi Fang Da Quan
), Culture Publishing House, Shanghai, Vol. 2, p. 203..
8. Zhou Cui Zhen 1996 Titbits from Dr Cai Xiao Sun Experience in Treating Difficult Gynaecological Diseases, Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi
) 37(2): 80..
9. An Explanation of the ABC of Acupuncture, p. 1476..
10. A New Explanation of the Synopsis of Prescriptions from the Golden Cabinet, p. 188..
11. Fu Qing Zhu’s Gynaecology, pp 22–23..
12. Ibid., p. 20..
13. Great Treatise of Secret Formulae in Chinese Medicine, p. 204..
14. Wang Xue Tai 1995 Great Treatise of Chinese Acupuncture (Zhong Guo Zhen Jiu Da Quan
), Henan Science and Technology Publishing House, p. 452..
15. Chen You Bang 1990 Chinese Acupuncture Therapy (Zhong Guo Zhen Jiu Zhi Liao Xue
), China Scientific Publishing House, Beijing, p. 884..
16. Ann McPherson 1993, Women’s Problems in General Practice, Oxford University Press, Oxford, p. 185..
17. Ibid., p. 300..
CHAPTER 15 Bleeding between Periods
AETIOLOGY 285 PATHOLOGY 286 IDENTIFICATION OF PATTERNS AND TREATMENT 286 Liver- and Kidney-Yin deficiency with Empty-Heat 286 Damp-Heat 288 Blood stasis 289 Spleen- and Kidney-Yang deficiency 290 PROGNOSIS AND PREVENTION 293 An irregularity of the cycle is menstrual bleeding that occurs consistently at about the mid-point of the cycle. The bleeding may last 1–2 days or even longer; if it lasts much longer and is relatively heavy, this condition may be mistakenly interpreted as being Early Periods. The main factors are usually a disharmony of Yin–Yang, imbalance of Qi and Blood, stasis of Blood or Damp-Heat. Bleeding between Periods should be differentiated from Early Periods, Flooding and Trickling (Beng Lou) and Red or White–Red Leucorrhoea. Early Periods are characterized by bleeding some time before the normal; the amount of bleeding is normal or profuse. Flooding and Trickling is characterized by either very heavy bleeding at or before the right time or long trickling of blood after the period. Red or Red–White Leucorrhoea is characterized by a persistent discharge, unrelated to the cycle, but which,
especially in the case of Red Leucorrhoea, may be mistaken for menstrual blood. An important feature of Bleeding between Periods is that the bleeding occurs roughly at mid-cycle, i.e. at ovulation time. Ovulation is due to the fluctuation of Kidney-Yin and Kidney-Yang under the control of the Directing and Penetrating Vessels: thus, the underlying cause of such irregularity of bleeding is a disharmony of the Kidneys, no matter what other pattern there might be (such as stasis of Blood or Damp-Heat). The mid-cycle phase is the ovulatory phase in Western medicine. The ancient Chinese doctors called this phase ‘heat’. Yuan Liao Fan, author of Jade Ruler of Gynaecology, says: Living things in the universe all have ‘heat’. Female cats and dogs run and yell ferociously during this period. Women have a menstrual period each month. There must be one day of ‘heat’ when she feels hot and stuffy with an intolerable desire to have sex.1 The occurrence of ‘heat’ in a woman is related to the fluctuation of Yin and Yang of the Kidney and the ebb and flow of Qi and Blood in the Directing and Penetrating Vessels. It is for this reason that most causes of bleeding between periods involve some Heat.
Aetiology
Overwork, too many children too close together Overwork in the sense of working long hours without adequate rest or having too many children in a short space of time may injure Liver- and Kidney-Yin; this may lead to Empty-Heat which agitates the Blood, makes the Directing and Penetrating Vessels unstable and therefore causes bleeding at mid-cycle. Irregular diet Excessive consumption of greasy foods or dairy foods weakens the Spleen and leads to Dampness. This mixes easily with Heat forming Damp-Heat. Heat agitates the Blood and leads to bleeding at mid-cycle. Traumas, abdominal operations, post-partum stasis of Blood Traumas, abdominal surgery and post-partum conditions may all cause stasis of Blood. This leads to obstruction of the Directing and Penetrating Vessels; the new blood that is formed has nowhere to go and leaks out, causing bleeding at mid-cycle. Excessive physical exercise Excessive physical exercise or sports, or excessive lifting (be it at work or in the gym) weaken the Spleen- and Kidney-Yang, the Directing and Penetrating Vessels are injured and bleeding occurs because Qi fails to hold blood.
Pathology The main pathological conditions in Bleeding between Periods are: • Liver- and Kidney-Yin deficiency with Empty-Heat • Damp-Heat • Blood Stasis • Spleen- and Kidney-Yang deficiency. Deficiency of Kidney-Yin leads to hyperactivity of the Minister Fire which may damage the Directing and Penetrating Vessels and impair their functions in controlling blood: this results in bleeding. This condition was described in the book Fu Qing Zhu’s Gynaecology which says: In some women with heavy menstrual bleeding the eyes become black and dark … Everybody believes this is due to Fire agitating the Blood; however, this is not Full Fire but Empty Fire. People use stop-bleeding herbs with some results at times, but if one does not use Yin tonics this allows the Empty Fire to rebel … Therefore one should never use stopping-bleeding herbs on their own but one should also nourish Yin in order to stop heavy uterine bleeding.2 In another chapter, Fu Qing Zhu says: People may think that shortened menstrual cycle with one or two spots of blood is due to extreme Heat in the Blood. Who would say that it is due to hyperactive Fire in the Kidneys and deficient Kidney Water? … A shortened menstrual cycle is the result of Fire, while the amount of flow is based on the condition of Water. Thus a shortened menstrual cycle with profuse flow indicates hyperactive Fire and abundant Water; a shortened menstrual cycle with scanty flow indicates hyperactive Fire and insufficient Water … In treatment, Fire
is not to be reduced, but Water should be strengthened. Once Water becomes sufficient, Fire will be extinguished spontaneously. The formula Liang Di Tang is recommended.3 This condition is more likely to occur in older women. Damp-Heat damages the Directing and Penetrating Vessels and may cause bleeding. Stasis of Blood in the Lower Burner may also damage the Penetrating Vessel (which is the Sea of Blood) and cause bleeding. When Spleen- and Kidney-Yang are deficient, the Kidneys fail to store the Essence and the Spleen fails to control Blood. This weakens the Directing and Penetrating Vessels and leads to bleeding of the deficient type.
Identification of patterns and treatment
Liver- and Kidney-Yin deficiency with Empty-Heat
Clinical manifestations Bleeding at mid-cycle that is scanty, scarlet red and without clots, no abdominal pain, dizziness, tinnitus, night sweating, backache, dark urine, feeling of heat in the evening. Tongue: Red without coating. Pulse: FloatingEmpty or Fine-Rapid. Treatment principle Nourish Yin, tonify Liver and Kidneys, clear Empty-Heat, consolidate the Directing and Penetrating Vessels, stop bleeding. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-7 Yinjiao, KI-5 Shuiquan, KI-13 Qixue, KI-3 Taixi, SP-6 Sanyinjiao, L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, SP-8 Diji. All with reducing or even method. No moxa. Explanation
– LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and nourish Yin. – Ren-4, KI-3 and SP-6 nourish the Kidneys. – Ren-7 nourishes Yin and strengthens the Uterus.
– KI-5, Accumulation point, stops bleeding. All Accumulation points, especially those of Yin channels, have this property. – KI-13, a point of the Penetrating Vessel, strengthens this vessel and tonifies the Kidneys. – L.I.-11 and SP-10 cool Blood and stop bleeding. – KI-2 clears Empty-Heat. – SP-8 stops uterine bleeding. Herbal treatment
a. Prescription
– LIANG DI TANG and ER ZHI WAN – Two ‘Di’ Decoction and Two Solstices Pill Explanation The first six herbs constitute the formula Liang Di Tang which nourishes Yin, clears Empty-Heat and cools Blood, while the last two herbs form the prescription Er Zhi Wan which nourishes Yin, clears Empty-Heat and stops bleeding from Empty-Heat. – Sheng Di Huang and Mai Men Dong nourish Yin. – Di Gu Pi clears Empty-Heat.
– Xuan Shen nourishes Yin, cools Blood and stops bleeding, – Bai Shao and E Jiao nourish Blood which helps to nourish Yin. They also ‘calm’ Blood to stop bleeding. – Nu Zhen Zi and Han Lian Cao nourish Heat, clear Empty-Heat and stop bleeding. b. Prescription
– LIU WEI DI HUANG WAN – Six-Ingredient Rehmannia Pill Explanation This prescription, which has already been explained, nourishes Liver- and Kidney-Yin. Compared with the previous formula, it only nourishes Yin and does little to clear Empty-Heat, nor does it cool Blood. It is therefore suitable when the deficiency of Yin occurs without much Empty-Heat. Modifications
• If there is Yin deficiency with Damp-Heat, use the Liu Wei Di Huang Wan plus Xiao Ji Herba Cirsii, Ce Bai Ye Cacumen Platycladi and Yi Yi Ren Semen Coicis. • If there is backache and a pronounced Kidney deficiency, add Du Zhong Cortex Eucommiae and Tu Si Zi Semen Cuscutae. Women’s Treasure remedy
– EASE THE JOURNEY-YIN This remedy is a variation of Zuo Gui Wan Restoring the Left [Kidney] Decoction. It nourishes Yin and clears Empty-Heat. It is suitable to treat bleeding because it contains herbs that are astringent and tend to stop bleeding (such as Mu Li and Suan Zao Ren). Damp-Heat
Clinical manifestations Mid-cycle bleeding that may be heavy or scanty, sticky, viscous blood, no clots, fatigue, joint aches, feeling of oppression of the chest, poor appetite, scanty, dark Summary Liver- and Kidney-Yin deficiency with Empty-Heat
Clinical manife stations
Bleeding at mid-cycle that is scanty, scarlet red and without clots, no abdominal pain, dizziness, tinnitus, night sweating, backache, dark urine, feeling of heat in the evening. Tongue: Red without coating. Pulse: FloatingEmpty or Fine-Rapid. Tre atme nt principle
Nourish Yin, tonify Liver and Kidneys, clear Empty-Heat, consolidate the Directing and Penetrating Vessels, stop bleeding.
Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-7 Yinjiao, KI-5 Shuiquan, KI-13 Qixue, KI-3 Taixi, SP-6 Sanyinjiao, L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, SP-8 Diji. All with reducing or even method. No moxa. He rbal tre atme nt
Prescriptions
• LIANG DI TANG and ER ZHI WAN Two ‘Di’ Decoction and Two Solstices Pill • LIU WEI DI HUANG WAN Six-Ingredient Rehmannia Pill Women’s Treasure re me dy
• EASE THE JOURNEY-YIN
urine, vaginal discharge. Tongue: sticky-yellow coating. Pulse: Slippery. Treatment principle Clear the Liver, strengthen the Spleen, resolve Dampness, stop bleeding. Acupuncture SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-9 Shuifen, Ren-3 Zhongji, G.B.-41 Zulinqi (on the right) and T.B.-5 Waiguan (on the left), ST-28 Shuidao, ST29 Guilai, SP-1 Yinbai (with moxa cones), BL-22 Sanjiaoshu, BL-32 Ciliao, SP-8 Diji. All with reducing or even method. Generally speaking, no moxa (except on SP-1); however, this pattern can often occur against a background of Yang deficiency, in which case some moxa can be used.
Explanation
– SP-9, SP-6, ST-28, Ren-9 and BL-22 resolve Dampness. – Ren-3 resolves Dampness and strengthens the Uterus. – G.B.-41 and T.B.-5 regulate the Girdle Vessel and resolve Damp-Heat from the Liver channel. This vessel affects the genitals and hypogastrium in general. – ST-29 drains Dampness from the Lower Burner and regulates Blood. – SP-1 is an empirical point to stop bleeding, with direct moxa cones. Moxa cones can be used even if there is Heat. – BL-32 drains Dampness from the genitourinary system. – SP-8 stops uterine bleeding. Herbal treatment
a. Prescription
– QING GAN ZHI LIN TANG Variation – Clearing the Liver and Stopping ‘Lin’ Decoction Variation Explanation The first 10 herbs constitute the original prescription from Fu Qing Zhu’s
Gynaecology. Please note that the dosages are taken from the source text and in my own practice I would probably reduce them by at least a half. Since this formula is originally for red vaginal discharge (rather than intermenstrual bleeding) it may seem strange that it concentrates so much on nourishing Blood rather than draining Dampness. Fu Qing Zhu gives an interesting explanation: The emphasis of the prescription is in nourishing Liver-Blood rather than draining Dampness from the Spleen. This is because the cause of red leucorrhoea is Fire primarily with little Dampness. Since Fire prevails when Blood is deficient, nourishing Blood is sufficient to clear Fire. In red leucorrhoea, Water and Blood are mixed together and it is difficult to distinguish whether there is Dampness or not, Dampness has become red and transformed into Blood: thus, treating Blood also eliminates Dampness.4 It is because this formula concentrates on treating Blood that it is suitable to treat intermenstrual bleeding. – Dang Gui, Bai Shao, Sheng Di Huang, Hei Xiao Dou and E Jiao nourish Blood. – Mu Dan Pi clears Liver-Heat. – Huang Bo drains Dampness. – Huai Niu Xi directs the formula to the Lower Burner. – Xiang Fu moves Qi and enters the Liver channel, thus directing the formula to the Liver channel. – Hong Zao harmonizes. – Fu Ling has been added to drain Dampness. b. Prescription
– BA ZHENG TANG Variation – Eight Corrections Powder Variation Explanation The first seven herbs constitute the formula Ba Zheng Tang minus Da Huang: this formula drains Damp-Heat from the Lower Burner. – Sheng Di Huang was added to cool and ‘calm’ Blood so as to stop bleeding. – Bai Mao Gen and Qian Cao Gen stop bleeding. Qian Cao Gen also cools and invigorates Blood. Modifications
• If Damp-Heat is pronounced, add the whole formula Si Miao San Four Wonderful Powder plus Xiao Ji Herba Cirsii. c . Prescription
– EMPIRICAL PRESCRIPTION by Dr Liu Geng Wu Explanation
– Qu Mai and Bian Xu resolve and drain Damp-Heat.
– Chuan Lian Zi moves Liver-Qi. – Yan Hu Suo and Chi Shao invigorate Blood and eliminate stasis. – Pu Gong Ying and Bai Jiang Cao resolve Toxic-Heat. – Bai Shao ‘calms’ Blood and helps to stop bleeding. This formula is suitable if Damp-Heat is accompanied by stasis of Blood and Toxic-Heat. Women’s Treasure remedy
– DRAIN THE JADE VALLEY This remedy drains Damp-Heat from the Lower Burner. The tongue presentation appropriate to this remedy is a sticky-yellow coating that is thicker on the root, possibly with red spots. Summary Damp-Heat
Clinical manifestations
Mid-cycle bleeding that may be heavy or scanty, sticky, viscous blood, no clots, fatigue, joint aches, feeling of oppression of the chest, poor appetite, scanty, dark urine, vaginal discharge. Tongue: sticky-yellow coating. Pulse: Slippery. Treatment principle
Clear the Liver, strengthen the Spleen, resolve Dampness, stop bleeding. Acupuncture
SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-9 Shuifen, Ren-3 Zhongji, G.B.-41 Zulinqi (on the right) and T.B.-5 Waiguan (on the left), ST-28 Shuidao, ST29 Guilai, SP-1 Yinbai (with moxa cones), BL-22 Sanjiaoshu, BL-32 Ciliao, SP-8 Diji. All with reducing or even method. Generally speaking, no moxa (except on SP-1); however, this pattern can often occur against a background of Yang deficiency, in which case some moxa can be used. Herbal treatment
Pre scriptions
• QING GAN ZHI LIN TANG Variation Clearing the Liver and Stopping ‘Lin’ Decoction Variation • BA ZHENG TANG Variation Eight Corrections Powder Variation • EMPIRICAL PRESCRIPTION by Dr Liu Geng Wu Women’s Treasure remedy
• DRAIN THE JADE VALLEY
Blood stasis
Clinical manifestations Bleeding between periods that may be scanty or profuse, dark blood with clots, lateral abdominal pain, mental restlessness. Tongue: Purple. Pulse: Wiry, Choppy or Firm. Treatment principle Move Qi, invigorate Blood, eliminate stasis, stop bleeding. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), Ren-6 Qihai, ST29 Guilai, SP-10 Xuehai, KI-14 Siman, BL-17 Geshu, SP-6 Sanyinjiao, SP-1 Yinbai, SP-8 Diji. All with reducing or even method. Moxa can be used if the tongue is Bluish-Purple. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel, invigorate Blood and subdue rebellious Qi. – Ren-6 moves Qi in the Lower Burner. – ST-29 invigorates Blood in the Lower Burner. – SP-10, BL-17, and SP-6 invigorate Blood.
– KI-14, a point of the Penetrating Vessel, moves Qi and Blood in the Uterus and generally the Lower Burner. – SP-1 is an empirical point to stop bleeding. – SP-8 stops uterine bleeding. Herbal treatment
Prescription
– ZHU YU ZHI XUE TANG – Eliminating Stasis and Stopping Bleeding Decoction Explanation This formula from Fu Qing Zhu was intended for menstrual bleeding deriving from injuries and falls. – Sheng Di Huang and Dang Gui nourish and cool Blood. Only the ‘tail’ of Dang Gui is used here to invigorate Blood. – Zhi Ke moves Qi to invigorate Blood. – Da Huang, Chi Shao, Mu Dan Pi and Tao Ren invigorate Blood and eliminate stasis. – Gui Ban is in the formula to enter the Directing and Penetrating Vessels and direct the formula to the Uterus to stop uterine bleeding. Modifications
• If the symptoms and signs of Blood stasis are pronounced, add the formula Shi Xiao San Breaking into a Smile. • If the stasis of Blood derives from Cold, add Ai Ye Folium Artemisiae argyi and Gui Zhi Ramulus Cinnamomi or use Gui Zhi Fu Ling Wan Ramulus Cinnamomi-Poria Pill instead. • If stasis of Blood is mixed with Damp-Heat, add Cang Zhu Rhizoma Atractylodis, Yi Yi Ren Semen Coicis, Bai Jiang Cao Herba Patriniae and Ze Xie Rhizoma Alismatis. Women’s Treasure remedies
– STIR FIELD OF ELIXIR This remedy invigorates Blood and stops bleeding. The tongue presentation appropriate to this remedy is a Purple body. – INVIGORATE BLOOD AND STEM THE FLOW This remedy invigorates Blood and stops bleeding. The tongue presentation appropriate to this remedy is a Purple body. Summary Blood stasis
Clinical manifestations
Bleeding between periods that may be scanty or profuse, dark blood with clots, lateral abdominal pain, mental restlessness. Tongue: Purple. Pulse:
Wiry, Choppy or Firm. Treatment principle
Move Qi, invigorate Blood, eliminate stasis, stop bleeding. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), Ren-6 Qihai, ST29 Guilai, SP-10 Xuehai, KI-14 Siman, BL-17 Geshu, SP-6 Sanyinjiao, SP-1 Yinbai, SP-8 Diji. All with reducing or even method. Moxa can be used if the tongue is Bluish-Purple. Herbal treatment
Pre scriptions
• ZHU YU ZHI XUE TANG Eliminating Stasis and Stopping Bleeding Decoction Women’s Treasure remedies
• STIR FIELD OF ELIXIR • INVIGORATE BLOOD AND STEM THE FLOW
Spleen- and Kidney-Yang deficiency
Clinical manifestations Bleeding between periods that may be scanty or profuse, red blood without clots, no abdominal pain, dizziness, tinnitus, backache, kneeache, loose stools, tiredness, depression, feeling cold, frequent urination. Tongue: Pale and Swollen. Pulse: Weak, Deep. Treatment principle Strengthen the Spleen and Kidneys, tonify Yang, warm the Uterus, contain Blood. Acupuncture BL-20 Pishu, BL-23 Shenshu, Ren-4 Guanyuan, Ren-6 Qihai, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, SP-8 Diji. All with reinforcing method; moxa should be used. Explanation
– BL-20, Ren-12, ST-36 and SP-6 tonify the Spleen. Warm needle on ST-36 is particularly effective to tonify the Yang. – BL-23 and Ren-4 tonify the Kidneys and strengthen the Uterus. Direct moxa cones should be used on Ren-4 to warm the Uterus. – Ren-6 tonifies and raises Qi and helps to tonify Qi to contain Blood.
– SP-8, Accumulation point, stops uterine bleeding. Herbal treatment
a. Prescription
– GU BEN ZHI BENG TANG Variation – Consolidating the Root and Stopping Flooding DecoctionVariation Explanation The first six herbs constitute the formula Gu Ben Zhi Beng Tang which has already been explained. This formula tonifies Spleen- and Kidney-Yang and nourishes Blood and is specific for menstrual bleeding from Yang deficiency. – Du Zhong and Xu Duan were added to tonify Kidney-Yang and firm Qi to stop bleeding. b. Prescription
– JIN GUI SHEN QI WAN – Golden Chest Kidney-Qi Pill Explanation This formula, already explained, tonifies Kidney-Yang and expels Cold. Compared with the previous formula, it does not tonify the Spleen as much
and is hotter in nature. It is therefore suitable when the Cold symptoms are pronounced and the tongue is very Pale and wet. Three Treasures remedy
– STRENGTHEN THE ROOT This remedy tonifies Spleen- and Kidney-Yang and nourishes Blood. The tongue presentation appropriate to this remedy is a Pale body. Women’s Treasure remedy
– UNICORN PEARL This remedy tonifies Kidney-Yang and the Kidney-Essence. The tongue presentation appropriate to this remedy is a Pale and wet body. Summary Spleen- and Kidney-Yang deficiency
Clinical manifestations
Bleeding between periods that may be scanty or profuse, red blood without clots, no abdominal pain, dizziness, tinnitus, backache, kneeache, loose stools, tiredness, depression, feeling cold, frequent urination. Tongue: Pale and Swollen. Pulse: Weak, Deep. Treatment principle
Strengthen the Spleen and Kidneys, tonify Yang, warm the Uterus, contain Blood. Acupuncture
BL-20 Pishu, BL-23 Shenshu, Ren-4 Guanyuan, Ren-6 Qihai, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, SP-8 Diji. All with reinforcing method; moxa should be used. Herbal treatment
Pre scriptions
• GU BEN ZHI BENG TANG Variation Consolidating the Root and Stopping Flooding Decoction Variation • JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill Three Treasuresremedy
• STRENGTHEN THE ROOT Women’s Treasure remedy
• UNICORN PEARL
Case history A 50-year-old woman had been suffering from bleeding in between periods for 3 years. The bleeding occurred for 3 days at mid-cycle, with fresh, red, scanty blood. The periods were regular, lasted 4 days and caused
her no problems. She actually sought treatment for a different condition which was a left abdominal pain extending towards the left loin: this pain was worse at night and when her bladder was full. Although she had all kinds of investigations for this pain, including the gynecological system, intestines, kidneys and bladder, no cause had been found. On interrogation, it transpired that she suffered from backache and dizziness and that in the past she had tried conceiving unsuccessfully. Her tongue was Pale and Swollen. Her pulse was Slippery on the left, Rapid, Full and slightly Overflowing on the left Middle positions, and Weak on the right Rear position. Diagnosis I thought that the bleeding derived from deficiency of the Spleen- and Kidney-Yang, being unable to hold Blood. This was confirmed by her previous infertility, the Pale tongue,the Weak pulse on the right Kidney position and the backache and dizziness. However, her pulse was interesting for its rapidity, which could not be reconciled with the Pale tongue and Yang deficiency, its Slipperiness and its Overflowing quality on the left Middle position. A pulse that is Slippery and Full on the Middle level, especially on the left side, indicates a pathology of the Penetrating Vessel, and I at first thought this was the case here. Such a pathology could also have accounted for the rapidity of the pulse, due not to Heat but to rebellious Qi in the Penetrating Vessel. For this reason, I used the opening points of the Penetrating Vessel in the first treatment. However, after the first treatment, reassessing the pulse, I realized that it was Full and slightly Overflowing only on the left Middle position. I attributed this to a Girdle Vessel pathology: this was also confirmed by the Slippery quality of the pulse, the swelling of the tongue and the type of abdominal pain (abdominal pain that extends to the loins and towards the back is typical of a Girdle Vessel pathology). This pathology is characterized by Dampness infusing downwards and this was confirmed by the swelling of the tongue and the Slipperiness of the pulse. I concluded that her infertility in the past must also have been due to a pathology of Dampness in the Girdle Vessel.
Treatment principle Apart from the first treatment, when I had treated the Penetrating Vessel points, I followed the principle of regulating the Girdle Vessel, resolving Dampness and tonifying Spleen- and Kidney-Yang. I treated this patient only with acupuncture. Acupuncture
In the first treatment I used the following points: • SP-4 Gongsun (on the right) and P-6 Neiguan (on the left) to regulate the Penetrating Vessel and subdue rebellious Qi. • L.I.-4 Hegu on the right, to regulate the ascending and descending of Qi. • LIV-3 Taichong on the left, to subdue rebellious Qi in the Penetrating Vessel. Thus, these two points L.I.-4 and LIV-3 were crossed over with the opening points of the Penetrating Vessel, SP-4 and P-6. • KI-14 Siman, a point of the Penetrating Vessel, on the left, to move Qi and eliminate stagnation in this vessel in the lower abdomen. • ST-28 Shuidao on the left to resolve Dampness. • ST-29 Guilai on the left, to move Qi and Blood in the lower abdomen. • G.B.-25 Daimai to regulate the Girdle Vessel and treat the left loin pain.
In the second and third treatments I used: • G.B.-41 Zulinqi (on the right) and T.B.-5 Waiguan (on the left) to regulate the Girdle Vessel and expel Dampness in the Lower Burner. • G.B.-25 Daimai on the left, to regulate the Girdle Vessel and treat the left abdominal pain. • LIV-13 Zhangmen, a point of the Girdle Vessel, on the left to harmonize Liver and Spleen and help to resolve Dampness.
• G.B.-34 Yanglingquan on the left to move Qi in the lower abdomen and treat the abdominal pain. • ST-27 Daju to resolve Dampness in the lower abdomen and treat the abdominal pain. • SP-6 Sanyinjiao, with warm needle, bilateral, to tonify Spleen-Yang. • BL-23 Shenshu, bilateral, to tonify Kidney-Yang.
After only three treatments, her abdominal pain disappeared and the mid-cycle bleeding stopped. I have since followed up her case and learned that it has not recurred. Although I concentrated more on treating the abdominal pain than the mid-cycle bleeding, the latter was also helped by treating the Girdle Vessel and by concentrating on resolving Dampness and moving Qi. This proved that, although the bleeding was caused by a deficiency of Kidney-Yan, Dampness also played a role in its pathogenesis.
Prognosis and prevention Bleeding between periods may take a fairly long time to treat. Both acupuncture and herbal therapy are effective either singly or in combination. The pattern from Kidney-Yin deficiency will take the longest to treat, followed by that of Damp-Heat. However, it is not at all unusual for these patterns to be combined, especially the pattern of Damp-Heat together with a Kidney deficiency, be it of Yin or Yang. In such cases, the treatment is more complicated and the condition will take even longer to cure. When Dampness is combined with a Kidney deficiency, I generally prefer to concentrate on eliminating Dampness first, with one of the formulae listed above. Only when the symptoms and signs of Dampness have receded would I proceed with a Kidney-tonifying prescription. Alternatively, the treatment can be given in accordance with the four phases of the menstrual cycle: the woman could take a Dampness-draining formula during the third and fourth phases of the cycle (i.e. mid-cycle and before the period) and a Kidney-tonic formula during the second phases (i.e. after the period). It is essential for women suffering from Kidney-Yin deficiency to try to have more rest and avoid overworking. Those suffering from Damp-Heat should avoid dairy foods and greasy foods, and those suffering from Yang deficiency too many raw, cold foods and iced drinks. End notes 1. Cited in Luo Yuan Kai 1986 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Shanghai Science and Technology Press, Shanghai, p. 58..
2. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p. 8. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
3. Ibid., p. 15..
4. Ibid., p. 7..
CHAPTER 16 No Periods
AETIOLOGY 295 PATHOLOGY 296 IDENTIFICATION OF PATTERNS AND TREATMENT 298 EMPTY CONDITIONS 298 Liver and Kidney deficiency 298 Blood deficiency 300 Spleen- and Kidney-Yang deficiency 303 Liver- and Kidney-Yin deficiency 304 Lung-Yin and Blood deficiency 306 Heart- and Kidney-Yin deficiency 307 Heart- and Spleen-Blood deficiency 308 FULL CONDITIONS 309 Stagnation of Qi and Blood 309 Damp-Phlegm in the Lower Burner 312 Ancient acupuncture prescriptions for amenorrhoea 314 PROGNOSIS AND PREVENTION 314 WESTERN VIEW 315 CLINICAL TRIALS 316 Herbal treatment 316
The absence of periods (amenorrhoea) is called Bi Jing in Chinese: jing means menstruation and bi means ‘shut’ or ‘closed’. Western medicine distinguishes between primary amenorrhoea which occurs when a woman has not had a period by the time she is 18, and secondary amenorrhoea, which occurs when a woman has had periods but they have stopped for at least 3 months. Obviously, the temporary interruption of the menses that occurs after childbirth and during breastfeeding is not considered amenorrhoea, nor, similarly, is the stopping of the menses for 1 or 2 months as a consequence of sudden environmental or living condition changes. If a woman presents with secondary amenorrhoea, it is of course very important to exclude pregnancy first of all because, were the patient treated for amenorrhoea, one might prescribe herbs which are contraindicated in pregnancy. I shall call this condition ‘No Periods’ rather than ‘amenorrhoea’. A basic differentiation must be made between No Periods from a deficiency and No Periods from an excess. No Periods from a deficiency includes Blood deficiency, Spleen and Kidney deficiency, and Liver and Kidney deficiency. It should be further differentiated between that from a pre-natal weakness and that from a post-natal weakness. Obviously primary amenorrhoea is more likely to be due to a deficiency of the Pre-Natal Essence and secondary amenorrhoea to a deficiency of the Post-Natal Qi. No Periods from excess is usually due to stagnation of Qi and/or Blood, Phlegm or Cold. In the Yellow Emperor’s Classic, No Periods was called “woman having no moon” (i.e. no monthly flow) or “moon affair not coming”, indicating the early connection of menstruation with the moon phases.
Aetiology
Emotional stress Anger, intended in a broad sense to include frustration, resentment, hatred and irritation, may cause stagnation of Qi which, with time, may lead to stasis of Blood: this causes an excess type of No Periods. Sadness and grief are very common factors in the development of amenorrhoea. They deplete Qi of the Lungs and Heart: the Lungs govern Qi, the Heart governs Blood, and when Qi cannot make or move Blood and Heart-Blood cannot descend to the Uterus, the menses stop. The Secret Prescriptions for Gynaecological Patterns and Treatment by Ye Tian Shi says: The Heart governs Blood and the Spleen is the Root of Qi and Blood. Worry and pensiveness injure the Heart making Heart-Qi depleted; this cannot generate Blood, the Spleen is the child of the Heart and [therefore] loses its nourishment, the appetite declines which cuts off the Root of generation and transformation [i.e. the Spleen].1 Worry and pensiveness affect Lungs and Spleen and may lead to deficiency and stagnation of Qi simultaneously. Deficient Qi fails to make Blood while stagnant Qi fails to move Blood leading to stasis of Blood. Amenorrhoea can therefore result from a simultaneous deficiency and stasis of Blood. Chen Jia Yuan says in his Secret Gynaecological Prescriptions (Qing dynasty): Worry injures the Lungs, pensiveness depletes the Spleen, since Lungs and Spleen are injured Qi and Blood stagnate, the woman becomes irritable and resentful and develops palpitations and a feeling of distension and oppression, and eventually amenorrhoea.2
Excessive physical work or exercise This weakens the Spleen which fails to make Blood and, when occurring at puberty time, it may also cause stagnation of Qi and Blood in the Lower Burner, thus causing primary amenorrhoea. In this case, the amenorrhoea is due to a deficiency (of Blood) complicated by an excess condition (stagnation of Qi and Blood in the Lower Burner). Hereditary weakness A hereditary Kidney weakness can of course cause primary amenorrhoea. In this case, there is a deficiency of Kidney-Essence and usually also of LiverBlood. Diet A diet poor in nourishment leads to depletion of Qi and Blood and therefore secondary amenorrhoea from Blood deficiency and Spleen deficiency. This becomes a cause of disease especially if it occurs at a young age when girls are likely to adopt a slimming diet or a vegetarian diet that fails to substitute for the meat protein a judicious combination of vegetable types of protein. Excessive consumption of dairy foods and greasy foods leads to the formation of Dampness and Phlegm: these can obstruct the Lower Burner and lead to amenorrhoea. These women are often overweight. The Chinese Medicine Gynaecology says: “Amenorrhoea in overweight women is due to Dampness and Phlegm obstructing the Membranes.”3 Overwork Overwork in the sense of working long hours without adequate rest for many
years leads to deficiency of Liver- and Kidney-Yin which, in turn, may cause secondary amenorrhoea. Contraceptive pill Very often, when a woman comes off the contraceptive pill after being on it a long time, the periods do not return for a long time. I have seen this happen in practice many times when a woman’s periods may not return for over a year after being on the pill for a number of years. My experience is that the contraceptive pill causes a Blood deficiency and a Kidney deficiency and those are the reasons why the periods do not return.
Pathology From a pathology point of view, the main distinction to be made is that between deficiency and excess types of amenorrhoea. The two main deficiency types are Qi and Blood deficiency and Liver and Kidneys deficiency. The two main excess patterns are Qi and Blood stagnation and retention of Dampness and Phlegm. The pathology of these patterns will be discussed briefly. Liver and Kidney deficiency Liver and Kidney deficiency involves a deficiency of Kidney-Essence and Liver-Blood, which in turn leads to emptiness of the Penetrating and Directing Vessels. It can be caused by hereditary weakness of the KidneyEssence, too many childbirths too close together or overwork. The Kidney-Essence is the origin of menstrual Blood and the Liver stores Blood: a deficiency of these two organs therefore leads to a malnourishment of the Uterus and of the Penetrating and Directing Vessels. The True Transmission of Medical Theory (Yi Xue Zheng Chuan, 1515) says: “The menses are a transformation of Kidney-Water, when this is deficient, menstrual Blood dries up.”4 The deficiency of Kidney-Essence could also take the form of KidneyYang deficiency; this leads to the formation of Cold which obstructs the Uterus and causes amenorrhoea. Qi and Blood deficiency A deficiency of Qi and Blood stems primarily from a weakness of the Spleen and Stomach which fail to make Blood. A deficiency of Heart-Blood is often also involved as Heart-Blood plays a role in the making of menstrual blood. Apart from this, of course a deficiency of Liver-Blood is a frequent cause of
amenorrhoea. The Simple Questions says in Chapter 40: Dryness of Blood may be caused by a severe loss of blood which occurred at a young age or by entering the bedroom [i.e. having sexual intercourse] in a drunken state. This will exhaust Qi and injure the Liver so that the period does not come.5 A deficiency of the Spleen and Stomach is of course primarily caused by dietary factors such as a diet lacking in nourishment and Blood-producing foods. A deficiency of Heart-Blood can result either from a failure of Spleen and Stomach in making Blood, or from emotional problems. There are, however, several other causes of Stomach and Spleen deficiency such as a long, severe disease, repeated miscarriages and breastfeeding for too long. The Secret Collection of the Orchid Room (Lan Shi Mi Cang, 1271) by Li Dong Yuan (celebrated author of the Discussion on Stomach and Spleen) says: “When in a woman Stomach and Spleen are deficient for a long time, Qi and Blood become depleted and menstruation ceases.”6 Yin deficiency, Blood dried up A primary deficiency of Liver- and Kidney-Yin, resulting from overwork, a long, chronic disease or too many children too close together, leads to a drying up of Yin and Blood and therefore the cessation of the menses, as the Sea of Blood of the Penetrating Vessel becomes Empty. In such cases, the disease may also pertain to the Chinese category of Exhaustion (Xulao) with amenorrhoea as a secondary symptom. The Complete Book of Jing Yue (Jing Yue Quan Shu, 1624) says: “When Yin is depleted and Blood dried up … there may be cough with a feeling of heat at night … and amenorrhoea …”.7 Qi stagnation and Blood stasis Qi stagnation and Blood stasis result from emotional stress such as anger,
irritation, frustration, resentment, worry, guilt or anxiety. Although ‘anger’ is always mentioned as the emotion that may lead to stagnation of Liver-Qi, other emotions such as worry, anxiety or even sadness may affect the Liver. Long-term stagnation of Liver-Qi in women easily leads to stasis of Blood: stagnant Blood obstructs the Uterus, the Penetrating Vessel’s Qi cannot flow to produce the menses, hence amenorrhoea results. This is an excess type of amenorrhoea as the period fails to arrive not because the Blood is deficient but because it is stagnant. Damp-Phlegm obstructing the Uterus Damp-Phlegm is usually associated with Spleen deficiency and it is caused by the excessive consumption of cold foods (such as iced water or icecream), raw foods, dairy foods or greasy foods. Dampness obstructs the Lower Burner and the Uterus so that Blood cannot flow in the Uterus vessel and amenorrhoea develops. Cold is also an important pathogenic factor in the pathogenesis of amenorrhoea: it obstructs the Uterus and this leads to stasis of Blood: obstruction of the Uterus Vessel and Uterus Channel prevents the Blood from flowing and the period from coming. The Synopsis of Prescriptions of the Golden Cabinet says: In gynaecological diseases, deficiency, accumulation of Cold and stagnation of Qi cause the cessation of the period which may last for over one year. The Blood becomes cold, the Uterus door is knotted and Cold injures the channels … When Cold is in the Lower Burner, the period is scantier than normal.8 The General Treatise on the Aetiology and Symptomatology of Diseases (AD 610) says: When the period does not come, it is due to injury of Qi and Blood. When the body is a weakened state, Wind-Cold invades the Uterus and injures the Directing and Penetrating vessels and the Small Intestine and Heart channels; the Uterus Channel is severed and
Blood cannot get through. The Directing and Penetrating vessels originate from the Uterus and are the Sea of the Channels. The Small Intestine and Heart channels are exteriorly–interiorly related and govern the downward [infusion] of menstrual Blood. Wind-Cold injures the menstrual Blood. When Blood is warm it flows well, when it is cold it shuts down because Cold causes stagnation. When Blood is knotted inside the period does not come.9 Differentiation from pregnancy Obviously No Periods should be differentiated from the symptoms and signs of the very early stages of pregnancy: Table 16.1 highlights the main differential points. Table 16.1 Differential signs of amenorrhoea and early stage of pregnancy
Amenorrhoea
The periods stop after
Early Pregnancy
Symptoms and signs
having been irregular for some time; they may also stop suddenly but in this case there is abdominal pain
Normally regular periods stop suddenly, there is nausea, possibly a strange attraction to or dislike of certain foods, desire to lie down
Deep, Choppy Slightly Slippery, relatively or Fine strong on the Rear position Uterus feels soft, cystic and round (after 5–6 weeks), enlarged (only after 8 weeks), breasts enlarged Gynecological No signs of with veins appearing on their examination pregnancy surface, Montgomery’s tubercles (enlargement of sebaceous glands around the edge of the areolae) Pulse
Summary of patterns The patterns discussed below are as follows: Empty
• Liver and Kidney deficiency. • Blood deficiency. • Spleen- and Kidney-Yang deficiency. • Liver- and Kidney-Yin deficiency. • Lung-Yin and Blood deficiency. • Heart- and Kidney-Yin deficiency. • Heart- and Spleen-Blood deficiency. Full
• Stagnation of Qi and Blood. • Damp-Phlegm in the Lower Burner.
Identification of patterns and treatment
Empty conditions
Liver and Kidney deficiency
Clinical manifestations
Menses not started by 18, or stopped after becoming scanty, tiredness, lower backache, knee-ache, dizziness, depression, mentally tired, lack of will-power, feeling cold. Tongue: Pale. Pulse: Deep, Weak. This is essentially a deficiency of Kidney-Yang and Liver-Blood not filling the Penetrating and Directing Vessels. This pattern occurs more frequently in young women. Treatment principle Tonify the Kidneys, nourish the Liver, regulate the periods. Acupuncture BL-18 Ganshu, BL-23 Shenshu, BL-52 Zhishi, Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), LIV-8 Ququan, SP-6 Sanyinjiao, ST-36 Zusanli, KI-3 Taixi, KI-13 Qixue, Xuefu (extra point), Ren-17 Shanzhong, Ren-6 Qihai. All with reinforcing method. Moxa is applicable. Explanation
– BL-18 and BL-23 tonify Liver and Kidneys.
– BL-52 tonifies the Kidneys and the Essence. – Ren-4, with direct moxa, tonifies Kidney and the Uterus. – LU-7 (on the right) and KI-6 (on the left) regulate the Directing Vessel and strengthen the Uterus. – LIV-8, SP-6, ST-36 and KI-3 tonify the Kidney and nourish LiverBlood. – KI-13, a point of the Penetrating Vessel, strengthens the Kidneys and nourishes the Essence. – Xuefu tonifies the Kidney-Essence. This point is level with BL-23 Shenshu, four cun lateral to the midline. – Ren-17 and Ren-6 are often used in combination especially when the periods have stopped after an emotional upset. Herbal treatment
a Prescription
– GUI SHEN WAN – Restoring the Kidneys Pill Explanation
– Tu Si Zi and Du Zhong tonify Kidney-Yang. Tu Si Zi, a more neutral
herb that tonifies Kidney-Yang, also promotes ovulation and nourishes the Essence. – Gou Qi Zi and Dang Gui nourish Liver-Blood. Gou Qi Zi also nourishes the Essence. – Shu Di Huang, Shan Yao and Shan Zhu Yu tonify Kidneys and Liver. These three herbs form the nucleus of several gynecological formulae to tonify Liver and Kidneys (e.g. You Gui Wan Restoring the Right [Kidney] Pill, You Gui Yin Restoring the Right [Kidney] Decoction, Zuo Gui Wan Restoring the Left [Kidney] Pill, Zuo Gui Yin Restoring the Left [Kidney] Decoction, Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill, etc.). – Fu Ling resolves Dampness to counteract the cloying nature of the tonic herbs. – Ji Xue Teng and Shou Wu were added to the original formula to increase its Blood-nourishing effect. b Prescription
– DANG GUI DI HUANG YIN – Angelica-Rehmannia Decoction Explanation This prescription, simpler than the previous one, nourishes Liver-Blood and tonifies Kidney-Yang. Compared with the previous prescription, it tonifies Kidney-Yang more than Liver-Blood.
– Shu Di Huang, Shan Yao and Shan Zhu Yu tonify Liver and Kidneys. – Dang Gui nourishes Liver-Blood. – Du Zhong tonifies Kidney-Yang and strengthens the Governing Vessel. – Huai Niu Xi nourishes Liver and Kidneys. – Gan Cao harmonizes. Modifications The following modifications apply to both of the above formulae. • If there are symptoms and signs of Yin deficiency and Empty-Heat (e.g. dry mouth, feeling of heat, night sweating, etc.) add Zhi Mu Rhizoma Anemarrhenae and Di Gu Pi Cortex Lycii. • If there is insomnia and poor memory add Suan Zao Ren Semen Ziziphi spinosae, Wu Wei Zi Fructus Schisandrae and Ye Jiao Teng Caulis Polygoni multiflori. c Prescription
– SAN CU TANG10 – Three Promotions Decoction Explanation This formula is composed of three separate formulae to be administered for about 1 week each, the idea being that the first is taken for a week before
ovulation, the second for a week during ovulation and the third for a week after ovulation. Obviously, since in this case the woman has no periods, these three formulae are to be taken for 3 consecutive weeks followed by a break of 1 week in order to establish a menstrual cycle. The first formula nourishes Kidney-Yin, the second nourishes and invigorates Blood and the third tonifies Kidney-Yang and Blood. d Prescription
– ZHONG YAO REN GONG TIAO QI ZU FANG11 – Chinese Herbal Formula to Artificially Regulate the Menstrual Cycle Explanation This formula is composed of four prescriptions: for the follicular phase, ovulation, the luteal phase and the menstrual phase. For each phase, there are two alternative formulae, one for Kidney-Yang and the other for KidneyYin deficiency. As explained in the chapter on Infertility (Ch. 57), the menstrual cycle is a manifestation of the waxing and waning of Kidney-Yin and Kidney-Yang and treatment of this organ is therefore essential to restore the regularity of menstruation. This formula is specific for amenorrhoea due to polycystic ovary syndrome. In the follicular phase, the treatment principle is to tonify the Kidneys; in the ovulation phase, to tonify the Kidneys, nourish and invigorate Blood; in the luteal phase, to tonify the Kidneys and nourish Blood; and during menstruation, to tonify the Kidneys and invigorate Blood. Obviously, in this case the patient has no periods and these formulae are therefore taken for 1 week each consecutively in order to establish a menstrual cycle. Three Treasures remedy
– STRENGTHEN THE ROOT This remedy tonifies Kidney-Yang and Liver-Blood and is particularly indicated for women. Summary Liver and Kidney deficiency
Clinical manifestations
Menses not started by 18, or stopped after becoming scanty, tiredness, lower backache, kneeache, dizziness, depression, mentally tired, lack of willpower, feeling cold. Tongue: Pale. Pulse: Deep, Weak. Treatment principle
Tonify the Kidneys, nourish the Liver, regulate the periods. Acupuncture
BL-18 Ganshu, BL-23 Shenshu, BL-52 Zhishi, Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), LIV-8 Ququan, SP-6 Sanyinjiao, ST-36 Zusanli, KI-3 Taixi, KI-13 Qixue, Xuefu (extra point), Ren-17 Shanzhong, Ren-6 Qihai. All with reinforcing method. Moxa is applicable. Herbal treatment
Pre scriptions
• GUI SHEN WAN Restoring the Kidneys Pill Variation • DANG GUI DI HUANG YIN Angelica-Rehmannia Decoction • SAN CU TANG Three Promotions Decoction • ZHONG YAO REN GONG TIAO QI ZU FANG Chinese Herbal Formula to Artificially Regulate the Menstrual Cycle Three Treasures remedy
• STRENGTHEN THE ROOT
Blood deficiency
Clinical manifestations Menstruation stops after several months of decreasing periods, dizziness, blurred vision, numbness and tingling, poor memory, insomnia, palpitations, slight anxiety, depression, dull, pale complexion, dry skin, dry hair, falling hair, dry eyes, tiredness. Tongue: Pale-Thin (unless there is also Spleen-Qi deficiency and Dampness in which case it would be Swollen). Pulse: Choppy or Fine. Treatment principle Nourish Blood, tonify Qi, strengthen the Liver. Acupuncture LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, BL-17 Geshu, BL-18 Ganshu, Zigong (extra point), Ren-17 Shanzhong, Ren-6 Qihai. All points with reinforcing method; direct moxa on BL-17 and BL-18. Moxa can be used on other points too unless there are symptoms of Empty-Heat from Blood deficiency. Explanation
– LIV-8 nourishes Liver-Blood. – ST-36 and SP-6 nourish Blood.
– KI-3 is used to help the Liver to nourish Blood even if there is no Kidney deficiency. – Ren-4 nourishes Blood and tonifies the Uterus. – BL-17 and BL-18 with direct moxa tonify Liver-Blood. – Zigong strengthens the Uterus, tonifies the Penetrating Vessel and nourishes Blood. This point is four cun below the navel (level with Ren-3 Zhongji) and three cun lateral to the midline. – Ren-17 and Ren-6 are often used in combination especially when the periods have stopped after an emotional upset. Herbal treatment
a Prescription
– BA ZHEN TANG Variation – Eight Precious Decoction Variation Explanation The first seven herbs are a variation of Ba Zhen Tang Eight Precious Decoction with the omission of Zhi Gan Cao and the use of Chi Shao instead of Bai Shao Radix Paeoniae alba. These herbs tonify Qi, nourish Blood and strengthen the Liver. – Sang Ji Sheng and Gou Qi Zi nourish Liver-Blood.
– Xiang Fu moves Liver-Qi: this is necessary to counterbalance the cloying effect of the Liver-Blood tonics. b Prescription
– REN SHEN YANG RONG TANG – Ginseng Nourishing and Flourishing Decoction Explanation
– Ren Shen tonifies the Original Qi. – Bai Zhu and Huang Qi tonify Qi: the method of tonifying Qi is often used when nourishing Blood. – Dang Gui, Bai Shao and Shu Di Huang nourish Blood and strengthen the Liver. – Rou Gui tonifies the Yang aspect of the Original Qi, warms the Gate of Life and strengthens the Kidneys. – Wu Wei Zi and Yuan Zhi strengthen the Heart and calm the Mind. These two herbs are added for deficiency of Heart-Blood and palpitations. – Fu Ling and Chen Pi resolve Dampness and counterbalance the many tonic herbs in the prescription. – Zhi Gan Cao harmonizes. This formula is indicated if Blood deficiency occurs against a background of Yang deficiency and the tongue is Pale and Swollen.
Modifications These modifications apply to both the above prescriptions. • If amenorrhoea occurs after childbirth during which there was severe loss of blood leaving the woman seriously depleted in Blood, Yin and Essence, add Lu Rong Cornu Cervi pantotrichum, Lu Jiao Shuang Cornu Cervi degelatinatum and Zi He Che Placenta hominis. • If there is a strong emotional component in the aetiology with HeartBlood deficiency, add Bai Zi Ren Semen Platycladi, Dan Shen Radix Salviae miltiorrhizae and E Jiao Colla Corii asini. c Prescription
– EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai12 Explanation
– Huang Qi, Dang Shen and Zhi Gan Cao tonify Qi to nourish Blood. – Dang Gui, Bai Shao and Sheng Di Huang nourish Blood. – Suan Zao Ren, Yuan Zhi and Fu Shen nourish the Heart and calm the Mind. – Fu Ling drains Dampness and counterbalances the cloying effect of Blood tonics. – Mu Xiang, Ban Xia and Chen Pi harmonize the Centre. This formula is particularly indicated when emotional problems underlie
the Blood deficiency. d Prescription
– DA TIAO JING WAN – Great Regulating the Period Pill Explanation
– Dang Gui, Bai Shao and Sheng Di Huang nourish Blood. – Shan Yao, Bai Zhu and Ren Shen tonify Qi. – Xiang Fu and Wu Yao move Qi and prevent stagnation. – Rou Gui stimulates the production of Qi and Blood. – Dan Shen and Chuan Xiong invigorate Blood and prevent stasis. – Xu Duan tonifies the Kidneys, strengthens the Uterus and consolidates the Directing and Penetrating Vessels. Women’s Treasure remedy
– PRECIOUS SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. The tongue presentation appropriate to this remedy is a Pale and Thin body.
Summary Blood deficiency
Clinical manifestations
Menstruation stops after several months of decreasing periods, dizziness, blurred vision, numbness and tingling, poor memory, insomnia, palpitations, slight anxiety, depression, dull, pale complexion, dry skin, dry hair, falling hair, dry eyes, tiredness. Tongue: Pale-Thin (unless there is also Spleen-Qi deficiency and Dampness in which case it would be Swollen). Pulse: Choppy or Fine. Treatment principle
Nourish Blood, tonify Qi, strengthen the Liver. Acupuncture
LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, BL-17 Geshu, BL-18 Ganshu, Zigong (extra point), Ren-17 Shanzhong, Ren-6 Qihai. All points with reinforcing method; direct moxa on BL-17 and BL-18. Moxa can be used on other points too unless there are symptoms of Empty-Heat from Blood Xu. Herbal treatment
Pre scriptions
• BA ZHEN TANG Variation Eight Precious Decoction Variation
• REN SHEN YANG RONG TANG Ginseng Nourishing and Flourishing Decoction • EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai • DA TIAO JING WAN Great Regulating the Period Pill Women’s Treasure remedy
• PRECIOUS SEA
Case history An 18-year-old girl had been on the contraceptive pill for 18 months starting when she was 16. She took this not for contraceptive reasons but as a cure for painful periods. She sought treatment when she had had no period for about a year. She had also contracted glandular fever (mononucleosis) when she was 13 and never completely recovered from it, suffering from chronic post-viral fatigue syndrome. When I saw her she complained of exhaustion, poor memory, mental confusion, depression, muscle-ache, headaches on the vertex, a feeling of oppression of the chest, insomnia and poor appetite. She spoke in a very soft, weak voice and her complexion was pale. Her tongue was Pale, without coating and cracked. Her pulse was Choppy. Diagnosis Her main condition was Blood deficiency as evidenced by the pale complexion, exhaustion, poor memory, mental confusion, depression, headaches on the vertex, insomnia, Pale tongue and Choppy pulse. As often happens, this condition was triggered off after stopping the contraceptive pill. Her tongue showed that the Blood deficiency was beginning to turn into Yin deficiency, for it was without coating and cracked. Apart from this, there was
also some Dampness, a residual pathogenic factor from the attack of glandular fever when she was 13. The symptoms of this are muscle-ache and a feeling of oppression of the chest. Treatment principle I treated her with a variation of Ba Zhen Tang Eight Precious Decoction: • Dang Gui Radix Angelicae sinensis 10 g • Chuan Xiong Rhizoma Chuanxiong 4 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Dang Shen Radix Codonopsis 10 g • Fu Ling Poria 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Tu Si Zi Semen Cuscutae 6 g • Sang Ji Sheng Herba Taxilli 4 g • Gou Qi Zi Fructus Lycii 6 g • Xiang Fu Rhizoma Cyperi 4 g • Sha Ren Fructus Amomi 3 g • Yi Yi Ren Semen Coicis 9 g
Explanation The first six herbs are a variation of Ba Zhen Tang to tonify Qi and Blood. • Tu Si Zi was added to tonify the Kidney and promote ovulation. • Sang Ji Sheng and Gou Qi Zi were added to nourish Blood. Sang Ji Sheng
would also help the muscle-ache because it expels Wind-Dampness from the channels and Gou Qi Zi also nourishes Yin. • Xiang Fu was added to move Qi as a counterbalance to the Qi and Blood tonics. • Sha Ren, a fragrant herb that resolves Dampness from the space between skin and muscles, was added to treat the muscle-ache. • Yi Yi Ren was added to drain Dampness via urination.
After 6 months of treatment along these lines, her periods started to come every 7–8 weeks, and after a further 6 months, they were coming every 5 weeks.
Spleen- and Kidney-Yang deficiency
Clinical manifestations No periods, tiredness, loose stools, feeling of cold, cold feet, poor appetite, lower backache, weak limbs, abdominal distension, dizziness, frequent, pale urination. Tongue: Pale, Swollen. Pulse: Weak, Slow, Deep. Treatment principle Tonify Yang, warm Spleen and Kidneys, warm the Uterus. Acupuncture Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu, KI-3 Taixi, Ren-4 Guanyuan, BL-23 Shenshu, BL-52 Zhishi, Xuefu (extra point), Zigong (extra point), Ren-17 Shanzhong, Ren-6 Qihai. All with reinforcing method; direct moxa on the Back-Shu points and Ren-4 and warming needle on some of the others. Explanation
– Ren-12, ST-36, SP-6, BL-20 and BL-21 tonify and warm the Spleen (direct moxa on BL-20 and BL-21 and warming needle on the others). – KI-3 and BL-23, with moxa, tonify and warm the Kidneys. – Ren-4, with direct moxa, tonifies Kidney-Yang and the Directing Vessel and warms the Uterus.
– BL-52, with direct moxa, tonifies Kidney-Yang and the Essence. This point is necessary as, in this pattern, there is a deficiency of the Yang aspect of the Essence, especially in primary amenorrhoea. – Xuefu tonifies the Kidney-Essence. This point is level with BL-23 Shenshu, four cun lateral to the midline. – Zigong strengthens the Uterus, tonifies the Penetrating Vessel and nourishes Blood. This point is four cun below the navel (level with Ren-3 Zhongji) and three cun lateral to the midline. – Ren-17 and Ren-6 are often used in combination especially when the periods have stopped after an emotional upset. Herbal treatment
a Prescription
– BA ZHEN TANG Variation – Eight Precious Decoction Variation Explanation The first eight herbs are a variation of Si Wu Tang to nourish Blood and strengthen the Liver. – Yin Yang Huo, Tu Si Zi and Fe Pen Zi tonify and warm Kidney-Yang. – Sang Ji Sheng nourishes Liver-Blood.
– Huang Qi and Dang Shen tonify Qi. – Xiang Fu moves Qi. b Prescription
– FU KE ZHU XIAN DAN – Gynaecological Helping the Immortals Pill Explanation This formula nourishes the Heavenly Gui, which is the basis for the reproductive function and which derives from the Kidney-Essence. This formula is used for amenorrhoea, especially in young women. – Fu Ling, Chen Pi, Shan Yao and Bai Zhu tonify Qi and resolve Dampness. – Bai Shao nourishes Liver-Blood. – Tu Si Zi and Du Zhong tonify and warm the Kidneys, and promote ovulation. – Gan Cao harmonizes. c . Prescription
– CU HUANG TI TANG13 – Promoting the Corpus Luteum Decoction
Explanation
– Shu Di Huang tonifies the Kidneys and nourishes Blood. – Gui Ban nourishes Kidney-Yin and consolidates the Directing and Penetrating Vessels. – Bai Zhu tonifies the Spleen. – Xu Duan and Rou Cong Rong tonify and warm Kidney-Yang. – Mei Gui Hua moves Qi. – Dang Gui nourishes Blood. This formula is specific for amenorrhoea from luteal phase defect. d Prescription
– GU YIN JIAN – Consolidating the Yin Decoction Explanation In spite of its name, this formula, from The Complete Works of Jing Yue (1624), tonifies Kidney-Yang. – Ren Shen tonifies Qi and the Original Qi. – Shu Di Huang, Shan Yao and Shan Zhu Yu tonify the Liver and Kidneys.
– Yuan Zhi calms the Mind. – Zhi Gan Cao harmonizes. – Wu Wei Zi nourishes the Essence. – Tu Si Zi tonifies Kidney-Yang. Women’s Treasure remedy
– UNICORN PEARL This remedy tonifies Kidney-Yang and nourishes Blood. Summary Spleen- and Kidney-Yang deficiency
Clinical manifestations
No periods, tiredness, loose stools, feeling of cold, cold feet, poor appetite, lower backache, weak limbs, abdominal distension, dizziness, frequent, pale urination. Tongue: Pale, Swollen. Pulse: Weak, Slow, Deep. Treatment principle
Tonify Yang, warm Spleen and Kidneys, warm the Uterus. Acupuncture
Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-21
Weishu, KI-3 Taixi, Ren-4 Guanyuan, BL-23 Shenshu, BL-52 Zhishi, Xuefu (extra point), Zigong (extra point), Ren-17 Shanzhong, Ren-6 Qihai. All with reinforcing method; direct moxa on the Back-Shu points and Ren-4 and warming needle on some of the others. Herbal treatment
Pre scriptions
• BA ZHEN TANG Variation Eight Precious Decoction Variation • FU KE ZHU XIAN DAN Gynaecological Helping the Immortals Pill • CU HUANG TI TANG Promoting the Corpus Luteum Decoction • GU YIN JIAN Consolidating the Yin Decoction Women’s Treasure remedy
• UNICORN PEARL
Liver- and Kidney-Yin deficiency
Clinical manifestations Dizziness, dry eyes, tiredness, blurred vision, insomnia, lower backache, night sweating, tinnitus. Tongue: without coating, cracks; also Red if there is Empty-Heat. Pulse: Floating-Empty. Fine-Rapid if there is Empty-Heat. This pattern is more likely to occur in women over 30. Treatment principle Nourish Liver- and Kidney-Yin, tonify the Uterus, nourish the Essence. Acupuncture LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, KI-3 Taixi, BL-52 Zhishi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-13 Qixue, Zigong (extra point). All with reinforcing method, generally no moxa. However, if the tongue is not too Red and there are no pronounced Empty-Heat signs (such as night sweating, a feeling of heat, malar flush, etc.), a small amount of moxa (warming needle) could be used on points such as KI-3 and SP-6: this is all the more effective if the pulse is particularly Fine. Explanation
– LIV-8, ST-36 and SP-6 nourish Liver-Yin. – Ren-4 nourishes Liver and Kidneys, tonifies the Uterus and strengthens
the Essence. – KI-3 nourishes the Kidneys. – BL-52 nourishes the Essence. – LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and nourish Yin. – KI-13 nourishes the Kidneys, tonifies the Uterus and strengthens the Penetrating Vessel. – Zigong strengthens the Uterus, tonifies the Penetrating Vessel and nourishes Blood. This point is four cun below the navel (level with Ren-3 Zhongji) and three cun lateral to the midline. Herbal treatment
a Prescription
– ZUO GUI YIN and SI WU TANG Variation – Restoring the Left [Kidney] Decoction and Four Substances Decoction Variation Explanation
– Dang Gui, Chi Shao and Shu Di Huang nourish Blood and strengthen the Liver.
– Shan Zhu Yu and Gou Qi Zi nourish Liver-Yin. – Tu Si Zi tonifies the Kidneys and promotes ovulation. – Gui Ban nourishes Kidney-Yin and clears Empty-Heat. It also nourishes the Directing and Penetrating Vessels. – Zi He Che nourishes Liver and Kidneys and the Essence. – Shan Yao tonifies Stomach, Spleen and Kidneys. – Huai Niu Xi nourishes Liver and Kidneys. b Prescription
– YI YIN JIAN Variation – One Yin Decoction Variation Explanation
– Sheng Di Huang and Shu Di Huang nourish Kidney-Yin. – Bai Shao and Mai Dong help to nourish Yin. – Zhi Mu and Di Gu Pi clear Empty-Heat. – Huang Jing is added to nourish Yin and the Essence. – Dan Shen is added to calm the Mind as Empty-Heat is likely to affect the Mind causing mental restlessness.
– Zhi Ke moves Qi and is added to counterbalance the cloying effect of the Yin tonics. c Prescription
– BU SHEN DI HUANG TANG – Tonifying the Kidneys Rehmannia Decoction Explanation
– Shu Di Huang, Mai Men Dong and Xuan Shen nourish Kidney-Yin. – Shan Yao, Sang Piao Xiao and Shan Zhu Yu tonify the Spleen, Kidneys and Liver. – Zhi Mu, Mu Dan Pi, Huang Bo and Ze Xie clear Empty-Heat. – Yuan Zhi, Fu Shen and Suan Zao Ren calm the Mind and open the Mind’s orifices. – Zhu Ye clears Heart-Heat and calms the Mind. – Gui Ban Jiao nourishes Yin, tonifies the Kidneys and nourishes the Directing and Penetrating Vessels. Modifications
• If there are pronounced symptoms and signs of Empty-Heat, add Qing Hao Herba Artemisiae annuae and Bie Jia Carapax Trionycis.
• If there is insomnia and palpitations, add Bai Zi Ren Semen Platycladi and Ye Jiao Teng Caulis Polygoni multiflori. Table 16.2 compares and contrasts the three formulae for amenorrhoea from Liver- and Kidney-Yin deficiency. Please note that the tongue corresponding to the formulae Zuo Gui Yin and Si Wu Tang is indicated as ‘normal coloured’ because Yin deficiency causes the lack of coating: if there is no Empty-Heat, the tongue may have a normal colour. Table 16.2 Comparison of formulae for amenorrhoea from Liver- and Kidney-Yin deficiency
Three Treasures remedy
– NOURISH THE ROOT This remedy nourishes Liver- and Kidney-Yin and is especially
indicated for women. The tongue presentation appropriate to this remedy is a Red body without coating. Summary Liver- and Kidney-Yin deficiency
Clinical manifestations
Dizziness, dry eyes, tiredness, blurred vision, insomnia, lower backache, night sweating, tinnitus. Tongue: without coating, cracks; also Red if there is Empty-Heat. Pulse: Floating-Empty. Fine-Rapid if there is Empty-Heat. Treatment principle
Nourish Liver- and Kidney-Yin, tonify the Uterus, nourish the Essence. Acupuncture
LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, KI-3 Taixi, BL-52 Zhishi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-13 Qixue, Zigong (extra point). All with reinforcing method, generally no moxa. However, if the tongue is not too Red and there are no pronounced Empty-Heat signs (such as night sweating, a feeling of heat, malar flush, etc.), a small amount of moxa (warming needle) could be used on points such as KI-3 and SP-6: this is all the more effective if the pulse is particularly Fine. Herbal treatment
Pre scriptions
• ZUO GUI YIN and SI WU TANG Variation Restoring the Left [Kidney] Decoction and Four Substances Decoction Variation • YI YIN JIAN Variation One Yin Decoction Variation • BU SHEN DI HUANG TANG Tonifying the Kidneys Rehmannia Decoction Three Treasures remedy
• NOURISH THE ROOT
Lung-Yin and Blood deficiency
Clinical manifestations No periods, a dry cough or with scanty, blood-speckled expectoration, breathlessness, bright red lips, five-palm heat, malar flush, depression, sighing, sadness. Tongue: without coating in the front. Pulse: Floating-Empty. This pattern underlying amenorrhoea is mentioned in Bai Ling’s Gynaecology, the only text to do so as far as I can tell.14 Its inclusion is interesting as it highlights the influence of the Lungs on the menstrual function, especially when amenorrhoea is caused by sadness, worry and grief affecting them. Lung-Qi declines and fails to govern Blood: this causes a Blood deficiency and amenorrhoea results. This happens all the more easily when, as it occurs in this pattern, Lung-Qi deficiency progresses to Lung-Yin deficiency: as Blood is part of Yin, amenorrhoea results. Treatment principle Nourish Lung-Yin, nourish Liver-Blood, moisten the Lungs, calm the Mind, settle the Corporeal Soul. Acupuncture LU-9 Taiyuan, Ren-17 Shanzhong, Ren-6 Qihai, BL-42 Pohu, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, LU-7 Lieque on the right and KI6 Zhaohai on the left, Ren-4 Guanyuan. All with reinforcing method. Explanation
– LU-9 nourishes Lung-Yin and settles the Corporeal Soul. – Ren-17 tonifies the Qi of the Upper Burner and settles the Corporeal Soul. – Ren-6 tonifies the Qi of the Lower Burner and also tonifies Lung-Qi because the Lung channel courses down to that level. – BL-42 calms the Mind, opens the chest and settles the Corporeal Soul. – ST-36 and SP-6 tonify the Lungs (Metal) by tonifying the Spleen (Earth). These two points also help to nourish Blood. – LIV-8 and Ren-4 nourish Liver-Blood. – LU-7 and KI-6 open the Directing Vessel, strengthen the Uterus and also nourish Lung-Yin and moisten the Lungs. Herbal treatment
Prescription
– BAI HE GU JIN TANG – Lilium Consolidating Metal Decoction Explanation
– Bai He and Mai Dong nourish Lung-Qi and settle the Corporeal Soul.
– Xuan Shen and Sheng Di Huang nourish Yin. – Shu Di Huang, Dang Gui and Bai Shao nourish Liver-Blood. – Jie Geng regulates Lung-Qi and stops cough. – Chuan Bei Mu restores the descending of Lung-Qi and stops cough. – Gan Cao harmonizes. Summary Lung-Yin and Blood deficiency
Clinical manife stations
No periods, a dry cough or with scanty, blood-speckled expectoration, breathlessness, bright red lips, five-palm heat, malar flush, depression, sighing, sadness. Tongue: without coating in the front. Pulse: Floating-Empty. Tre atme nt principle
Nourish Lung-Yin, nourish Liver-Blood, moisten the Lungs, calm the Mind, settle the Corporeal Soul. Acupuncture
LU-9 Taiyuan, Ren-17 Shanzhong, Ren-6 Qihai, BL-42 Pohu, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan. All with reinforcing method. He rbal tre atme nt
Prescription
• BAI HE GU JIN TANG Lilium Consolidating Metal Decoction
Heart- and Kidney-Yin deficiency
Clinical manifestations No periods, palpitations, insomnia, malar flush, depression, anxiety, dizziness, tinnitus, backache, night sweating, a dry mouth and throat at night. Tongue: without coating, dry, cracked; Red if there is Empty-Heat. Pulse: FloatingEmpty; also Rapid if there is Empty-Heat. This pattern is also mentioned in Bai Ling’s Gynaecology.15 Again, its inclusion is interesting as it highlights the influence of the Heart on the gynecological function. The Heart governs Blood: some gynecologists emphasize this function of the Heart in relation to menstrual blood (whereas most emphasize the Liver-Blood’s role). Apart from this, the Heart is connected to the Uterus through the Uterus vessel and, finally, Fu Qing Zhu says that Heart-Yang flows down to communicate with Kidney-Yin to generate menstrual blood (see Ch. 2 on physiology). This type of amenorrhoea is typically caused by emotional problems affecting the Heart such as sadness, grief and guilt. Treatment principle Nourish Heart- and Kidney-Yin, clear Empty-Heat, calm the Mind. Acupuncture HE-7 Shenmen, P-7 Daling, BL-44 Shentang, Ren-15 Jiuwei, Ren-14 Juque, Ren-4 Guanyuan, KI-3 Taixi, SP-6 Sanyinjiao, LU-7 Lieque on the right and KI-6 Zhaohai on the left. All with reinforcing method. Explanation
– HE-7, P-7, BL-44, Ren-15 and Ren-14 calm the Mind and nourish the Heart. – Ren-4, KI-3 and SP-6 nourish Kidney-Yin. – LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and nourish Yin. Herbal treatment
Prescription
– TIAN WANG BU XIN DAN – Heavenly Emperor Tonifying the Heart Pill Explanation
– Sheng Di Huang, Xuan Shen, Mai Men Dong and Tian Men Dong nourish Heart- and Kidney-Yin. – Ren Shen and Fu Ling tonify Qi and the Original Qi, as well as the Heart. – Wu Wei Zi tonifies the Heart and nourishes the Essence. – Dang Gui and Bai Zi Ren nourish Blood and the Heart and calm the Mind.
– Dan Shen calms the Mind. – Suan Zao Ren and Yuan Zhi calm the Mind. – Jie Geng directs the formula to the Upper Burner; this last herb could be dropped as, in the case of amenorrhoea, we want the formula to go to the Lower Burner. Summary Heart- and Kidney-Yin deficiency
Clinical manife stations
No periods, palpitations, insomnia, malar flush, depression, anxiety, dizziness, tinnitus, backache, night sweating, a dry mouth and throat at night. Tongue: without coating, dry, cracked; Red if there is Empty-Heat. Pulse: FloatingEmpty; also Rapid if there is Empty-Heat. Tre atme nt principle
Nourish Heart- and Kidney-Yin, clear Empty-Heat, calm the Mind. Acupuncture
HE-7 Shenmen, P-7 Daling, BL-44 Shentang, Ren-15 Jiuwei, Ren-14 Juque, Ren-4 Guanyuan, KI-3 Taixi, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left). All with reinforcing method. He rbal tre atme nt
Prescription
• TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill
Heart- and Spleen-Blood deficiency
Clinical manifestations Palpitations, depression, anxiety, insomnia, pale, dull complexion, no periods, tiredness, loose stools, poor appetite, abdominal distension. Tongue: Pale. Pulse: Weak or Choppy. This pattern is also mentioned in Bai Ling’s Gynaecology.16 It arises when the Spleen and Heart are affected by emotional problems such as sadness, worry or grief. The Spleen and Heart become deficient, Spleen-Qi fails to make Blood, Blood deficiency develops and the periods stop. A similar pattern is mentioned in the General Collection for Holy Relief (1117) which says: When a woman is afflicted by pensiveness and worry, Heart-Qi becomes deficient, Qi stagnates and cannot descend and the periods do not come on time or do not come at all; Qi is exhausted in the diaphragm, there are chills and feeling of heat, the flesh and muscles do not flourish, and there is no appetite. This disease cannot be treated with herbs that break up Blood, but by making Heart-Qi flow and by freeing the channels. Use Ren Shen Tang.17 The formula Ren Shen Tang is given below. Treatment principle
Tonify Spleen-Qi, nourish Blood, strengthen the Heart. Acupuncture
Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, LIV8 Ququan, Ren-4 Guanyuan, HE-7 Shenmen, Ren-14 Juque, BL-15 Xinshu. All with reinforcing method. Explanation
– Ren-12, ST-36, SP-6 and BL-20 tonify the Spleen. – LIV-8 and Ren-4 nourish Liver-Blood. – HE-7 and Ren-14 nourish the Heart. – BL-15, with moxa cones, tonifies the Heart. Herbal treatment
a Prescription
– GUI PI TANG – Tonifying the Spleen Decoction Explanation
– Ren Shen, Huang Qi and Bai Zhu tonify Spleen-Qi.
– Dang Gui and Long Yan Rou nourish Blood and the Heart. – Fu Shen resolves Dampness and calms the Mind. – Yuan Zhi and Suan Zao Ren calm the Mind and open the Mind’s orifices. – Mu Xiang moves Qi to prevent any stagnation that may derive from the tonic herbs. – Sheng Jiang, Hong Zao and Zhi Gan Cao tonify Qi and harmonize. b Prescription
– REN SHEN TANG – Ginseng Decoction Explanation
– Ren Shen, Bai Zhu and Mai Men Dong tonify the Spleen and Heart. – Bing Lang, Da Fu Pi, Bai Dou Kou and Zhi Ke move Qi and free the diaphragm. – Mu Dan Pi clears Liver-Heat and is added in case Liver-Qi stagnation has generated Heat. – Bai Shao, Sheng Di Huang and Dang Gui nourish Heart-Blood. – Fang Ji and Fu Ling resolve Dampness.
– Chuan Xiong invigorates Blood. – Ding Xiang and Gui Zhi warm the channels which helps to eliminate stagnation. – Jie Geng directs the formula to the Upper Burner. – Yuan Zhi calms the Mind, clears the Heart and opens the Mind’s orifices. – Da Huang: it is difficult to explain the inclusion of this herb. One possible explanation is that it frees the obstruction of the Upper Burner by moving downwards. – Gan Cao harmonizes. Three Treasures remedy
– CALM THE SPIRIT This remedy is a variation of the formula Gui Pi Tang Tonifying the Spleen Decoction which tonifies Heart- and Spleen-Blood. The tongue presentation appropriate to this remedy is a Pale body. Summary Heart- and Spleen-Blood deficiency
Clinical manifestations
Palpitations, depression, anxiety, insomnia, pale, dull complexion, no periods, tiredness, loose stools, poor appetite, abdominal distension. Tongue: Pale. Pulse: Weak or Choppy.
Treatment principle
Tonify Spleen-Qi, nourish Blood, strengthen the Heart. Acupuncture
Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, LIV-8 Ququan, Ren-4 Guanyuan, HE-7 Shenmen, Ren-14 Juque, BL-15 Xinshu. All with reinforcing method. Herbal treatment
Pre scriptions
• GUI PI TANG Tonifying the Spleen Decoction • REN SHEN TANG Ginseng Decoction Three Treasures remedy
• CALM THE SPIRIT
Full conditions
Stagnation of Qi and Blood
Clinical manifestations Secondary amenorrhoea, irritability, moodiness, abdominal distension and pain, depression, dark complexion. Tongue: Purple, or Purple sides. Pulse: Wiry, Choppy or Firm. Treatment principle Pacify the Liver, move Qi and Blood. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), Ren-6 Qihai, ST30 Qichong, LIV-3 Taichong, SP-6 Sanyinjiao, KI-14 Siman, KI-6 Zhaohai. All with reducing or even method. Explanation
– SP-4 and P-6, in combination, regulate the Penetrating Vessel and subdue rebellious Qi. The Penetrating Vessel, being the Sea of Blood, also moves Blood. – Ren-6 moves Qi in the lower abdomen. – ST-30 is an important point on the Penetrating Vessel that moves Qi and Blood in the lower abdomen. – LIV-3 pacifies the Liver and moves Qi and Blood.
– SP-6 moves Blood. – KI-14 subdues rebellious Qi in the Penetrating Vessel and moves Qi and Blood in the lower abdomen. – KI-6 is recommended by Huang Fu Mi in the ABC of Acupuncture (AD 259) for amenorrhoea caused by shock or sadness.18 It may be that this point has this effect as opening point of the Yin Stepping Vessel which eliminates stagnation in the lower abdomen. Herbal treatment
a Prescription
– TAO HONG SI WU TANG Variation – Persica-Carthamus Four Substances Decoction Variation Explanation
– Dang Gui, Chuan Xiong and Chi Shao nourish and invigorate Blood. – Tao Ren and Hong Hua invigorate Blood. – Ze Lan ‘breaks Blood’, i.e. it invigorates Blood strongly and breaks up accumulations such as abdominal lumps, cysts, etc. – Mu Xiang and Xiang Fu move Qi and eliminate stagnation. – Niu Xi nourishes Liver and Kidneys and also invigorates Blood.
b Prescription
– SHAO FU ZHU YU TANG – Lower Abdomen Eliminating Stasis Decoction Explanation This prescription is for stasis of Blood in the lower abdomen caused by Cold. – Xiao Hui Xiang expels Cold and subdues rebellious Qi in the Penetrating Vessel. – Gan Jiang and Rou Gui expel Cold and warm the Uterus. – Yan Hu Suo, Mo Yao, Pu Huang, Wu Ling Zhi, Dang Gui, Chuan Xiong and Chi Shao move Blood. c Prescription
– WEN JING TANG – Warming the Menses Decoction Explanation This prescription is for a complex condition characterized by Cold obstructing the Uterus for a long time giving rise to Blood deficiency, a slight Yin deficiency (only as a consequence of Blood deficiency) and some
Empty-Heat. Compared with the first of these three formulae, the emphasis of Wen Jing Tang is on expelling Cold, whereas that of Tao Hong Si Wu Tang is on invigorating Blood. d Prescription
– WU YAO SAN – Linderia Powder Explanation
– Wu Yao, Xiang Fu, Chen Pi, Chai Hu, Bo He and Mu Xiang move Qi and eliminate stagnation. – Su Zi makes Lung-Qi descend and frees the diaphragm. – Mu Dan Pi clears Liver-Heat. – Gui Zhi warms the channels which helps to eliminate stagnation. – Dang Gui and Chuan Xiong harmonize Liver-Blood which helps to eliminate stagnation of Qi. – Gan Cao harmonizes. e Prescription
– EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai19
Explanation
– Chai Hu, Xiang Fu, Su Geng and Bai Ji Li pacify the Liver, move Qi and eliminate stagnation. – Dang Gui, Ze Lan, Chuan Xiong and Chi Shao invigorate Blood and free the menses. – Hou Po, Ban Xia and Chen Pi harmonize the Centre. – Shan Zhi Zi clears any Heat that may derive from long-term Qi stagnation. – Fu Ling resolves Dampness. – Gan Cao harmonizes. Dr Zhang says that this pattern may arise from worry, anxiety, anger, resentment or hatred. f Prescription
– QING GAN BU SHEN TANG20 – Clearing the Liver and Tonifying the Kidneys Decoction Explanation
– Mu Dan Pi and Shan Zhi Zi clear Liver-Heat. – Chai Hu and Qing Pi move Qi, pacify the Liver and eliminate stagnation.
– Dang Gui nourishes Blood and pacifies the Liver. – Sheng Di Huang and Huang Jing nourish Kidney-Yin and the Essence. – Yin Yang Huo and Bu Gu Zhi tonify Kidney-Yang. – Chuan Shan Jia invigorate Blood and eliminate stasis. – Mai Ya inhibits prolactin. This formula is specific for amenorrhoea with excess of prolactin. g Prescription
– PAI LUAN TANG21 – Ovulation Decoction Explanation
– Chai Hu pacifies the Liver, moves Qi and eliminates stagnation. – Chi Shao, Ze Lan, Pu Huang, Liu Ji Nu, Chuan Niu Xi and Ji Xue Teng invigorate Blood and eliminate stasis. – Bai Shao, Shou Wu and E Jiao nourish Blood. – Xu Duan tonifies Kidney-Yang. – Nu Zhen Zi and Han Lian Cao nourish Kidney-Yin. This formula is specific for amenorrhoea from luteal phase defect occurring against a background of Kidney deficiency and Liver-Qi and Liver-Blood stagnation.
Modifications These modifications apply to all the above formulae. • If there are signs of Qi stagnation, add Qing Pi Pericarpium Citri reticulatae viride and Mu Xiang Radix Aucklandiae. • If the symptoms and signs of stasis of Blood are very pronounced (such as stabbing abdominal pain with abdominal masses), add San Leng Rhizoma Sparganii. • If there are symptoms of Heat, add Huang Bo Cortex Phellodendri, Bai Jiang Cao Herba Patriniae and Mu Dan Pi Cortex Moutan. Table 16.3 compares and contrasts the seven formulae. Table 16.3 Comparison of formulae for amenorrhoea from stagnation of Qi and Blood
Women’s Treasure remedy
– STIR FIELD OF ELIXIR Explanation This remedy (a variation of Shao Fu Zhu Yu Tang) moves Blood in the Lower Burner and Uterus. The tongue presentation appropriate to this remedy is a Purple body.
Summary Stagnation of Qi and Blood
Clinical manife stations
Secondary amenorrhoea, irritability, moodiness, abdominal distension and pain, depression, dark complexion. Tongue: Purple, or Purple sides. Pulse: Wiry, Choppy or Firm. Tre atme nt principle
Pacify the Liver, move Qi and Blood. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), Ren-6 Qihai, ST30 Qichong, LIV-3 Taichong, SP-6 Sanyinjiao, KI-14 Siman, KI-6 Zhaohai. All with reducing or even method. He rbal tre atme nt
Prescriptions
• TAO HONG SI WU TANG Variation Persica-Carthamus Four Substances Decoction Variation • SHAO FU ZHU YU TANG Lower Abdomen Eliminating Stasis Decoction • WEN JING TANG Warming the Menses Decoction • WU YAO SAN Linderia Powder • EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai • QING GAN BU SHEN TANG Clearing the Liver and Tonifying the Kidneys Decoction
• PAI LUAN TANG Ovulation Decoction Women’s Treasure re me dy
• STIR FIELD OF ELIXIR
Damp-Phlegm in the Lower Burner
Clinical manifestations Secondary amenorrhoea, prolonged cycle gradually developing to amenorrhoea, obesity, vaginal discharge, lassitude, feeling of heaviness, feeling of oppression in the chest, nausea. Tongue: Swollen, sticky-yellow coating which is thicker on the root. Pulse: Slippery. Treatment principle Resolve Dampness, move Qi, resolve Phlegm, penetrate the Connecting channels, tonify the Uterus. Acupuncture SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-6 Qihai, ST-28 Shuidao, ST-27 Daju, LU-7 Lieque (on the right) and KI-6 Zhaohai, BL-22 Sanjiaoshu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, Ren-5 Shimen. All with reducing or even method, except for Ren-12 which should be reinforced. Explanation
– SP-9, SP-6 and BL-22 resolve Dampness. – ST-28 and ST-27 resolve Dampness and Phlegm in the Lower Burner. – Ren-6 moves Qi in the abdomen. Moving Qi helps to resolve Dampness.
– LU-7 and KI-6 regulate the Directing Vessel. – Ren-12 tonifies the Spleen and resolves Dampness. – Ren-9 promotes the transformation of fluids. – ST-40 resolves Phlegm. – Ren-5 promotes the transformation and excretion of fluids by the Lower Burner. Herbal treatment
Prescription
– CANG FU DAO TAN WAN and FO SHOU SAN Variation – Atractylodes-Cyperus Conducting Phlegm Pill and Buddha’s Hand Powder Variation Explanation The first nine herbs constitute the formula Cang Fu Dao Tan Wan which resolves Dampness and Phlegm. The two herbs Dang Gui and Chuan Xiong constitute the formula Fo Shou Wan which moves Blood. Women’s Treasure remedy
– CLEAR THE PALACE
This remedy resolves Dampness and Phlegm from the genital system. The tongue presentation appropriate to this remedy is a Swollen body with a sticky coating. Summary Damp-Phlegm in the Lower Burner
Clinical manifestations
Secondary amenorrhoea, prolonged cycle gradually developing to amenorrhoea, obesity, vaginal discharge, lassitude, feeling of heaviness, feeling of oppression in the chest, nausea. Tongue: Swollen, sticky-yellow coating which is thicker on the root. Pulse: Slippery. Treatment principle
Resolve Dampness, move Qi, resolve Phlegm, penetrate the Connecting channels, tonify the Uterus. Acupuncture
SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-6 Qihai, ST-28 Shuidao, ST-27 Daju, LU-7 Lieque (on the right) and KI-6 Zhaohai, BL-22 Sanjiaoshu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, Ren-5 Shimen. All with reducing or even method, except for Ren-12 which should be reinforced. Herbal treatment
Pre scriptions
• CANG FU DAO TAN WAN and FO SHOU SAN Variation AtractylodesCyperus Conducting Phlegm Pill and Buddha’s Hand Powder Variation Women’s Treasure remedy
• CLEAR THE PALACE
Case history A 43-year-old-woman’s periods had stopped suddenly 6 months previously. She started suffering from hot flushes, sweating and insomnia. She also felt always anxious and agitated. She looked very anxious and depressed and her face was flushed. On interrogation, other symptoms came up: backache, feeling cold, tinnitus, a feeling of masses in the abdomen, skin spots, a feeling of oppression of the chest. She had four children, ages 12, 10, 8 and 6. Her tongue had a very thick and sticky coating and her pulse was Weak on both Rear positions, Choppy, but also Slippery on both Middle positions. Diagnosis I diagnosed three main patterns: Kidney-Yang deficiency (feeling cold, tinnitus, backache, Weak Kidney pulse), Phlegm and Dampness (very thick, sticky tongue coating, skin spots, a feeling of oppression in the chest) and stagnation of Qi (feeling of masses in the abdomen). In my opinion, her periods had stopped not from the Kidney deficiency but from a combination of Phlegm, Dampness and stagnation of Qi. The periods had stopped suddenly: this is characteristic when their stopping is caused by a Full condition. Had a Kidney deficiency (from which she did also suffer) been the cause, the periods would have stopped gradually. I thought that the main cause was emotional and that she must have had a shock or an emotional upset: when I put this to her she did confirm that her ‘family situation’ had
been very difficult and tears welled up in her eyes as she said this. Treatment principle The treatment principle was first to dry Dampness, resolve Phlegm and move Qi. I resolved to tackle the Full condition first as I find this approach more effective in mixed deficiency/excess conditions. After eliminating Dampness, Phlegm and Qi stagnation, I would tonify Kidney-Yang. I treated her with both acupuncture and herbs. Acupuncture
In the first treatment I used the following points: • LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to regulate the Directing Vessel and strengthen the Uterus. • P-7 Daling (on the left) with even method, to calm the Mind. I use P-7 when there are emotional problems from relationship difficulties: I felt this was the cause of her ‘family problems’ even though she did not like to talk about them. • ST-40 Fenglong (on the right) with even method to resolve Phlegm and calm the Mind. • Thus, the above four points are coordinated, with LU-7 (on the right), KI-6 (on the left), P-7 (on the left) and ST-40 (on the right): this combination is balanced in terms of Above–Below, Yin–Yang and left–right. • SP-6 Sanyinjiao and SP-9 Yinlingquan (bilateral) with even method to resolve Dampness in the Lower Burner. • KI-3 Taixi (bilateral) with reinforcing method to tonify the Kidneys. • BL-23 Shenshu (bilateral) with reinforcing method to tonify the Kidneys and strengthen the back. • Shiqizhuixia to strengthen the Governing Vessel and treat the back. I find this point excellent to treat backache in the sacroiliac region.
• BL-26 Guanyuanshu (on the left, where the pain was), with even method to eliminate stagnation of Qi in the back. • BL-40 Weizhong (on the left) with reducing method to eliminate stagnation from the back. • These last two points were used on the left side because that was the painful side. Herbal treatment
I used a variation of the formulae Cang Fu Dao Tan Wan AtractylodesCyperus Conducting Phlegm Pill and Fo Shou San Buddha’s Hand Powder: • Cang Zhu Rhizoma Atractylodis 6 g • Fu Ling Poria 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Gan Cao Radix Glycyrrhizae uralensis 3 g • Xiang Fu Rhizoma Cyperi 6 g • Dan Nan Xing Rhizoma Arisaematis preparatum 4.5 g • Zhi Ke Fructus Aurantii 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Shen Qu Massa medicata fermentata 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Radix Chuanxiong 4 g • Yuan Zhi Radix Polygalae 6 g • Bai Zi Ren Semen Platycladi 6 g
• Qin Jiao Radix Gentianae macrophyllae 6 g
Explanation To the two above formulae that resolve Dampness and Phlegm and move Qi, I added: • Yuan Zhi and Bai Zi Ren to calm the Mind and open the Mind’s orifices. Yuan Zhi also resolves Phlegm. • Qin Jiao to alleviate the hot flushes; because it eliminates Wind-Dampness from the joints, it would help the backache at the same time.
Her periods returned after only one acupuncture treatment and five packets of the above decoction. When she came for her second treatment she looked brighter in herself and much happier. Her backache was also much improved. I repeated the same points and prescribed the same formula and another period came on time. After 4 months of treatment and when the signs of Phlegm had greatly diminished, I changed the treatment principle to tonifying Kidney-Yang with a variation of You Gui Wan Restoring the Right [Kidney] Pill: • Shu Di Huang Radix Rehmanniae preparata 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Shan Zhu Yu Fructus Corni 4 g • Gou Qi Zi Fructus Lycii 6 g • Dang Gui Radix Angelicae sinensis 6 g • Du Zhong Cortex Eucommiae 4.5 g • Tu Si Zi Semen Cuscutae 6 g • Rou Gui Cortex Cinnamomi 2 g • Lu Jiao Cornu Cervi 6 g
• Fu Ling Poria 6 g • Yuan Zhi Radix Polygalae 6 g • Bai Xian Pi Cortex Dictami 6 g • Suan Zao Ren Semen Ziziphi spinosae 4.5 g • Shou Wu Radix Polygoni multiflori preparata 6 g
Explanation
• Shu Di Huang, Shan Yao and Shan Zhu Yu tonify the Kidneys and the Directing and Penetrating Vessels. • Gou Qi Zi and Dang Gui nourish Kidney-Yin and Blood. • Du Zhong and Tu Si Zi tonify Kidney-Yang. • Rou Gui warms and tonifies Kidney-Yang and warms the Uterus. • Lu Jiao strengthens the Governing Vessel. • Fu Ling resolves Dampness. • Yuan Zhi and Suan Zao Ren calm the Mind and settle the Ethereal Soul. • Bai Xian Pi resolves Damp-Heat and was added to help her skin problem. • Shou Wu nourishes Blood.
Ancient acupuncture prescriptions for amenorrhoea
1. Du-2 Yaoshu and KI-6 Zhaohai with moxibustion (Treatise on Miraculous Moxibustion, Shen Jiu Jing Lun, 1851). 2. L.I.-4 Hegu, SP-6 Sanyinjiao, SP-10 Xuehai and ST-30 Qichong (Collection of Acupuncture and Moxibustion, Zhen Jiu Ji Cheng, 1874). 3. Ren-3 Zhongji, BL-23 Shenshu, L.I.-4 Hegu and SP-6 Sanyinjiao (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601).
Prognosis and prevention Amenorrhoea responds well to treatment with acupuncture and/or herbs but both the patient and the practitioner must give it time; in some cases, it may take several months, even a year or longer, to bring the periods back. Amenorrhoea of the excess type responds better to treatment with Chinese herbs. If acupuncture only is used to treat amenorrhoea of the excess type, then it is advisable to assist the treatment with prepared remedies. The prognosis obviously depends also on the Western differentiation as amenorrhoea due to congenital anomalies will not respond to treatment at all. To treat amenorrhoea, it takes a minimum of 3 months, and is more likely to take from 6 months to a year. If the amenorrhoea has a very obvious cause, such as a diet lacking in nourishment, or excessive exercise, that must be addressed for the treatment to be successful. Of all the patterns, the one from Damp-Phlegm in the Lower Burner is probably the most difficult to treat. This pattern is frequently seen in amenorrhoea due to polycystic ovary syndrome. Of the deficiency patterns, the one from deficiency of Liver- and Kidney-Yin is the most difficult to treat.
Western view Amenorrhoea is usually classified into primary or secondary amenorrhoea. Primary amenorrhoea is defined as the absence of menarche by the age of 18. Secondary amenorrhoea, which is much more common that the primary type, is the absence of menstruation for at least three cycles in women who were previously menstruating. The causes of amenorrhoea from a Western medical perspective are numerous. The following lists summarize the causes of primary and secondary amenorrhoea. Primary amenorrhoea
1. Uterovaginal disorder: • Congenital anomalies (absent or hypoplastic uterus). • Imperforate hymen, transverse vaginal system, or congenital absence of the vagina. 2. Ovarian disorder: • Primary gonadal disorder (gonadal dysgenesis). About 40–50% of women with amenorrhoea have a sex chromosomal disorder. • Congenital absence of ovaries. • Hypogonadotropic hypogonadism probably of central nervous system origin. The hypogonadism is most frequently due to hypothalamic dysfunction with a GnRH (gonadotropin-releasing hormone). 3. Hypothalamic disorder: • Generalized hypothalamic defect with deficiency of thyrotropin-, adrenocorticotropin- and gonadotropin-releasing hormones. • Isolated gonadotropin deficiency (low or absent luteinizing hormone (LH), follicle-stimulating hormone (FSH) and oestradiol) with normal
thyroid-stimulating hormone, adrenocorticotropin hormone and growth hormone secretion. The defect resides in the hypothalamus (lack of gonadotropin-releasing hormone). 4. Pituitary insufficiency. 5. Pre-menarchal occurrence of any of the disorders usually producing secondary amenorrhoea (see below). Secondary amenorrhoea
1. Physiological changes: • Pregnancy. • Post-partum (if menstruation fails to return within 18 months after delivery). • Menopause (there would be elevated FSH and LH levels). 2. Pituitary or hypothalamic disorders: • Insufficiency or failure. • Tumours (adenomas, cysts) of the pituitary gland. 3. Ovarian disorders: • Dysfunction (anovulatory cycles with oligomenorrhoea or amenorrhoea). • Neoplasms. • Ovarian hyperthecosis. • Premature menopause (ovarian failure). • Severe pelvic inflammatory disease or oophoritis with bilateral ovarian destruction. 4. Adrenal disorders: • Adrenogenital syndrome. • Cushing’s disease.
• Addison’s disease. 5. Thyroid disorders: • Hyperthyroidism. • Hypothyroidism. 6. Diabetes mellitus. 7. Nutritional disorders: • Severe malnutrition. • Marked obesity. 8. Chronic disease (tuberculosis, nephritis, rheumatoid arthritis). 9. Psychosomatic and neurogenic disorders (psychosis, anorexia nervosa, emotional shock, organic brain disease). 10. Artificial causes (hysterectomy, oophorectomy, radiation therapy, traumatic curettage, severe endometritis, intra-uterine adhesions).22 A simpler classification of amenorrhoea according to the site of the problem is illustrated in Table 16.4.23 Table 16.4 Causes of amenorrhoea according to site
Site
Factors
Psychosomatic factors, Hypothalamus obesity, brain tumour, cyst
Pituitary
Ovary
Uterus
Nutritional, chronic disease, pituitary tumours or hypofunction Thyroid disorder, primary ovarian dysfunction, polycystic ovarian disease, hyperthecosis syndromes, gonadal dysgenesis, premature menopause Congenital absence or hypoplasia, surgery, radiation, uterine disease, endometritis
Hormone Affected
Gonadotropinreleasing hormone Folliclestimulating hormone, luteinizing hormone, prolactin Oestrogen, progesterone, androgens
None
To summarize, the most likely causes of amenorrhoea: in 25–40% of patients with primary amenorrhoea, the problem lies in the hypothalamic– pituitary–ovarian axis; in 40–50% of cases, in sex chromosomal disorders;
and in 15% of cases, in miscellaneous systemic, nutritional or psychological factors. It is strange that Western medicine textbooks nearly always disregard two causes: first, amenorrhoea following long-term use of the contraceptive pill; and second, amenorrhoea stemming from excessive physical exercise and sports. Interpreted from a Chinese medical perspective, long-term use of the contraceptive pill seems to cause a deficiency of Blood and/or the Kidneys. As for excessive sports (a type of amenorrhoea which is not a ‘disease’ from the Western point of view), this is interesting from a Chinese medical perspective as it confirms that excessive exercise can become a cause of disease. The amenorrhoea caused by excessive exercise is probably due to deficiency of the Spleen and Liver caused by overuse of the muscles and sinews respectively. The Spleen therefore fails to produce Blood and the Liver to store Blood.
Clinical trials
Herbal treatment
A clinical observation on the effect of Yang Jing (Nourishing Jing) decoction in promoting follicular growth
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 1998 18(4): 217–220. – Lu H, Liu M, Li C. – Chengdu University of Traditional Chinese Medicine, Chengdu, China. Objective
To investigate the effect of Yang Jing decoction (YJD), a Chinese formula that tonifies Kidney essence, in promoting follicular growth and the medicine’s influence on the blood supply to the ovaries and uterus. Methods
Twenty-two patients with secondary amenorrhoea and 4 patients with infertility with infrequent menstruation caused by follicle maldevelopment were treated with YJD. In 7 patients, the blood supply to the ovaries and uterus was measured by colour Doppler before and after treatment. Results
The 26 patients underwent 116 therapeutic cycles. There were a total of 69
menstrual cycles (59.48%), 37 follicular maturation cycles (31.90%), 21 ovulation cycles (18.10%), and the follicular maturation rate was 84.62%. In all 7 patients tested for blood supply to the ovaries and uterus, the impeded supply was significantly improved along with follicular development. Conclusion
YJD improved follicular development and blood supply to the ovaries and uterus. The treatment of secondary amenorrhoea and oligohypomenorrhoea with combined traditional Chinese and Western medicine
– Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Modern Developments in Traditional Medicine 1991 11(11): 661–663, 645. – Ge X L. – Department of Gynaecology, Second Affiliated Hospital, Hebei Medical College, Shijiazhuang, China. Objective
To ascertain the efficacy of treating secondary amenorrhoea and oligohypomenorrhoea with combined traditional Chinese and Western medicine. Methods
Out of 149 women (1087 cycles) with secondary amenorrhoea and oligohypomenorrhoea, 42 women were treated by traditional Chinese medicine (TCM) and clomifene, 67 were treated by just clomifene and 40 by just TCM. Results
The ovulatory rate of those with secondary amenorrhoea, calculated according to menstrual cycles, was significantly higher in the combined TCM and clomifene group (P < 0.01). The efficacy of clomifene on its own was better than that of just TCM (P < 0.01). The ovulatory rate of the oligohypomenorrhoea patients was significantly increased in the combined TCM and clomifene group which was in contrast to the clomifene only group (P < 0.05). Conclusion
Combined TCM and Western medicine has advantages in treating secondary amenorrhoea and oligohypomenorrhoea over either medicine used on its own. The effect of Japanese Kampo medicine on the hypothalamic– pituitary–ovarian function in women with ovarian insufficiency
– American Journal of Chinese Medicine 1988 16(1–2): 47–55. – Koyama T, Ohara M, Ichimura M, Saito M. – Department of Obstetrics and Gynaecology, School of Medicine, Tokyo Medical and Dental University, Japan.
Objective
To ascertain the efficacy of Japanese herbal medicine upon the hypothalamic–pituitary–ovarian function in women with ovarian insufficiency. Methods
Twenty-five women with either amenorrhoea, anovulation or luteal phase dysfunction were treated orally with Tokishakuyakusan (Dang Gui Shao Yao San Angelica-Paeonia powder) and Unkeito (Wen Jing Tang Warm the Menses Decoction) for 10 to 30 weeks. Blood was taken every fortnight prior to, and during, treatment and serum levels of LH, FSH, prolactin, oestrogen, progesterone and testosterone were examined. The Premarin test and luteinizing hormone-releasing hormone (LHRH) test were also assessed prior to, and during, treatment. Results
Dang Gui Shao Yao San brought about menstruation in 4 out of 7 women who were suffering with amenorrhoea, 3 of whom ovulated. Wen Jing Tang elicited menstruation in 3 women, 2 of whom ovulated. Dang Gui Shao Yao San or Wen Jing Tang brought about ovulation in 2 out of 4 anovulatory women. Dang Gui Shao Yao San resulted in normal mid-luteal progesterone levels in 7 out of 10 women with luteal phase dysfunction, 4 of whom became pregnant. Wen Jing Tang caused normal progesterone levels in 6 women, 1 of whom became pregnant. Improvement of the hypothalamic– pituitary axis function was suggested during treatment by the results of the Premarin test and LHRH test. Conclusion
The results suggest that Dang Gui Shao Yao San and Wen Jing Tang may exert their effect on the hypothalamic–pituitary axis and may activate ovarian function; however, direct effects on ovarian function and factors outside of the endocrine mechanism may not be excluded. End notes 1. Ye Tian Shi 1817 Secret Prescriptions for Gynaecological Patterns and Treatment by Ye Tian Shi (Ye Tian Shi Nu Ke Zheng Zhi Mi Fang), cited in Cong Chun Yu 1989 Chinese Medicine Gynaecology (Zhong Yi Fu Ke Xue
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 74..
2. Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong
), Ancient Chinese Medical Books Publishing House, Beijing, p. 153. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang) and published in 1729..
3. Chinese Medicine Gynaecology, p. 74..
4. Luo Yuan Kai 1986 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Shanghai Science and Technology Press, Shanghai, p. 60..
5. 1979 The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen
), People’s Health Publishing House, Beijing, p. 223. First published c. 100 BC..
6. Li Dong Yuan 1271 The Secret Collection of the Orchid Room (Lan Shi Mi Cang), cited in Gynaecology in Chinese Medicine, p. 61..
7. Zhang Jing Yue 1986 The Complete Works of Jing Yue (Jing Yue Quan Shu
), Shanghai Science and Technology Press, Shanghai, p. 647. First published in 1624..
8. He Ren 1981 A New Explanation of the Synopsis of Prescriptions from the Golden Cabinet (Jin Gui Yao Lue Xin Jie
), Zhejiang Science Publishing House, pp 186–187. The Synopsis of Prescriptions from the Golden Cabinet was written by Zhang Zhong Jing c. AD 200..
9. Chao Yuan Fang AD 610 General Treatise on the Aetiology and Symptomatology of Diseases (Zhu Bing Yuan Hou Zong Lun) cited in Zhang Qi Wen 1995 Menstrual Diseases (Yue Jing Bing Zheng
), People’s Hygiene Publishing House, Beijing, p. 179..
10. Hu Xi Ming 1990 Great Treatise of Secret Formulae in Chinese Medicine (Zhong Guo Zhong Yi Mi Fang Da Quan
), Culture Publishing House, Shanghai, Vol. 2, p. 170..
11. Ibid., p. 176..
12. Long Jiajun, Zhang Qi, Shen Kang, Lin Hongyang 1996 Dr Zhang Jian Zhai’s Experience in Treating Gynaecological Diseases (Zhang Jian Zhai Zhi Liao Fu Ke Bing Jing Yan), Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi
), China Academy of Traditional Chinese Medicine, Beijing, No. 1, p. 16..
13. Great Treatise of Secret Formulae in Chinese Medicine, p. 183..
14. Han Bai Ling 1983 Bai Ling’s Gynaecology (Bai Ling Fu Ke
), Heilongjiang People’s Publishing House, p. 62..
15. Ibid., p. 62..
16. Ibid., p. 63..
17. 1117 General Collection for Holy Relief (Sheng Ji Zong Lu) cited in Menstrual Diseases, p. 192..
18. Shandong College of Traditional Chinese Medicine 1980 An Explanation of the ABC of Acupuncture (Zhen Jiu Jia Yi Jing Jiao Shi
), People’s Health Publishing House, Beijing, p. 1482. The ABC of Acupuncture was written by Huang Fu Mi c. AD 259..
19. Dr Zhang Jian Zhai’s Experience in Treating Gynaecological Diseases, p. 16..
20. Great Treatise of Secret Formulae in Chinese Medicine, p. 180..
21. Ibid., p. 184..
22. Clarke-Pearson D L, Yussof Dawood M 1977 Green’s Gynaecology: Essentials of Clinical Practice, Little, Brown and Co., Boston, p. 213..
23. Ibid., p. 213..
CHAPTER 17 Flooding and Trickling
AETIOLOGY 320 PATHOLOGY 321 TREATMENT PRINCIPLES 324 Three steps in treatment 326 Herbal treatment 327 Acupuncture 328 Treating Flooding and Trickling according to the four phases 329 IDENTIFICATION OF PATTERNS AND TREATMENT 330 FULL CONDITIONS 330 Blood-Heat 330 Liver-Qi stagnation turning into Heat 335 Blood Empty-Heat 336 Stasis of Blood 338 Damp-Heat in the Uterus 339 EMPTY CONDITIONS 343 Spleen not holding Blood 343 Kidney-Yang deficiency 346 Kidney-Yin deficiency 349 COMPLEX PATTERNS 351 Full with Full 352 Empty with Empty 352
Empty with Full 352 Ancient acupuncture prescriptions for Flooding and Trickling 352 PROGNOSIS AND PREVENTION 353 WESTERN VIEW 353 Carcinoma of the cervix 353 Endometriosis 353 Carcinoma of the uterus 353 Myomas 353 Endometrial polyps 354 CLINICAL TRIALS 354 Herbal treatment 354 The condition of Flooding and Trickling is called Beng Lou in Chinese: beng means ‘flood’ or ‘flooding, bursting through’ and lou means ‘trickle, drip, dribble’ or ‘trickling, dripping, dribbling, leaking’. It corresponds to metrorrhagia in Western medicine but I prefer the more descriptive Chinese name. Flooding and Trickling encompasses two distinct symptoms, the former (Beng) indicating a period that starts suddenly with a flood, often before the proper time, and the latter (Lou) a period that continues with a trickle after the proper time. Flooding and Trickling should be distinguished from Heavy Periods (Ch. 11): the latter indicates heavy blood loss during the proper period time (about 5 days), with the periods coming at regular intervals, rather than the sudden, profuse and often early bleeding of Flooding. In terms of quantity, Flooding involves a heavier bleeding than Heavy Periods. In general, the pathology of Heavy Periods and of Flooding and Trickling is the same although the latter is a more serious condition and therefore more difficult to treat. See Figure S4.1 (p. 198). The earliest reference to Flooding (Beng) is in Chapter 7 of the Simple Questions: “When Yin is deficient and Yang throbs, Flooding occurs”.1 In
the context of this chapter, this statement refers to pulse diagnosis, i.e. when the Yin pulses are deficient and the Yang pulses forceful, a woman may suffer from Flooding. However, the statement may also be interpreted in a general sense, i.e. when Yin is deficient and Yang in excess, there may be Flooding because excess Yang heats the Blood and makes it spill from the blood vessels. The Synopsis of Prescriptions from the Golden Cabinet mentions Trickling (Lou): “Continuous menstrual bleeding with an incessant trickling of dark blood [can be treated with] E Jiao Sheng Jiang Tang”.2 E Jiao Colla Corii asini is still widely used to stop uterine bleeding.
Aetiology
Emotional strain Any emotion may lead to stagnation of Qi and this, in turn, to Fire. Fire usually affects the Liver and, as this stores Blood, it may cause Blood-Heat. Heat makes the Blood reckless and causes it to burst out of the blood vessels. This is a major cause of bleeding of the excess type in gynecological problems. On the other hand, Fire may injure Yin and therefore lead to Blood Empty-Heat which may also cause menorrhagia. Emotional problems may also cause bleeding in a different way, by leading to stagnation of Qi which will, in time, cause stasis of Blood. Stasis of Blood in the Uterus prevents new blood from taking its place and it therefore leaks out (Fig. 17.1).
Figure 17.1 Emotional stress as aetiological factor in metrorrhagia.
Overwork Overwork weakens Liver- and Kidney-Yin. Deficiency of Yin over a long period of time gives rise to Empty-Heat which may heat the Blood. EmptyHeat may also make the Blood reckless just as Blood-Heat does, causing it to burst out of the blood vessels. Deficiency of Kidney-Yin may also cause excessive menstrual bleeding by itself, without Empty-Heat, when Kidney-Yin fails to hold Blood. Physical overwork, chronic illness Physical overwork and chronic illness weaken the Spleen which fails to control Blood so that this leaks out. This is another major cause of excessive menstrual bleeding of the deficient type. Childbirth Excessive loss of blood at childbirth can weaken the Kidneys and Liver which fail to hold Blood and therefore cause bleeding. On the other hand, stasis of Blood often occurs after childbirth in women who have a tendency to stagnation. Stasis of Blood in the Uterus may cause bleeding in the way described above. Irregular diet Irregular diet consisting in the excessive consumption of hot-energy foods may lead to Blood-Heat which may cause blood to spill out of the vessels. Please note that under ‘hot-energy foods’ we should include alcohol. Early sexual activity
By ‘early’ sexual activity I mean sexual activity that takes place before puberty and also within 2 years of puberty. Around the time of puberty, the Uterus is in a vulnerable condition and it is easily invaded by external pathogenic factors or damaged by sexual activity. Early sexual activity also ‘destabilizes’ the Directing and Penetrating Vessels (Ren and Chong Mai) possibly leading to metrorrhagia.
Pathology As for pathology, the major patterns in uterine bleeding are: • Blood-Heat • Blood Empty-Heat • Qi deficiency • Kidney deficiency • Blood stasis. In addition to these five main pathological conditions, we also need to discuss: • unstable Directing and Penetrating Vessels • sinking of Qi • complex pathological conditions. Blood-Heat Blood-Heat is characterized by profuse bleeding with bright red or dark red blood. It may cause both Flooding and Trickling. Blood-Heat most commonly derives from Liver-Fire (itself deriving from emotional problems as explained above): as the Liver stores Blood and influences the Directing and Penetrating Vessels, Fire in this organ may heat the Blood and make it spill from the blood vessels. This is a very common cause of Flooding and Trickling from Blood-Heat. Blood-Heat may also derive from invasion of an external pathogenic factor which reaches the Blood level (within the Four Levels) or from the
excessive consumption of hot, spicy foods and alcohol. Blood-Heat agitates the Directing and Penetrating Vessels and the Uterus and causes Flooding and Trickling. The Liver is not the only organ involved in Blood-Heat as the Heart also plays its part. Emotional problems affecting the Heart may lead to Heart-Fire and, as this organ governs Blood and is linked to the Uterus through the Uterus vessel (bao mai), this may lead to excessive uterine bleeding. Blood Empty-Heat Blood Empty-Heat is characterized by lesser bleeding or by prolonged spotting after the end of the proper period. The colour of the blood is red or scarlet red. Blood Empty-Heat can be generated in two ways: either a prolonged deficiency of Yin leads to Empty-Heat, or a chronic condition of Blood Full-Heat may lead to injury of Yin by Heat and consequently EmptyHeat. In the latter case, the pathology may be quite complex: Blood-Heat causes Yin deficiency, which generates Empty-Heat, which, in turn, causes Blood Empty-Heat. In such complex cases, a woman may display symptoms of excessive bleeding from both Full-Heat and Empty-Heat agitating the Blood. Qi deficiency Qi deficiency may cause flooding at the beginning of the period or prolonged spotting after the period. The menstrual blood is pale red. Qi deficiency involves mainly the Spleen, although this is often associated with Lung-Qi deficiency too. The deficient Spleen-Qi fails to raise Qi and to hold Blood in the vessels, which therefore leaks out. Deficient Spleen-Qi not holding Blood in the vessels is also associated with sinking of Qi. In my experience, many practitioners have a ‘bias’ towards Spleen-Qi deficiency as a cause of Flooding and Trickling. I would say that, in my experience, Blood-Heat and Qi deficiency account for roughly 50% of cases
of Blood-Heat and Qi deficiency each. Kidney deficiency Kidney deficiency is very important in the pathogenesis of Flooding and Trickling. When Kidney-Qi or Kidney-Yang is deficient, the Directing and Penetrating Vessels do not thrive: this may happen because of a hereditary Kidney deficiency in young women or because of the natural decline of Kidney-Qi in the menopause. When the Directing and Penetrating Vessels are affected by a Kidney deficiency, they become ‘unstable’: they fail to contain Blood, and Flooding and Trickling result. If Kidney-Yin is deficient, excessive bleeding occurs for two reasons: first of all, Kidney-Yin fails to hold Blood in the vessels (in much the same way as Kidney-Qi does), and second, Yin deficiency may lead to EmptyHeat which heats the Blood and makes it spill out of the vessels. Blood stasis Blood stasis causes excessive blood loss during the period and also some blood loss before the proper period time. The blood is dark with dark clots and the period usually painful. Excessive bleeding from stagnant Blood is caused by the fact that stagnant Blood obstructs the Uterus and the blood vessels, newly-formed blood cannot take its normal place in the Uterus and blood vessels, and therefore leaks out (Fig. 17.2).
Figure 17.2 How Blood stasis leads to bleeding. Thus, there are three major areas of pathology causing Flooding and Trickling. The first is Blood-Heat which may be Full or Empty; the second is deficiency, which may be of Qi/Yang (Spleen and Kidneys) or of Yin (Liver and Kidneys); the third is Blood stasis which usually is an aggravating rather than a causative factor (Table 17.1). Table 17.1 Pathology of Flooding and Trickling
Blood-Heat
Blood Full-Heat (Liver and
Deficiency
Qi deficiency
Blood stasis
Blood stasis
Heart) = Full condition Blood Empty-Heat (Liver and Kidneys) = Full/Empty condition
(Spleen and Kidneys) Yin deficiency (Liver and Kidneys)
(Liver and Heart)
The Jade Rule of Gynaecology says: “There are six major causes of Flooding and Trickling: Fire, Deficient Cold, Exhaustion (xulao), sinking Qi, Blood stasis and Deficiency”.3 Deficient Cold, mentioned in this text, is not a frequent cause of excessive menstrual bleeding. The Golden Mirror of Medicine (1742) relates Flooding and Trickling to the three basic conditions of Heat, Qi deficiency and Blood stasis: Continuous dripping is called Lou, while a sudden flood is called Beng. Dark blood with clots and pain is due to Blood-Heat, after a long time it injures the Directing and Penetrating vessels. A deficient Spleen fails to hold Blood, Qi sinks, anger injures the Liver which makes Blood reckless: one must differentiate clearly, in Deficiency one must tonify, in stasis dissolve, and in Heat clear.4 Directing and Penetrating Vessels (Ren and Chong Mai) unstable Whatever the cause and pathology of Flooding and Trickling, the Directing and Penetrating Vessels are always involved in this condition as they are responsible for the Uterus, Blood storage and menstruation. The General Treatise on the Aetiology and Symptoms of Diseases (AD 610) says: Flooding is due to injury of the Directing and Penetrating vessels. These vessels originate from the Uterus and are the Sea of channels; when they are injured their Qi becomes deficient and fails to hold Blood in the blood vessels and channels.5
Of the two vessels, the Directing Vessel is particularly involved in the pathology of Flooding and Trickling because this vessel influences the Uterus and the Kidneys. Chinese books describe this pathology of these two vessels as ‘Ren and Chong unstable’ (Ren Chong Bu Gu): this condition of the Directing and Penetrating Vessels is a factor in Flooding and Trickling, whatever the pattern (i.e. Blood-Heat or deficiency). For this reason, to treat this condition, I nearly always needle LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to regulate the Directing Vessel plus Ren-4 Guanyuan and KI-13 Qixue. Due to the importance of the Directing Vessel in the pathology of Flooding and Trickling, the Kidneys also play a very important and central role in the pathology and treatment of this condition. Whatever the type of Flooding and Trickling, eventually the Kidneys have to be treated. It is a very important principle that Flooding and Trickling is eventually treated not by stopping bleeding but by tonifying the Kidneys and consolidating the Directing and Penetrating Vessels. The main herbs that ‘stabilize’ the Directing and Penetrating Vessels are Xu Duan Radix Dipsaci, Du Zhong Radix Eucommiae and Gui Ban Plastrum Testudinis. Although the first two herbs are Yang tonics, one of them may be added to a formula for Blood-Heat or Yin deficiency to consolidate the Directing and Penetrating Vessels; vice versa for Gui Ban which is a Yin tonic. ! Whatever the pattern (e.g. Blood-Heat, Qi deficiency), in Flooding and Trickling the Directing and Penetrating Vessels are unstable. Clinical Note To stabilize Directing and Penetrating Vessels with acupuncture, needle LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) plus Ren-4 Guanyuan and KI-13 Qixue. The main herbs that ‘stabilize’ the Directing and Penetrating Vessels are Xu Duan Radix Dipsaci, Du Zhong Radix
Eucommiae and Gui Ban Plastrum Testudinis. Sinking of Qi There is another important feature in the pathology of Flooding and Trickling and that is sinking of Spleen- and Kidney-Qi. Whatever the pattern causing Flooding and Trickling, the constant downwards flow of Blood over several years means that sinking of Qi is always a factor in the pathology of this disease. This applies not only to deficient patterns but also to excess ones. It follows that, in treatment, besides treating the pattern (e.g. Blood-Heat), one must also lift Qi of the Spleen and Kidneys. This is the reason why even some formulae for Flooding and Trickling from Yin deficiency include the herb Xu Duan Radix Dipsaci to consolidate the Directing and Penetrating Vessels and lift Kidney-Qi. Please note that, in Flooding and Trickling, it is not only Spleen-Qi that is sinking but also Kidney-Qi. With acupuncture, to lift Spleen- and KidneyQi in Flooding and Trickling, I would use the following point combination: LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), together with Du20 Baihui and Ren-4 Guanyuan. With herbal medicine, one raises Qi by combining Huang Qi Radix Astragali with Chai Hu Radix Bupleuri and Sheng Ma Rhizoma Cimicifugae. This combination of herbs can be added to any formula addressing the pattern that is causing Flooding and Trickling. ! It is a very important principle that Flooding and Trickling is eventually treated not by stopping bleeding but by tonifying the Kidneys and consolidating the Directing and Penetrating Vessels. Complex pathological conditions
Excessive menstrual bleeding often leads to complex pathological conditions as, over many years, the blood loss itself becomes a pathogenic factor. For example, bleeding for many years from Blood-Heat may lead to Blood deficiency; as Blood is the mother of Qi, this leads to Qi deficiency and deficient Qi fails to hold Blood, further contributing to bleeding. In such a case, it is easy to misdiagnose the cause of bleeding as the woman would present with many Qi deficiency manifestations and we may conclude (wrongly) that the bleeding is from Spleen- and Kidney-Qi not holding Blood. The following case history is a good example of this situation. Case history A 33-year-old woman had been suffering from Flooding and Trickling for over 10 years. She suffered from both Flooding and Trickling after the period. During some months, she bled almost constantly, so much so that it was sometimes difficult to know when she had a period. Most of her clinical manifestations pointed to Qi and Blood deficiency. She was pale, her voice was low, she looked depressed, her eyes lacked shen, she felt cold. Her tongue was Pale and her pulse was Deep. The diagnosis seemed to be very obvious: deficiency of Qi and Yang with Qi not holding Blood. On the basis of other manifestations (slight abdominal distension, poor appetite, backache and frequent urination), it seemed to be obvious that there was a deficiency of both Spleen and Kidneys. The treatment principle I adopted was therefore to tonify Spleen- and Kidney-Qi, consolidate Directing and Penetrating Vessels and stop bleeding. I used a variation of the formula Yi Qi Gu Chong Tang Benefiting Qi and Consolidating the Penetrating Vessel Decoction (see below under Spleen not holding Blood). • Huang Qi Radix Astragali 15 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Dang Shen Radix Codonopsis 9 g
• Ai Ye Folium Artemisiae argyi 4.5 g • Xian He Cao Herba Agrimoniae 6 g • Jing Jie Herba Schizonepetae 6 g (charred) • Dang Gui Radix Angelicae sinensis 6 g • Xu Duan Radix Dipsaci 6 g • Sheng Ma Rhizoma Cimicifugae 3 g • Gan Cao Radix Glycyrrhizae 3 g
After using variations of this formula for 3 months, there was no improvement at all. When this happens, I usually check the diagnosis again. On careful analysis of the manifestations, I noticed certain ones that I had overlooked. These were: a certain redness of the cheekbones, slightly red sides of the tongue, the occasional feeling of heat, occasional thirst, dry lips. I therefore concluded that the bleeding was originally caused by Blood-Heat and that Qi deficiency was the result rather than the cause of the bleeding. This misdiagnosis had happened because the Qi and Blood deficiency deriving from the blood loss masked the Blood-Heat so that the manifestations of this pathology became mild and somewhat hidden. I therefore changed my treatment principle to cool Blood and this produced an immediate improvement. Another example of a complex pathology deriving from the bleeding itself is that of excessive bleeding from Blood-Heat which may eventually lead to Blood and Yin deficiency. This, in turn, leads to Empty-Heat, which itself becomes a further cause of bleeding. Excessive bleeding from Qi deficiency will eventually also cause Blood deficiency. As Blood is the mother of Qi, blood loss will further weaken Qi thus perpetuating the condition. Furthermore, Flooding and Trickling may interact with or cause one another. In fact, chronic flooding may lead to trickling and vice versa. A Chinese medicine saying states: “Flooding is an extreme form of Trickling;
Trickling is the saturation of Flooding”. Figure 17.3 illustrates three possible complex pathological conditions resulting from bleeding.
Figure 17.3 Three complex pathological conditions deriving from bleeding. The pathology associated with Flooding and Trickling is somewhat related to the age of the patient: in young girls, Flooding and Trickling is usually due to ahereditary Kidney weakness; in young women, it is more often caused by Blood-Heat from Liver Fire; and, in pre-menopausal women, it often results from Liver- and Kidney-Yin deficiency. Of course, these are only generalizations from which clinical practice may deviate. Summary Pathology
• Blood-Heat
• Blood Empty-Heat • Qi deficiency • Kidney deficiency • Blood stasis • Directing and Penetrating Vessels unstable • Qi sinking • Complex pathological conditions
Treatment principles The treatment strategy for Flooding and Trickling is largely based on the general principles to stop bleeding.6 These were first advanced in the book Discussion of Blood Syndromes by Dr Tang Zong Hai (1884). There are four aims in the strategy to stop bleeding: 1. Harmonize Blood. 2. Treat the root cause of bleeding. 3. Astringe. 4. Treat Qi. The first of these treatment aims, in turn, is composed of four steps advanced by Tang Zong Hai in his Discussion of Blood Syndromes: 1. Stop bleeding. 2. Eliminate stasis. 3. Calm Blood. 4. Nourish Blood. Let us now analyse these four treatment aims to stop bleeding with particular reference to gynecology (see Fig. 17.4).
Figure 17.4 The four aims and four steps of treatment to stop bleeding.
Harmonize Blood In a nutshell, the reasons for adopting the above four steps to harmonize Blood in bleeding are as follows: • Stop bleeding: to arrest blood loss. • Eliminate stasis: to prevent Blood from congealing. • Calm Blood: to prevent recurrence of bleeding. • Nourish Blood: to restore Blood after the blood loss. These four treatment aims to harmonize Blood are all the more important in gynecology as Blood is obviously central to all women’s gynecological complaints. Stop bleeding
Examples of herbs that stop bleeding especially from the uterus are: – Pu Huang Pollen Typhae – Xian He Cao Herba Agrimoniae – Di Yu Radix Sanguisorbae – Qian Cao Gen Radix Rubiae – Ai Ye Folium Artemisiae argyi. Eliminate stasis
Eliminating stasis is necessary to prevent blood from congealing when stopping-bleeding herbs are used. As the proper movement and circulation of Blood is extremely important to women’s physiology and stopping-bleeding herbs may have a tendency to congeal blood, herbs which simultaneously stop bleeding and invigorate Blood are particularly useful. These are: – Pu Huang Pollen Typhae – San Qi Radix Notoginseng – Qian Cao Gen Radix Rubiae. Apart from these three, many other Blood-invigorating herbs are used in Flooding and Trickling; for example, Chuan Xiong Rhizoma Chuanxiong, Yi Mu Cao Herba Leonuri, Hong Hua Flos Carthami and Tao Ren Semen Persicae. Calm Blood
In bleeding, especially from Blood-Heat, the Blood is reckless and bursts out of the blood vessels. ‘Calming’ Blood means that it will stay in the vessels. Examples of Blood-calming herbs are: – Bai Shao Radix Paeoniae alba – Sheng Di Huang Radix Rehmanniae – Han Lian Cao Herba Ecliptae – Mu Dan Pi Cortex Moutan. Nourish Blood
Nourishing Blood is necessary to restore it to replace the Blood lost in bleeding. The main herbs which nourish Blood are of course Dang Gui Radix Angelicae sinensis and Shu Di Huang Radix Rehmanniae preparata. E Jiao Colla Corii asini is also very important as it nourishes Blood and stops bleeding. Treat the root cause of bleeding The root cause of bleeding in Flooding and Trickling may be: • Blood-Heat • Blood Empty-Heat • Qi deficiency • Kidney deficiency
• stasis of Blood • Cold (this is quite rare). Blood-Heat
Herbs are chosen from the category of clearing Heat and draining Fire and, especially, the category of clearing Heat and cooling Blood: • Clear Heat and drain Fire: the most important of all in this category is Shan Zhi Zi Fructus Gardeniae especially if charred. Other herbs that help to stop bleeding by clearing Heat are Shi Gao Gypsum fibrosum, Huang Qin Radix Scutellariae and Huang Lian Rhizoma Coptidis. • Clear Heat and cool Blood: herbs from this category are the most important ones to stop bleeding from Blood-Heat in gynecology. The three most important ones are Sheng Di Huang Radix Rehmanniae, Chi Shao Radix Paeoniae rubra and Mu Dan Pi Cortex Moutan. Blood Empty-Heat
The two main herbs that stop bleeding by clearing Empty-Heat are Qing Hao Herba Artemisiae annuae and Han Lian Cao Herba Ecliptae. Han Lian Cao is the more important one in gynecology and is often used in conjunction with Nu Zhen Zi Fructus Ligustri lucidi. Qi deficiency
Any Qi tonic will stop bleeding from Qi deficiency but the most effective one is Huang Qi Radix Astragali. The main formula to stop bleeding from Qi deficiency in gynecology is Dang Gui Bu Xue Tang Angelica Tonifying Blood Decoction which is composed only of Huang Qi Radix Astragali and
Dang Gui Radix Angelicae sinensis in the proportions of 5:1. Kidney deficiency
The two most important Kidney tonics that stop excessive uterine bleeding are Xu Duan Radix Dipsaci and Du Zhong Cortex Eucommiae. If there is a Kidney-Yin deficiency, the two most important herbs are Nu Zhen Zi Fructus Ligustri and Han Lian Cao Herba Ecliptae. Stasis of Blood
Any Blood-invigorating herb can stop bleeding from Blood stasis, but the best are those which invigorate Blood and stop bleeding such as Pu Huang Pollen Typhae, San Qi Radix Notoginseng and Qian Cao Gen Radix Rubiae. Other herbs particularly used in gynecology to invigorate Blood are Yi Mu Cao Herba Leonuri and a combination of Hong Hua Flos Carthami and Tao Ren Semen Persicae. Yang deficiency and Cold
Yang deficiency is quite a rare cause of bleeding in gynecology as internal Cold deriving from it has the tendency to coagulate Blood. The main herb to stop bleeding from the Uterus by warming it is Ai Ye Folium Artemisiae argyi. Astringe The main astringent herbs used in this context in gynecology are Shan Zhu Yu Fructus Corni and Bai Shao Radix Paeoniae alba. One of the stopping-bleeding herbs used in gynecology is also astringent: this is Di Yu Radix Sanguisorbae.
Treat Qi Treating Qi includes tonifying and firming Qi, used especially for bleeding from Qi deficiency. However, please note that one herb to firm Qi is usually included also in formulae for bleeding from other causes such as Blood-Heat. The main herbs used in gynecology for this purpose are Huang Qi Radix Astragali, Ren Shen Radix Ginseng, Fu Zi Radix Aconiti lateralis preparata (if there is deficiency of Yang), Mu Li Concha Ostreae and Zhi Gan Cao Radix Glycyrrhizae preparata. Mu Li is included in this category because it is astringent and absorbent, thus helping to stabilize Qi. Also included in this strategy of treatment is raising Qi to stop bleeding downwards caused by sinking of Spleen-Qi and/or Kidney-Qi. The two herbs that do this are Chai Hu Radix Bupleuri and Sheng Ma Rhizoma Cimicifugae. In gynecology, excessive bleeding may occur not only from Spleen-Qi sinking but often also from Kidney-Qi sinking. In this case, the main herb to use is Xu Duan Radix Dipsaci.
Three steps in treatment With specific reference to gynecology, the steps in the strategy of treatment are traditionally three, following the general principle of “urgently treating the Manifestation (biao) in acute cases and slowly treating the Root (ben) in chronic cases”. 1. Shore up the flow ‘Shore up the flow’ means stopping the bleeding. This is the method adopted in acute cases or during the period itself, especially for flooding (as opposed to trickling). To stop bleeding, one should harmonize Blood (the first aim of treatment outlined above, consisting of four steps) and stop bleeding with haemostatic herbs. 2. Settle the Source ‘Settle the Source’ means treating the Root (Ben) of the condition by addressing the cause, the ‘Source’ being the source of bleeding, i.e. the underlying pattern that is causing bleeding (Blood-Heat, Qi deficiency, etc.). This method must be adopted to treat the underlying cause of bleeding, once the bleeding itself has been dealt with in the preceding step. This therefore consists in clearing Heat and cooling Blood for Blood-Heat, clearing EmptyHeat, cooling Blood and nourishing Yin for Empty-Heat, tonifying and raising Qi for Qi deficiency, invigorating Blood for Blood stasis, and tonifying the Kidneys for Kidney deficiency. Following the four aims of treatment mentioned above, ‘settling the Source’ involves harmonizing Blood, firming Qi and treating the root cause. As indicated above, apart from treating the pattern at the root of Flooding and Trickling (e.g. Blood-Heat, Qi deficiency), it is necessary to ‘consolidate’ the Directing and Penetrating Vessels and to tonify the Kidneys: these two treatment methods are closely connected, i.e. tonifying the Kidneys
will consolidate the Directing and Penetrating Vessels and vice versa. Whatever the type of Flooding and Trickling, eventually the Kidneys have to be treated. It is a very important principle that Flooding and Trickling is eventually treated not by stopping bleeding but by tonifying the Kidneys and consolidating the Directing and Penetrating Vessels. The best time to treat the Kidneys and to consolidate the Directing and Penetrating Vessels is in phase 2. The treatment to ‘consolidate’ the Directing and Penetrating Vessels is very simple: I use LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), together with Ren-4 Guanyuan and KI-13 Qixue. Please note that the Penetrating Vessel goes through Ren-4 and this point therefore tonifies and ‘consolidates’ both the Directing and the Penetrating Vessel. 3. Restore the old ‘Restore the old’ means to treat the organs involved in the disharmony which caused bleeding. This method is adopted after a woman has been successfully treated for Flooding and Trickling and consists in tonifying the Kidneys, regulating the Liver, strengthening the Spleen and tonifying the Heart, according to circumstances. These three approaches to the strategy of treating Flooding and Trickling can be applied separately. For example, one would concentrate on treating the Manifestation (‘shoring up the flow’) during the period, on the Root (‘settle the Source’) outside the period, and on the organs involved (‘restore the old’) after the patient has been treated successfully. However, these three approaches need not necessarily be separated in time and may be used in combination: for example, in a chronic, longstanding case of Flooding and Trickling, one can treat the Manifestation (‘shore up the flow’) and the Root (‘settle the Source’) simultaneously, as well as treating the relevant internal organs.
Herbal treatment There are specific guidelines one should follow when treating Flooding and Trickling; in particular, different treatment methods apply to the two separate conditions, one being flooding, the other trickling. As far as herbal treatment is concerned, in flooding (as opposed to trickling), in general one should use herbs that lift Qi, consolidate and astringe, and not use warm, pungent herbs that move Blood (except, of course, if there is stasis of Blood). In trickling (as opposed to flooding), in general one must nourish Blood and regulate Qi and not make much use of consolidating, astringent herbs. In young girls, one must tonify the Kidneys and strengthen the Directing and Penetrating Vessels; in young women, one must pacify and nourish the Liver; and in pre-menopausal women, one must nourish Liver- and Kidney-Yin, strengthen the Spleen and consolidate the Directing and Penetrating Vessels. Some modern doctors place the emphasis on invigorating Blood and eliminating stasis for any type of Flooding and Trickling. For example, Dr Kuang Yi Huang advocates always invigorating Blood in this condition and combining this treatment method with cooling Blood, tonifying the Kidney or tonifying the Spleen according to clinical manifestations.7 The main rationale behind this approach is that stagnant blood obstructs the Uterus so that newly formed blood cannot take its proper place and leaks out. The following case history illustrates the importance of invigorating Blood in Flooding and Trickling. Case history A 42-year-old woman had been suffering from Flooding and Trickling for about 10 years. The condition was serious insofar as she was bleeding practically all the time, at times flooding and at others trickling. Her periods (during which she flooded) were very heavy, painful and with dark clots. The cause of her bleeding was clearly a deficiency of Spleen and Kidneys. She was overweight and suffered from tiredness, poor digestion,
backache, frequent urination, dizziness and cold knees. Her tongue was Pale and her pulse was Deep and Weak. As the bleeding was due clearly to a deficiency (and sinking) of Spleen and Kidneys, I adopted the method of tonifying and raising Spleen- and Kidney-Qi with variations of Gu Ben Zhi Beng Tang Consolidating the Root and Stopping Flooding Decoction (see below). This formula produced no improvement whatsoever in 3 months. I re-checked the diagnosis and, although the main diagnosis was correct (deficient Spleen and Kidney-Qi not holding Blood), I had overlooked the complicating factor of Blood stasis. Somehow, I had overlooked the fact that her periods were painful and with dark clots, clear signs of Blood stasis. Interestingly, the only remedy that started to produce an improvement and reduced bleeding was one that invigorates Blood (and simultaneously stops bleeding) called Invigorate Blood and Stem the Flow (from the Women’s Treasure range).
Acupuncture As for acupuncture, although it is effective in stopping bleeding, its points are less specific in their action than the above herbs. Although in order to stop bleeding with acupuncture one can follow the four-step protocol outlined above, unlike herbs there are no ‘astringent’ points, nor are there points which ‘calm Blood’ as such. However, the general principle of treating the root cause of bleeding, harmonizing Blood and stopping bleeding is still valid. Harmonize Blood
This consists in the four steps: 1. Stop bleeding: SP-8 Diji, KI-8 Jiaoxin, KI-4 Dazhong, LIV-5 Ligou, SP-1 Yinbai. 2. Eliminate stasis: KI-14 Siman, SP-10 Xuehai, BL-17 Geshu, SP-6 Sanyinjiao, LIV-3 Taichong, ST-29 Guilai. 3. Calm Blood: SP-6 Sanyinjiao, KI-3 Taixi. 4. Nourish Blood: ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, Ren-4 Guanyuan, BL-20 Pishu, BL-23 Shenshu. Treat the root cause
• Blood-Heat: L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, LIV-3 Taichong, LIV-2 Xingjian, P-3 Quze, HE-3 Shoahai. • Blood Empty-Heat: KI-2 Rangu with LIV-3 Taichong, KI-6 Zhaohai, SP-6 Sanyinjiao.
• Qi deficiency: ST-36 Zusanli, SP-6 Sanyinjiao, Ren-6 Qihai, BL-20 Pishu, BL-21 Weishu. • Kidney deficiency: KI-3 Taixi, BL-23 Shenshu, BL-52 Zhishi, Ren-4 Guanyuan, KI-13 Qixue. • Stasis of Blood: see above under Harmonize Blood. • Cold: Ren-4 Guanyuan with direct moxa, ST-36 Zusanli with warm needle, Ren-6 Qihai with moxa, BL-23 Shenshu. Astringe
No points have this specific action. Treat Qi
To tonify and raise Qi, use Ren-6 Qihai, Ren-12 Zhongwan, Du-20 Baihui. Stop bleeding
As for points which specifically stop bleeding, Accumulation points, and especially those of the Yin channels, can stop bleeding. For example: – LU-6 Kongzui: coughing of blood. – L.I.-7 Wenliu: nosebleed, bleeding gums. – ST-34 Liangqiu: nosebleed, bleeding gums, vomiting of blood. – SP-8 Diji: uterine bleeding.
– HE-6 Yinxi: vomiting of blood and epistaxis. – S.I.-6 Yanglao: blood-shot eyes. – BL-63 Jinmen: urinary bleeding. – KI-5 Shuiquan: urinary and uterine bleeding. – P-4 Ximen: vomiting of blood, coughing of blood, bleeding under the skin. – T.B.-7 Huizong: bleeding from ear-drum. – G.B.-36 Waiqiu: not for bleeding. – LIV-6 Zhongdu: urinary and uterine bleeding. – KI-8 Jiaoxin (Accumulation point of the Yin Stepping Vessel): bloody leucorrhoea and uterine bleeding. Thus, the two main points to stop uterine bleeding are SP-8 Diji and KI-8 Jiaoxin. Other points specifically affect the Sea of Blood and can therefore be used to direct the effect of the treatment to the Blood portion in order to stop bleeding. These points are BL-17 Geshu and SP-10 Xuehai. The Connecting points, especially those of the Yin channels, can also stop bleeding. This is because they control the Blood-Connecting channels, a network of Connecting channels that occupy a deeper energetic space than that occupied by the main channels. Chapter 81 of the Spiritual Axis says: If fluids are harmonized … in the Middle Burner, they are transformed into Blood, when Blood is harmonized it first fills and irrigates the Blood Connecting channels, then percolates to the Connecting channels and finally in the main channels.8 The Blood-Connecting channels are particularly involved in chronic
conditions with stasis of Blood. The Connecting points, especially those of the Yin channels, can therefore be used to stop bleeding in chronic cases, particularly if there is some stasis of Blood. For example: – LU-7 Lieque: coughing of blood, nosebleed. – HE-5 Yinxi: coughing or vomiting of blood. – SP-4 Gongsun: bleeding under the skin. – KI-4 Dazhong: uterine or urinary bleeding. – P-6 Neiguan: coughing of blood and bleeding under the skin. – LIV-5 Ligou: urinary or uterine bleeding and bleeding under the skin. Thus, the two most important Connecting points to stop excessive uterine bleeding are KI-4 Dazhong and LIV-5 Ligou.
Treating Flooding and Trickling according to the four phases Treating Flooding and Trickling according to the four phases gives very good results and it is something that should be attempted. I say ‘attempted’ because sometimes when Flooding and Trickling is particularly severe, the woman may be bleeding the whole month and it may even be difficult to identify when she has a period (i.e. is in phase 1). I will therefore describe the treatment principle in each phase for each of the patterns. Blood-Heat
• Phase 1: clear Heat, cool Blood, stop bleeding with astringent herbs. • Phase 2: tonify the Kidneys, nourish Blood. If the woman is spotting (trickling), I would not concentrate on stopping it. • Phases 3 and 4: clear Heat, cool Blood. Blood Empty-Heat
• Phase 1: clear Empty-Heat, cool Blood, stop bleeding with astringent herbs. • Phase 2: tonify the Kidneys, nourish Blood, nourish Yin. If the woman is spotting (trickling), I would not concentrate on stopping it. • Phases 3 and 4: clear Empty-Heat, cool Blood. Spleen- and Kidney-Qi deficiency
• Phase 1: tonify and raise Qi to stop bleeding. Use astringent herbs. • Phase 2: tonify the Kidney, tonify and raise Qi, nourish Blood. • Phase 3: tonify the Spleen. • Phase 4: tonify and raise Qi to stop bleeding. Liver- and Kidney-Yin deficiency
• Phase 1: tonify and raise Qi to stop bleeding. Use astringent, sweet, cold herbs. • Phases 2 and 3: tonify the Liver and Kidneys, nourish Blood, nourish Yin. • Phase 4: nourish Liver- and Kidney-Yin, move Liver-Qi. Blood stasis
• Phase 1: invigorate Blood and stop bleeding. • Phases 2 and 3: tonify the Kidneys, nourish Blood. • Phase 3: invigorate Blood and stop bleeding, move Qi. Summary Treatment principles
• Harmonize Blood • Stop bleeding • Eliminate stasis • Calm Blood • Nourish Blood • Treat the root cause of bleeding • Blood-Heat • Blood Empty-Heat • Qi deficiency • Kidney deficiency • Stasis of Blood • Yang deficiency and Cold • Astringe • Treat Qi Three steps in treatment
1. Shore up the flow 2. Settle the Source 3. Restore the old Herbal treatment
Acupuncture
• Harmonize Blood • Treat the root cause • Astringe
• Treat Qi • Stop bleeding Treating Flooding and Trickling according to the four phases
• Blood-Heat: • Phase 1: clear Heat, cool Blood, stop bleeding with astringent herbs. • Phase 2: tonify the Kidneys, nourish Blood. If the woman is spotting (trickling), I would not concentrate on stopping it. • Phases 3 and 4: clear Heat, cool Blood. • Blood Empty-Heat • Phase 1: clear Empty-Heat, cool Blood, stop bleeding with astringent herbs. • Phase 2: tonify the Kidneys, nourish Blood, nourish Yin. If the woman is spotting (trickling), I would not concentrate on stopping it. • Phases 3 and 4: clear Empty-Heat, cool Blood. • Spleen- and Kidney-Qi deficiency • Phase 1: tonify and raise Qi to stop bleeding. Use astringent herbs. • Phase 2: tonify the Kidney, tonify and raise Qi, nourish Blood. • Phase 3: tonify the Spleen. • Phase 4: tonify and raise Qi to stop bleeding. • Liver- and Kidney-Yin deficiency • Phase 1: tonify and raise Qi to stop bleeding. Use astringent, sweet, cold herbs. • Phases 2 and 3: tonify the Liver and Kidneys, nourish Blood, nourish Yin. • Phase 4: nourish Liver- and Kidney-Yin, move Liver-Qi. • Blood stasis • Phase 1: invigorate Blood and stop bleeding. • Phases 2 and 3: tonify the Kidneys, nourish Blood. • Phase 3: invigorate Blood and stop bleeding, move Qi.
Identification of patterns and treatment The patterns examined are: Full
• Blood-Heat. • Liver-Qi stagnation turning into Heat. • Blood Empty-Heat. • Stasis of Blood. • Damp-Heat in the Uterus. Empty
• Spleen not holding Blood. • Kidney-Yang deficiency. • Kidney-Yin deficiency.
Full conditions
Blood-Heat
Clinical manifestations Flooding suddenly, often before the proper time, or trickling of blood for a long time after the end of the proper period, blood bright red or dark red, thirst, red face, agitation, feeling of heat, dark urine, constipation. Tongue: Red with a yellow coating. Pulse: Rapid-Overflowing. Treatment principle Clear Heat, cool Blood, stop bleeding. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), L.I.-11 Quchi, SP-10 Xuehai, SP-8 Diji, SP-1 Yinbai, KI-5 Shuiquan, SP-6 Sanyinjiao, KI-2 Rangu and LIV-3 Taichong, LIV-5 Ligou, KI-4 Dazhong, LIV-1 Dadun. Reducing method, no moxa. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel which is the Sea of Blood and controls all the Blood-Connecting channels. In bleeding, Blood bursts out of the Blood-Connecting channels. – L.I.-11 and SP-10 cool Blood and stop bleeding. – SP-8, Accumulation point, stops bleeding from the uterus.
– SP-1 is an empirical point to stop uterine bleeding. – KI-5 cools Blood in the Uterus. – SP-6 cools and invigorates Blood. – KI-2 and LIV-3, in combination, cool Blood. – LIV-5 and KI-4, Accumulation points, stop bleeding. – LIV-1 cools Liver Blood-Heat and stops bleeding much as SP-1 does. Prescriptions from the Great Compendium of Acupuncture9
– Ren-6 Qihai, LIV-1 Dadun, KI-10 Yingu, LIV-3 Taichong, KI-2 Rangu, SP-6 Sanyinjiao, Ren-3 Zhongji. – HE-5 Tongli, LIV-2 Xingjian, SP-6 Sanyinjiao. Herbal treatment
a Prescription
– QING RE ZHI BENG TANG – Clearing Heat and Arresting Flooding Decoction Explanation
– Zhi Zi, Huang Qin and Huang Bo clear Heat. – Sheng Di Huang and Mu Dan Pi cool Blood. – Di Yu, Ce Bai Ye and Chun Gen Bai Pi stop bleeding. Di Yu also cools Blood. – Gui Ban and Bai Shao nourish Yin and calm Blood. We can analyse this prescription in the light of the four aims of treatment to stop bleeding outlined above. 1. Harmonize Blood: • stop bleeding: Ce Bai Ye, Di Yu and Chun Gen Bai Pi • eliminate stasis: Mu Dan Pi • calm Blood: Sheng Di Huang and Bai Shao • nourish Blood: Bai Shao. 2. Treat the root cause: • Shan Zhi Zi, Huang Qin and Huang Bo to clear Heat and Sheng Di Huang and Mu Dan Pi to cool Blood. 3. Astringe • Di Yu. 4. Treat Qi • Gui Ban to firm Qi. b. Prescription
– QING JING SAN – Clearing the Menses Powder Explanation
– Mu Dan Pi cools Blood. – Bai Shao and Shu Di Huang nourish Blood. – Di Gu Pi and Qing Hao clear Heat. – Fu Ling and Huang Bo resolve Damp-Heat in the Lower Burner. Compared with the previous formula, Qing Jing San also resolves Damp-Heat. Modifications These modifications apply to both prescriptions above. • If the bleeding is very profuse, add Xian He Cao Herba Agrimoniae, Ou Jie Nodus Nelumbinis rhizomatis, Bai Mao Gen Rhizoma Imperatae and Yi Mu Cao Herba Leonuri. • If there is abdominal and hypochondrial pain, irritability and a Wiry pulse, due to stagnant Liver-Qi turning into Fire and heating the Blood, add Chai Hu Radix Bupleuri, Long Dan Cao Radix Gentianae and Xia Ku Cao Spica Prunellae. • If there are symptoms of Damp-Heat obstructing the Directing and Penetrating Vessels, add Huang Bo Cortex Phellodendri and Zhi Mu Rhizoma Anemarrhenae. c. Prescription
– ZHI BO SI WU TANG
– Anemarrhena-Phellodendron Four Substances Decoction Explanation This formula, from the Golden Mirror of Medicine (1742), nourishes Blood, cools Blood, stops bleeding and resolves Damp-Heat. It is suitable when there is both Blood-Heat and Blood deficiency and the tongue is Red on the whole but Pale on the sides, or the opposite, i.e. Red on the sides and Pale on the whole. The first four herbs constitute the formula Si Wu Tang which nourishes and invigorates Blood. – Zhi Mu clears Heat and cools Blood. – Huang Bo clears Heat and resolves Dampness. These two herbs in combination also clear Heat deriving from pathological Minister Fire. d. Prescription
– JING QIN SI WU TANG – Schizonepeta-Scutellaria Four Substances Decoction Explanation This formula, also from the Golden Mirror of Medicine, is specific for Flooding and Trickling from mild Blood-Heat combined with Blood deficiency. This prescription is therefore suitable when the tongue is only slightly Red and Pale on the sides, or when it is Pale in general and only slightly Red on the sides. The first four herbs constitute the formula Si Wu Tang which nourishes and invigorates Blood.
– Jing Jie enters the Blood portion and stops bleeding, especially when charred. – Huang Qin clears Heat, resolves Dampness and stops bleeding. e. Prescription
– QING RE GU JING TANG – Clearing Heat and Consolidating the Menses Decoction Explanation
– Huang Qin and Shan Zhi Zi clear Heat. The latter also stops bleeding. – Sheng Di Huang and Di Gu Pi cool Blood. – Di Yu cools Blood and stops bleeding. – E Jiao nourishes Blood and stops bleeding. – Ou Jie and Zong Lu Zi stop bleeding. – Gui Ban and Mu Li nourish Yin and have an astringent effect, thus helping to stop bleeding. – Gan Cao harmonizes. Women’s Treasure remedy
– COOL THE MENSES This remedy is a variation of the formula Qing Re Zhi Beng Tang Clearing Heat and Arresting Flooding and Trickling Decoction, which clears Heat, cools Blood and stops bleeding. The tongue presentation appropriate to this remedy is a Red body. Summary Blood-heat
Clinical manifestations
Flooding suddenly, often before the proper time, or Trickling of Blood for a long time after the end of the proper period, Blood bright red or dark red, thirst, red face, agitation, feeling of heat, dark urine, constipation. Tongue: Red with a yellow coating. Pulse: Rapid-Overflowing. Treatment principle
Clear Heat, cool Blood, stop bleeding. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), L.I.-11 Quchi, SP-10 Xuehai, SP-8 Diji, SP-1 Yinbai, KI-5 Shuiquan, SP-6 Sanyinjiao, KI-2 Rangu and LIV-3 Taichong, LIV-5 Ligou, KI-4 Dazhong, LIV-1 Dadun. Reducing method, no moxa. Herbal treatment
Pre scriptions
• QING RE ZHI BENG TANG Clearing Heat and Arresting Flooding Decoction • QING JING SAN Clearing the Menses Powder • ZHI BO SI WU TANG Anemarrhena-Phellodendron Four Substances Decoction • JING QIN SI WU TANG Schizonepeta-Scutellaria Four Substances Decoction • QING RE GU JING TANG Clearing Heat and Consolidating the Menses Decoction Women’s Treasure remedy
• COOL THE MENSES
Case history A 48-year-old woman had been suffering from very heavy periods for 1 year. The cycle was short, being about 3 weeks long, and the menstrual blood was bright red. The period started suddenly with a flood and often trickled on for several days after the end of the period proper. Besides the heavy bleeding, she also suffered from severe pre-menstrual tension, manifesting with a pronounced irritability, flying off the handle, and swelling and distension. She felt easily hot and also suffered from headaches and mouth ulcers. She also complained of backache and dizziness. Her face was quite red, her eyes were restless and she generally looked very tense. Her tongue was Red with a thick, yellow coating; in parts, the coating was slightly rootless. Her pulse was Rapid, Wiry and slightly Overflowing. Diagnosis
This is a clear case of Blood-Heat deriving from Liver-Fire. Blood-Heat is evident from the feeling of heat, red face, Rapid-Overflowing pulse, heavy period, Red tongue with yellow coating and mouth ulcers. Liver-Fire is evident from the headaches and Wiry pulse. In conjunction with Liver-Fire, there is also some Liver-Qi stagnation causing the pre-menstrual tension. Besides this, there is also a slight Kidney-Yin deficiency: in this case, presumably the Liver-Fire had begun to injure Yin. Treatment principle The treatment should be articulated into two stages: first one should concentrate on treating the Blood-Heat as it is causing the more acute problem of Flooding and Trickling. After the Blood-Heat has been cleared, one should pay attention to nourishing Yin. This patient was treated with both acupuncture and herbs. Acupuncture
The points used were selected from the following: • LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to regulate the Directing Vessel, strengthen the Uterus and nourish Yin. • L.I.-4 Hegu to calm the Mind, even method. • LIV-2 to drain Liver-Fire, reducing method. • SP-10 Xuehai to cool Blood, even method. • SP-8 Diji to stop bleeding, even method. • SP-6 Sanyinjiao to calm Blood and calm the Mind, even method. Herbal treatment
The formula used was Qing Re Zhi Beng Tang Clearing Heat and Arresting Flooding Decoction: • Shan Zhi Zi Fructus Gardeniae 4.5 g • Huang Qin Radix Scutellariae 6 g • Huang Bo Cortex Phellodendri 4.5 g • Sheng Di Huang Radix Rehmanniae 6 g • Mu Dan Pi Cortex Moutan 6 g • Di Yu Radix Sanguisorbae 4.5 g • Ce Bai Ye Cacumen Platycladi 4.5 g • Bai Shao Radix Paeoniae alba 6 g • Qian Cao Gen Radix Rubiae 6 g • Dang Gui Radix Angelicae sinensis 4.5 g • Mu Li Concha Ostreae 10 g • Qing Pi Pericarpium Citri reticulatae viride 3 g
Explanation The first eight herbs form part of the root formula (with reduced dosages) which clears Heat, cools Blood and stops bleeding and is quite suitable to this patient’s condition. • I replaced Chun Gen Bai Pi Cortex Ailanthi and Gui Ban Plastrum Testudinis with Qian Cao Gen which cools Blood, invigorates Blood and stops bleeding (an ideal combination of actions in bleeding) and Mu Li which is absorbent and astringent to stop bleeding. • I added Dang Gui to invigorate Blood and enter the Blood portion (to stop bleeding).
• Qing Pi was added to move Liver-Qi.
She was treated with slight variations of this formula for 3 months. Occasional additions were as follows: • Long Dan Cao Radix Gentianae, instead of Shan Zhi Zi Fructus Gardeniae, to drain Liver-Fire. • Xian He Cao Herba Agrimoniae, instead of Ce Bai Ye Cacumen Platycladi, to stop menstrual bleeding. • Yuan Zhi Radix Polygalae and Suan Zao Ren Semen Ziziphi spinosae to calm the Mind. • Xu Duan Radix Dipsaci to consolidate the Penetrating Vessel.
After 4 months, her condition was much improved: her period was back to a normal amount of bleeding, the pre-menstrual tension had disappeared and she felt generally much calmer. Case history A 32-year-old woman had been suffering from heavy periods since she was 23. She had been on the contraceptive pill from 16 to 18 years of age; after that, her periods became disrupted, and she often missed a period. At the time of consultation her periods were very irregular, coming every 3–5 weeks. Lately, the bleeding time had been so long that it had become difficult to distinguish an actual period time. In fact, the menstrual bleeding lasted between 7 days and 3 weeks and, at times, she was practically bleeding continuously. The bleeding started in scanty amounts, then became heavy like a flood and then went on trickling for a long time. The menstrual blood was dark and had clots but it was not painful. She had been trying to conceive for the previous 4 years unsuccessfully for which she had been prescribed a fertility drug, Clomid, but she had stopped it because it did not help either her fertility or her menstrual cycle. On interrogation, the following symptoms came up: a feeling of fullness in the abdomen rising towards the chest, agitation, thirst, a feeling of heat and
dry lips. Her complexion was dull and pale. Her tongue was slightly Red on the sides and Thin, and her pulse was Wiry. Diagnosis Most of the manifestations point to Blood-Heat: the Flooding and Trickling of the period, the Red tongue, the thirst, the dry lips, the feeling of heat and the Wiry pulse. I attributed the feeling of fullness in the abdomen rising towards the chest with a feeling of agitation to Qi rebelling upwards in the Penetrating Vessel. The only manifestations which contradicted this diagnosis were the dull and pale complexion and the Thin tongue, both of which indicate Blood deficiency. I concluded that these were contradictory signs due to the complex pathology of this case: in fact, she had developed some Blood deficiency as a consequence of the continuous, heavy bleeding over 9 years. For the same reason, the tongue was only slightly Red rather than being definitely Red because, while Heat was making the tongue Red, the Blood deficiency was making it Pale: thus, there were two contradicting influences on the tongue body colour which made it more or less normal. Treatment principle I decided that the main emphasis of treatment should be on clearing Heat and cooling Blood because the Blood deficiency was a consequence of this pathology. I treated her with acupuncture and herbal medicine. With acupuncture, I used certain points to tonify Qi and Blood. With herbal medicine, I concentrated on clearing Heat and cooling Blood. Acupuncture
She was treated every 2 weeks and I used the following points: • LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to regulate the Directing Vessel.
• Du-20 Baihui to raise Qi and counteract the downward flow of Blood. • SP-8 Diji, Accumulation point, to stop uterine bleeding (even method). • Ren-6 Qihai to tonify Qi to hold Blood (reinforcing method). • ST-36 Zusanli and SP-6 Sanyinjiao (reinforcing method) to tonify Qi and Blood. Herbal treatment
I used a variation of the formula Qing Re Zhi Beng Tang Clearing Heat and Arresting Flooding Decoction • Shan Zhi Zi Fructus Gardeniae 4.5 g • Huang Qin Radix Scutellariae 4.5 g • Huang Bo Cortex Phellodendri 4.5 g • Sheng Di Huang Radix Rehmanniae 9 g • Mu Dan Pi Cortex Moutan 9 g • Di Yu Radix Sanguisorbae 6 g • Ce Bai Ye Cacumen Platycladi 6 g • Gui Ban Plastrum Testudinis 15 g • Bai Shao Radix Paeoniae alba 9 g • Qian Cao Gen Radix Rubiae 6 g • Suan Zao Ren Semen Ziziphi spinosae 4.5 g
Explanation The first nine herbs constitute the formula Qing Ren Zhi Beng Tang, without
Chun Gen Bai Pi Cortex Ailanthi (an astringent herb) which was unavailable. • Qian Cao Gen was added to cool and invigorate Blood and stop bleeding. • Suan Zao Ren was added to calm the Mind and also to stop bleeding since it is an astringent herb.
After 5 weeks of treatment with this formula, there was no improvement at all and she bled more or less continuously. Even though 5 weeks was quite a short time to see much improvement, I began to doubt my own diagnosis and wondered whether the bleeding was not from deficient Qi not holding Blood. I therefore prescribed a variation of Gui Pi Tang Restoring the Spleen Decoction to tonify Qi to hold Blood. This produced no improvement at all and, interestingly, it made her feel more tired and depressed. I concluded that my original diagnosis was right and that I should persevere with the original treatment principle: the switch to tonifying Qi to hold Blood was made more because of a desire to stop her bleeding at all costs than because of a cool assessment of her pathology. I therefore reverted to using the formula Qing Ren Zhi Beng Tang but with more herbs to stop bleeding. I therefore removed Huang Qin Radix Scutellariae and added the following: • Dang Gui Radix Angelicae sinensis 4.5 g, to direct the herbs to the Blood portion. • Xian He Cao Herba Agrimoniae, E Jiao Colla Corii asini, Wu Zei Gu Endoconcha Sepiae and San Qi Radix Notoginseng (the last herb as a powder) to stop bleeding.
With acupuncture, I also added the point SP-1 Yinbai. I persevered with this formula and, after 3 months, she began to improve and experienced a reduction in the bleeding. After 5 months, the continuous bleeding stopped and she had two recognizable periods lasting 6 days each: although the period was still heavy for the first 2 days, she was not bleeding during the rest of the cycle and the establishment of a regular cycle was a very good sign. I continued to treat her with a variation of the same formula, but reducing the dosage of the Blood-cooling herbs and adding some Blood-
invigorating herbs such as Yi Mu Cao Herba Leonuri and Chi Shao Radix Paeoniae rubra to balance out the stopping-bleeding herbs. With acupuncture I also added the points BL-20 Pishu and BL-23 Shenshu (with reinforcing method) to tonify Qi and Blood and consolidate the Directing Vessel. The combination of acupuncture to tonify and herbs to clear pathogenic factors is particularly effective in complicated pathologies such as this case. After a further 3 months, her periods were regular, still heavy but much less than before, and the blood was bright red. This patient is still under treatment for her infertility problem. I envisage a gradual change in the formula by reducing the cooling-Blood herbs, eliminating the stoppingbleeding herbs and adding some Blood and Kidney tonics to improve fertility.
Liver-Qi stagnation turning into Heat
Clinical manifestations Profuse menstrual bleeding with sudden flood, depression, irritability, moodiness, thirst, nausea, vomiting, acid regurgitation, hypochondrial pain and distension. Tongue: Red sides. Pulse: Wiry. This pattern is essentially caused by stagnant Liver-Qi turning into Heat which heats the Blood and causes excessive bleeding; its aetiology is always from emotional problems such as repressed anger, resentment and frustration. Fu Qing Zhu says: Some women who are depressed suffer from thirst, vomiting, sour regurgitation and heavy bleeding … This is due to Liver-Qi stagnation. The Liver stores Blood, when Qi stagnates Blood also stagnates … The Liver is restless by nature, when Qi stagnates its restlessness is even worse so that Blood cannot be stored and heavy bleeding results.10 Treatment principle Pacify the Liver, move Qi, eliminate stagnation, clear Heat, cool Blood, stop bleeding. Acupuncture G.B.-34 Yanglingquan, LIV-3 Taichong, LIV-14 Qimen, BL-18 Ganshu, T.B.-6 Zhigou, P-6 Neiguan, P-7 Daling, Du-24 Shenting, G.B.-13 Benshen, SP-8 Diji, Ren-6 Qihai, L.I.-11 Quchi, SP-10 Xuehai, LIV-1 Dadun. All with reducing or even method.
Explanation
– G.B.-34, LIV-3, LIV-14, BL-18 and T.B.-6 pacify the Liver, move Qi and eliminate stagnation. – P-6 and P-7 indirectly move Liver-Qi, calm the Mind and settle the Ethereal Soul. – Du-24 and G.B.-13 calm the Mind and settle the Ethereal Soul. – SP-8 stops uterine bleeding. – L.I.-11 and SP-10 clear Heat and cool Blood. – Ren-6 moves Qi in the Lower Burner. – LIV-1 cools Liver Blood-Heat and stops bleeding. Herbal treatment
Prescription
– PING GAN KAI YU ZHI XUE TANG – Balancing the Liver Opening Stagnation and Stopping Bleeding Decoction Explanation
– Bai Shao and Dang Gui nourish Liver-Blood and pacify the Liver. – Bai Zhu tonifies the Spleen. – Mu Dan Pi and Sheng Di Huang cool Blood and stop bleeding. – San Qi and Jing Jie stop bleeding. – Chai Hu pacifies the Liver, moves Qi and eliminates stagnation. – Gan Cao harmonizes. Three Treasures remedy
– FREEING THE SUN This remedy is a variation of Dan Zhi Xiao Yao San which moves Liver-Qi and clears Liver-Heat (deriving from such stagnation). Summary Liver-Qi stagnation turning into Heat
Clinical manifestations
Profuse menstrual bleeding with sudden flood, depression, irritability, moodiness, thirst, nausea, vomiting, acid regurgitation, hypochondrial pain and distension. Tongue: Red sides. Pulse: Wiry. Treatment principle
Pacify the Liver, move Qi, eliminate stagnation, clear Heat, cool Blood, stop
bleeding. Acupuncture
G.B.-34 Yanglingquan, LIV-3 Taichong, LIV-14 Qimen, BL-18 Ganshu, T.B.-6 Zhigou, P-6 Neiguan, P-7 Daling, Du-24 Shenting, G.B.-13 Benshen, SP-8 Diji, Ren-6 Qihai, L.I.-11 Quchi, SP-10 Xuehai, LIV-1 Dadun. All with reducing or even method. Herbal treatment
Pre scription
• PING GAN KAI YU ZHI XUE TANG Balancing the Liver Opening Stagnation and Stopping Bleeding Decoction Three Treasures remedy
• FREEING THE SUN
Blood Empty-Heat
Clinical manifestations Sudden flooding outside the time of the proper period or trickling for many days after the period, blood fresh red and rather watery, mental restlessness, feeling of heat in the evening, malar flush, scanty, dark urine, dry stools. Tongue: Red without coating. Pulse: Floating-Empty or Fine-Rapid. Treatment principle Clear Empty-Heat, cool Blood, nourish Yin, stop bleeding. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-2 Rangu, LIV-3 Taichong, KI-5 Shuiquan, SP-1 Yinbai, SP-6 Sanyinjiao, SP-8 Diji, Ren-4 Guanyuan, L.I.-11 Quchi, SP-10 Xuehai, LIV-1 Dadun. Reducing method except on Ren-4 which should be reinforced. Explanation
– LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and nourish Yin. – KI-2 and LIV-3, in combination, cool Blood. KI-2 also clears EmptyHeat. – KI-5 cools Blood and stops bleeding from the uterus.
– SP-1 and SP-8 stop uterine bleeding. – SP-6 cools Blood. – Ren-4 nourishes Yin. – L.I.-11 and SP-10 cool Blood and stop bleeding. – LIV-1 cools Liver Blood-Heat and stops bleeding. Herbal treatment
a. Prescription
– BAO YIN JIAN Variation – Protecting Yin Decoction Variation Explanation The first eight herbs constitute the Bao Yin Jian. – Sheng Di Huang, Shu Di Huang, Bai Shao and Shan Yao nourish Yin. Sheng Di and Bai Shao also calm Blood. Sheng Di also cools Blood and stops bleeding. Shu Di and Bai Shao also nourish Blood. – Huang Qin and Huang Bo clear Heat. – Xu Duan: although this herb tonifies Kidney-Yang and should be contraindicated when there is Blood Empty-Heat, it is added here to firm Qi, stop bleeding, consolidate the Uterus and strengthen the Kidneys. The
combination of these actions will consolidate the Directing and Penetrating Vessels and help to stop bleeding. – Gan Cao harmonizes. – Han Lian Cao and Qing Hao clear Empty-Heat and stop bleeding. – Di Yu cools Blood, stops bleeding and astringes. – Qian Cao Gen cools Blood, stops bleeding and invigorates Blood. b. Prescription
– QING RE GU JING TANG – Clearing Heat and Consolidating the Menses Decoction Explanation
– Huang Qin and Shan Zhi Zi clear Heat. – Sheng Di Huang and Di Gu Pi clear Heat and cool Blood. Sheng Di Huang also calms Blood and Di Gu Pi also clears Empty-Heat. – Di Yu cools Blood and stops bleeding. – E Jiao nourishes Blood and stops bleeding. – Ou Jie and Zong Lu Zi stop bleeding. – Gui Ban and Mu Li are absorbent and help to stop bleeding with their astringent quality. Gui Ban also nourishes the Directing and Penetrating
Vessels. They also nourish Yin. – Gan Cao harmonizes. c. Prescription
– LIANG DI TANG – Two ‘Di’ Decoction Explanation
– Sheng Di Huang, Xuan Shen and Mai Men Dong nourish Yin. Sheng Di and Xuan Shen also cool Blood and stop bleeding. – Di Gu Pi clears Empty-Heat. – Bai Shao and E Jiao nourish Blood, which helps to nourish Yin. Modifications These variations apply to all three above formulae. • If there is very profuse, unstoppable bleeding of the Flooding type, add Xian He Cao Herba Agrimoniae, Wu Zei Gu Endoconcha Sepiae and Ou Jie Nodus Nelumbinis rhizomatis. • If the bleeding goes on for a long time like a trickle, add San Qi Radix Notoginseng and Pu Huang Pollen Typhae. Table 17.2 compares and contrasts the three above formulae.
Table 17.2 Comparison of Bao Yin Jian, Qing Re Gu Jing Tang and Liang Di Tang
Women’s Treasure remedy
– CLEAR EMPTY-HEAT AND COOL THE MENSES This remedy is a variation of the formula Bao Yin Jian Protecting the Yin Decoction which cools Blood, clears Empty-Heat, nourishes Yin and stops bleeding. The tongue presentation appropriate to this remedy is a Red body without coating. Summary Blood Empty-Heat
Clinical manifestations
Sudden flooding outside the time of the proper period or trickling for many days after the period, blood fresh red and rather watery, mental restlessness,
feeling of heat in the evening, malar flush, scanty, dark urine, dry stools. Tongue: Red without coating. Pulse: Floating-Empty or Fine-Rapid. Treatment principle
Clear Empty-Heat, cool Blood, nourish Yin, stop bleeding. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-2 Rangu, LIV-3 Taichong, KI-5 Shuiquan, SP-1 Yinbai, SP-6 Sanyinjiao, SP-8 Diji, Ren-4 Guanyuan, L.I.-11 Quchi, SP-10 Xuehai, LIV-1 Dadun. Reducing method except on Ren-4 which should be reinforced. Herbal treatment
Pre scriptions
• BAO YIN JIAN Variation Protecting Yin Decoction Variation • QING RE GU JING TANG Clearing Heat and Consolidating the Menses Decoction • LIANG DI TANG Two ‘Di’ Decoction Women’s Treasure remedy
• CLEAR EMPTY-HEAT AND COOL THE MENSES
Stasis of Blood
Clinical manifestations The period is hesitant, starting and stopping; it may seem to stop then start again with a flood or it may trickle for a long time after the period; pain before the period; blood dark with clots, abdominal distension, dark complexion. Tongue: Bluish-Purple or Reddish-Purple. Pulse: Choppy or Wiry. Treatment principle Invigorate Blood, eliminate stasis, stop bleeding. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), LIV-3 Taichong, T.B.-6 Zhigou, LIV-1 Dadun, SP-8 Diji, ST-30 Qichong, SP-12 Chongmen, SP-10 Xuehai, SP-6 Sanyinjiao. Reducing method. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel which controls the Sea of Blood and the Blood Connecting channels. The Penetrating Vessel’s opening points also invigorate Blood and subdue rebellious Qi. – LIV-3 stimulates the free flow of Liver-Qi and invigorates Blood. – T.B.-6 stimulates the free flow of Liver-Qi.
– LIV-1 invigorates Liver-Blood, cools Blood and stops bleeding. – SP-8 stops uterine bleeding. – ST-30 and SP-12, points on the Penetrating Vessel, invigorate Blood. The ‘chong’ in their names refers to ‘Chong Mai’, i.e. the Penetrating Vessel. – SP-10 invigorates Blood and stops bleeding. – SP-6 invigorates Blood. Herbal treatment
a. Prescription
– TAO HONG SI WU TANG and SHI XIAO SAN Variation – Persica-Carthamus Four Substances Decoction and Breaking into a Smile Powder Variation Explanation The first six herbs constitute the Tao Hong Si Wu Tang which nourishes and invigorates Blood. – Pu Huang and Wu Ling Zhi constitute Shi Xiao San which invigorates Blood and stops pain. Pu Huang also stops bleeding. – Qian Cao Gen and San Qi are added because they invigorate Blood and stop bleeding.
Modifications
• If the stasis of Blood derives from Cold in the Uterus (tongue BluishPurple), add Ai Ye Folium Artemisiae argyi and Fu Zi Radix Aconiti lateralis preparata. • If the stasis of Blood derives from Heat (tongue Reddish-Purple), add Sheng Di Huang Radix Rehmanniae, Mu Dan Pi Cortex Moutan and Di Yu Radix Sanguisorbae. • If there are also symptoms of Qi stagnation, add Chuan Lian Zi Fructus Toosendan and Xiang Fu Rhizoma Cyperi. • If there is profuse bleeding of the Flooding type, remove Chuan Xiong and add Xian He Cao Herba Agrimoniae. • If the stasis of Blood is severe (perhaps also deriving from abdominal operations and consequent adhesions) with abdominal pain and masses, use Fu Qing Zhu’s formula Zhu Yu Zhi Xue Tang Eliminating Stasis and Stopping Bleeding Decoction which consists of Sheng Di Huang Radix Rehmanniae 30 g, Da Huang Radix et Rhizoma Rhei 9 g, Chi Shao Radix Paeoniae rubra 9 g, Mu Dan Pi Cortex Moutan 3 g, Dang Gui (Wei) Radix Angelicae sinensis (‘tail’) 15 g, Zhi Ke Fructus Aurantii 15 g (fried with vinegar), Gui Ban Plastrum Testudinis 9 g (toasted) and Tao Ren Semen Persicae 10 pieces. b. Prescription
– HU PO SAN – Succinum Powder
Explanation This formula from the Golden Mirror of Medicine (1742) strongly invigorates Blood, eliminates stasis and stops pain. It is specific for stasis of Blood in the Uterus. – Hu Po, E Zhu, San Leng, Chi Shao, Mu Dan Pi, Liu Ji Nu and Yan Hu Suo invigorate Blood and eliminate stasis. E Zhu and San Leng also ‘break’ Blood. – Dang Gui and Shu Di Huang nourish Blood. – Wu Yao moves Qi in the Lower Burner and stops pain. – Rou Gui expels Cold in the Lower Burner Women’s Treasure remedy
– INVIGORATE BLOOD AND STEM THE FLOW This remedy is a variation of the formula Tao Hong Si Wu Tang Persica-Carthamus Four Substances Decoction which invigorates Blood and eliminates stasis. The tongue presentation appropriate to this remedy is a Purple body. Summary Stasis of Blood
Clinical manifestations
The period is hesitant, starting and stopping; it may seem to stop then start again with a flood or it may trickle for a long time after the period; pain before the period; blood dark with clots, abdominal distension, dark complexion. Tongue: Bluish-Purple or Reddish-Purple. Pulse: Choppy or Wiry. Treatment principle
Invigorate Blood, eliminate stasis, stop bleeding. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), LIV-3 Taichong, T.B.-6 Zhigou, LIV-1 Dadun, SP-8 Diji, ST-30 Qichong, SP-12 Chongmen, SP-10 Xuehai, SP-6 Sanyinjiao. Reducing method. Herbal treatment
Pre scriptions
• TAO HONG SI WU TANG and SHI XIAO SAN Variation PersicaCarthamus Four Substances Decoction and Breaking into a Smile Powder Variation • HU PO SAN Succinum Powder Women’s Treasure remedy
• INVIGORATE BLOOD AND STEM THE FLOW
Damp-Heat in the Uterus
Clinical manifestations Menstrual bleeding which could be either scanty or abundant, bleeding on mid-cycle, blood sticky, yellow-brownish discharge appearing before bleeding starts, no clots, feeling of heaviness, dragging sensation in the lower abdomen, burning pain in the lower abdomen, pain in the joints, a feeling of oppression of the chest, irritability, scanty, dark urine, burning on urination, vaginal discharge. Tongue: Sticky-yellow coating. Pulse: Slippery. Treatment principle Clear Heat, resolve Dampness, cool Blood, stop bleeding. Case history A 22-year-old woman had been suffering from very heavy periods for about 4 years. Her cycle was always delayed with her periods coming every 6 weeks. The period always started suddenly with a flood and lasted 7 days; it was painful and the menstrual blood was dark with clots. She also complained of backache, dizziness, slight tinnitus and night sweating which occurred only during the periods. Her tongue was slightly Red with a slightly rootless coating and her pulse was Weak on the left Kidney position. Diagnosis There are two main patterns, i.e. stasis of Blood and deficiency of KidneyYin. The stasis of Blood is obvious from the painful period, late cycle, dark menstrual blood with clots. Her tongue is not Purple, however. This simply means that the stasis of Blood is not that severe yet, also due to her young
age. The Kidney deficiency is not too severe either as the tongue is only slightly Red and with a slightly rootless coating. Treatment principle This is an example of a complex condition with the two patterns of Blood stasis and Kidney deficiency. These two patterns can be treated simultaneously. I treated this patient only with acupuncture as she did not want to take Chinese herbs. In any case, if a condition is particularly complicated, I often start by using acupuncture only due to the self-regulating effect of this therapy. For example, in this case, nourishing Yin with sticky, sweet herbs may aggravate the Blood stasis; on the other hand, using pungent herbs to invigorate Blood may tend to injure Yin. Thus, the herbal formula has to be carefully balanced to avoid these pitfalls. There is no such problem with acupuncture as no substances are introduced into the body. Acupuncture is particularly effective when there is stagnation of Qi or Blood, as, by its nature, practically all points will tend to move Qi and Blood. Thus one can move Qi and Blood at the same time as attending to any other patterns. In this case, for example, using Ren-4 Guanyuan will nourish Kidney-Yin, and strengthen the Uterus, but it will also automatically move Qi and Blood in the lower abdomen. Acupuncture I used points selected from the following: • LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to regulate the Directing Vessel, strengthen the Uterus, regulate the periods and nourish KidneyYin. • KI-3 Taixi to nourish Kidney-Yin. • Ren-4 Guanyuan to nourish Kidney-Yin, strengthen the Uterus and consolidate the Directing Vessel.
• SP-10 Xuehai, SP-6 Sanyinjiao, P-6 Neiguan and BL-17 Geshu to invigorate Blood and eliminate stasis.
This patient was treated for about 3 months along these lines, making a good improvement. Her periods are much lighter, lasting about 5 days and her cycle is down to 5 weeks’ length. She is still receiving treatment at the time of writing. Case history A 48-year-old woman had been suffering from a myoma for the previous 4 years. This was very large and clearly palpable, feeling like a hard, round mass. Her periods had become frequent, coming every 3 weeks and were very heavy and painful, the period lasting 9–10 days and sometimes continuing for up to 17 days, which meant that she was bleeding practically all the time. The menstrual blood was bright red but there were small, dark clots. She complained of catarrh on the chest and tiredness. She looked pale, talked with a low voice and looked extremely depressed and sad, speaking with her head bowed. Her eyes lacked shen to quite a severe degree. Her tongue was Pale-Purplish and Swollen and her pulse was Weak on both Rear positions and Weak in general. Diagnosis This is a clear case of stasis of Blood from Cold. The myoma is caused by the stasis of Blood and so is the heavy bleeding with small, dark clots. Small, dark clots with bright red blood are particularly indicative of stasis of Blood deriving from Cold. Apart from the stasis of Blood, there is also Qi deficiency and some Phlegm, manifesting in the tiredness, catarrh, Weak pulse and Pale tongue. The Blood deficiency manifested mainly in her general sad and depressed look and the lack of shen in the eyes. She had obviously been suffering from sadness for several years. Thus, this condition is quite complex, with a mixture of deficiency (of Qi and Blood) and excess (stasis of Blood, Cold and Phlegm).
Treatment principle In complex conditions of mixed deficiency and excess, my general approach is to deal with the Full condition first. I therefore decided to deal with the stasis of Blood first by invigorating Blood and eliminating stasis. She was treated with both acupuncture and Chinese herbs. Acupuncture Since I started with a formula to invigorate Blood and eliminate stasis, with the acupuncture I concentrated on tonifying Qi and Blood and the Directing and Penetrating Vessels. I used points selected from the following: • LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to regulate the Directing Vessel, strengthen the Uterus and nourish the Kidneys. One of the main indications for the use of this vessel is abdominal masses in women. • Du-20 to tonify and raise Qi and lift the mood. I frequently use this point for mental depression. • Ren-12 Zhongwan to tonify the Spleen and resolve Phlegm. • Ren-6 to tonify and move Qi in the lower abdomen. The myoma extended to the level of Ren-5 Shimen. • ST-36 Zusanli and SP-6 to tonify Qi and Blood and strengthen the Spleen. SP-6 also invigorates Blood.
Herbal treatment As I decided to concentrate on the Full condition first, I chose a formula to invigorate Blood, eliminate stasis and dissolve abdominal masses, i.e. Gui Zhi Fu Ling Wan Ramulus Cinnamomi-Poria Pill Variation: • Gui Zhi Ramulus Cinnamomi 4.5 g
• Fu Ling Poria 6 g • Tao Ren Semen Persicae 4.5 g • Chi Shao Radix Paeoniae rubra 6 g • Mu Dan Pi Cortex Moutan 6 g • Ze Lan Herba Lycopi 4.5 g • E Zhu Rhizoma Curcumae 6 g • San Leng Rhizoma Sparganii 4.5 g • Xian He Cao Herba Agrimoniae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Pu Huang Pollen Typhae 4.5 g
Explanation
• The first five herbs constitute the formula Gui Zhi Fu Ling Wan which invigorates Blood, eliminates stasis and dissolves masses: it is specific for abdominal masses such as myomas. • Ze Lan, E Zhu and San Leng strongly invigorate and ‘break’ Blood to dissolve abdominal masses. • Xian He Cao stops bleeding. • Dang Gui nourishes and invigorates Blood. • Pu Huang invigorates Blood and stops bleeding.
She was treated with this formula for about a month and made some small improvement, experiencing a slight decrease in the bleeding. However, her period was still very heavy and she was still bleeding most of the time, although the menstrual blood was without clots. I reassessed the situation and
decided to change to a different prescription placing the emphasis on tonifying the deficiency rather than attacking the excess. I therefore prescribed a variation of Gui Pi Tang Restoring the Spleen Decoction. I chose this formula not only because it specifically stops bleeding from a deficient Spleen-Qi, but also because I thought that her mental state should take priority over other considerations. The formula used was as follows: • Dang Shen Radix Codonopsis 9g • Huang Qi Radix Astragali 9g • Bai Zhu Rhizoma Atractylodis macrocephalae 6g • Fu Ling Poria 6g • Mu Xiang Radix Aucklandiae 3g • Yuan Zhi Radix Polygalae 6g • Suan Zao Ren Semen Ziziphi spinosae 4.5g • Bai Zi Ren Semen Platycladi 6g • Long Yan Rou Arillus Longan 6g • Dang Gui Radix Angelicae sinensis 6g • Mu Li Concha Ostreae 12g • Chi Shao Radix Paeoniae rubra 6g • Yu Jin Radix Curcumae 6g • Xian He Cao Herba Agrimoniae 6g
Explanation The first 10 herbs constitute the formula Gui Pi Tang to tonify the Spleen and the Heart and stop bleeding.
• Mu Li is absorbent and helps to stop bleeding. • Chi Shao and Yu Jin invigorate Blood and eliminate stasis. Yu Jin was selected also because it opens the Mind’s orifices and lifts depression. • Xian He Cao stops bleeding.
This formula gave much better results than the former. I used it for about 3 months after which her period still lasted 7 days but at least she did not bleed at all in between periods. Of course, a myoma of that size cannot be dissolved and the aim of the treatment was purely to regulate the periods and stop bleeding while she made up her mind whether to have an operation or not. In this case, contrary to my usual approach, better results were obtained by concentrating on tonifying the body’s Qi rather than expelling pathogenic factors. I believe that the improvement was also owed to the fact that the formula Gui Pi Tang treated the Heart and the underlying emotional sadness. Case history A 14-year-old girl had been suffering from heavy periods ever since they started (when she was 11). The cycle was irregular, ranging between 15 and 35 days, and the period lasted at least 8 days with a heavy flow. The menstrual blood was dark with clots and the period was also painful. A laparoscopy had revealed what the gynecologist defined as ‘preendometriosis’ cells: he prescribed the contraceptive pill first and progesterone pills afterwards, neither of which helped at all. The menstrual pain was in the back and sacrum rather than in the abdomen with a bearingdown feeling and a desire to curl up. However, she disliked the idea of a hotwater bottle and felt hot and thirsty. Besides this, she also suffered from asthma and hay fever. On interrogation, it transpired that she occasionally suffered from dizziness and slight tinnitus. Her tongue was slightly Red, with red points on the sides. Her pulse was generally Weak. Diagnosis
This is quite a complex condition. From the point of view of identification of disease (bian bing), it could be treated as Flooding and Trickling, as Painful Periods or as Irregular Periods. The two main patterns emerging are stasis of Blood and a Kidney deficiency, and the symptoms and signs point to a mixture of deficiency and excess: for example, the location and nature of the menstrual pain and the patient’s liking to curl up, to deficiency; but her dislike of a hot-water bottle, thirst, hot feeling, her Red tongue with red points, and severe pain, to excess. The stasis of Blood is apparent from the painful period and dark blood with clots and is also the cause of heavy bleeding. The tongue is Red with red points rather than Purple: red points are quite common in young girls, and the tongue is not Purple simply because of her young age. Besides this, there is a Kidney deficiency evident from the asthma and hay fever (which I usually attribute to a deficiency of the Kidney’s Defensive Qi system), the pain in the back, the dizziness and the tinnitus. This Kidney deficiency may be either of Yin or Yang, but although it is not clear which, it tends more to the latter. Treatment principle This girl was treated only with acupuncture: I would have normally prescribed herbs but she did not want to take them. The points used were selected from the following: • SP-4 Gongsun (on the right) and P-6 Neiguan (on the left) to regulate the Penetrating Vessel and invigorate Blood. • SP-8 Diji, with even method, to stop bleeding. • SP-6 Sanyinjiao, with even method, to invigorate Blood. • LIV-3 Taichong, with reducing method, to invigorate Blood. • Ren-4, with reinforcing method, to strengthen the Uterus and the Kidneys. • BL-32 Ciliao, with even method, to invigorate Blood in the Uterus.
• Huatuojiaji points besides the fourth and fifth lumbar vertebrae. Some doctors use these points to activate the spine branch of the Penetrating Vessel and therefore invigorate Blood in the Uterus. 11
After 5 months of fortnightly sessions, her periods became much less heavy and less painful and the cycle was restored to about 30 days. Acupuncture G.B.-41 Zulinqi (on the right) and T.B.-5 Waiguan (on the left), L.I.-11 Quchi, SP-10 Xuehai, SP-8 Diji, SP-1 Yinbai, KI-5 Shuiquan, SP-6 Sanyinjiao, SP-9 Yinlingquan, Ren-3 Zhongji, BL-22 Sanjiaoshu, BL-32 Ciliao. Reducing method, no moxa. Explanation
– G.B.-41 and T.B.-5 regulate the Girdle Vessel and drain Dampness from the Lower Burner. Dampness in the genitourinary system is this vessel’s main symptom. – L.I.-11 and SP-10 cool Blood and stop bleeding. L.I.-11 also resolves Damp-Heat. – SP-8, Accumulation point, stops bleeding from the uterus. – SP-1 is an empirical point to stop uterine bleeding. – KI-5 cools Blood in the Uterus and stops uterine bleeding. – SP-6 cools and invigorates Blood. – SP-9 and Ren-3 resolve Damp-Heat in the Lower Burner.
– BL-22 and BL-32 promote the transformation of fluids and resolve Damp-Heat from the Uterus. Herbal treatment
Prescription
– QING RE LI SHI TANG Variation – Clearing Heat and Resolving Dampness Decoction Variation Explanation
– Bi Xie and Qu Mai drain Dampness via urination. – Shan Zhi Zi, Huang Qin and Huang Lian drain Damp-Heat. Zhi Zi, especially charred, also stops bleeding. – Zhi Mu clears Heat. – Mu Dan Pi cools Blood and stops bleeding. – Ou Jie, astringent, helps to stop bleeding. – Xian He Cao, substituted for Bai Mao Gen from the original prescription, stops uterine bleeding. Women’s Treasure remedy
– COOL THE MENSES This remedy cools Blood, resolves Dampness, clears Heat and stops bleeding. The tongue presentation appropriate to this remedy is a Red body with a sticky yellow coating that is thicker on the root. Summary Damp-Heat in the Uterus
Clinical manifestations
Menstrual bleeding which could be either scanty or abundant, bleeding on mid-cycle, blood sticky, yellow-brownish discharge appearing before bleeding starts, no clots, feeling of heaviness, dragging sensation in the lower abdomen, burning pain in the lower abdomen, pain in the joints, a feeling of oppression of the chest, irritability, scanty, dark urine, burning on urination, vaginal discharge. Tongue: Sticky-yellow coating. Pulse: Slippery. Treatment principle
Clear Heat, resolve Dampness, cool Blood, stop bleeding. Acupuncture
G.B.-41 Zulinqi (on the right) and T.B.-5 Waiguan (on the left), L.I.-11 Quchi, SP-10 Xuehai, SP-8 Diji, SP-1 Yinbai, KI-5 Shuiquan, SP-6 Sanyinjiao, SP-9 Yinlingquan, Ren-3 Zhongji, BL-22 Sanjiaoshu, BL-32 Ciliao. Reducing method, no moxa. Herbal treatment
Pre scription
• QING RE LI SHI TANG Variation Clearing Heat and Resolving Dampness Decoction Variation Women’s Treasure remedy
• COOL THE MENSES
Empty conditions
Spleen not holding Blood
Clinical manifestations Flooding at the beginning of the period which then stops and goes on with a trickle for a long time after the period proper, pale and watery blood, pale face, tiredness, slight dizziness, no appetite, loose stools. Tongue: Pale, teethmarks. Pulse: Weak. Treatment principle Tonify Qi, strengthen the Spleen, nourish Blood, stop bleeding. Acupuncture Ren-6 Qihai, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu, Du-20 Baihui, SP-8 Diji. Reinforcing method, moxa may be used. Explanation
– Ren-6 tonifies Qi and stops bleeding from Qi sinking. – Ren-12, ST-36, SP-6, BL-20, and BL-21 tonify Spleen-Qi. – Du-20 raises Qi and stops bleeding from sinking Qi. – SP-8, Accumulation point, stops uterine bleeding. Herbal treatment
a Prescription
– GU BEN ZHI BENG TANG – Consolidating the Root and Stopping Flooding Decoction Explanation
– Huang Qi, Ren Shen and Bai Zhu tonify and raise Qi. – Shu Di Huang and Dang Gui nourish Blood and firm Qi. They are also included so that the formula enters the Blood portion to stop bleeding. Dang Gui also calms Blood. – Pao Jiang warms the channels and stops bleeding. b Prescription
– DANG GUI BU XUE TANG – Angelica Tonifying Blood Decoction Explanation
– This is a very simple formula to stop bleeding from Qi deficiency which may be added to other formulae.
– Huang Qi tonifies and raises Qi. – Dang Gui enters the Blood portion and directs the formula to the Blood so that it stops bleeding from Qi deficiency. c Prescription
– GUI PI TANG – Tonifying the Spleen Decoction Explanation This formula, which has already been explained, is very frequently used to stop bleeding from Qi deficiency. It is selected in preference to the previous two when there is also a deficiency of Heart-Blood causing insomnia, anxiety and forgetfulness. The formula stops bleeding not only by tonifying Qi to hold Blood, but also by tonifying the Heart which governs Blood. It is therefore particularly indicated if the excessive menstrual bleeding is caused not only by Spleen-Qi deficiency but also by Heart-Qi and Heart-Blood deficiency deriving from emotional problems. Modifications These modification apply to all the above formulae. • If there are symptoms of Blood deficiency, add Shou Wu Radix Polygoni multiflori preparata and Gou Qi Zi Fructus Lycii. • If there is chronic, persistent bleeding of the Trickling type, add (Hei) Jing Jie Herba Schizonepetae (charred) and Yi Mu Cao Herba Leonuri.
• If there are pronounced symptoms of Qi sinking, add Chai Hu Radix Bupleuri and Sheng Ma Rhizoma Cimicifugae and increase the dosage of Huang Qi Radix Astragali. Alternatively, use a variation of Ju Yuan Jian Raising the Original [Qi] Decoction. • If the bleeding is profuse, add Xian He Cao Herba Agrimoniae and Wu Zei Gu Endoconcha Sepiae. • If there are digestive symptoms deriving from Spleen- and Stomach-Qi deficiency, add Sha Ren Fructus Amomi, Chen Pi Pericarpium Citri reticulatae and Mu Xiang Radix Aucklandiae. • If there are pronounced symptoms of Qi deficiency or even the beginning of collapse of Yang with very profuse, acute bleeding of the Flooding type, administer Du Shen Tang Solitary Ginseng Decoction which consists only of Ginseng. This is best given in powder form with a dosage of 15–30 g according to the severity of the condition. The symptoms of collapse of Yang are an extremely pale face, cold limbs, sweating, weak breathing and a Scattered pulse. d. Prescription
– YI QI GU CHONG TANG – Benefiting Qi and Consolidating the Penetrating Vessel Decoction Explanation This formula is essentially a variation of Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction specifically adapted to stop uterine bleeding from Qi deficiency. It is particularly suitable if, besides a Qi deficiency, there is also some Kidney deficiency (a very common
occurrence). – Huang Qi, Bai Zhu and Dang Shen tonify and raise Qi. – Ai Ye, Xian He Cao and Jing Jie stop bleeding. – Dang Gui nourishes Blood and enters the Blood portion so that the other herbs can stop bleeding. – Xu Duan tonifies the Kidneys and consolidates the Penetrating Vessel. – Sheng Ma, in conjunction with Huang Qi, raises Qi. – Gan Cao harmonizes. e. Prescription
– FU ZHENG ZHI BENG TANG12 – Supporting the Upright Qi and Stopping Flooding Decoction Explanation
– Dang Gui and Bai Shao nourish and calm Blood to stop bleeding. – Huang Qi and Dang Shen tonify Qi. – Xian He Cao and Ce Bai Ye stop bleeding. Women’s Treasure remedy
– RESTRAIN THE FLOW This remedy is a variation of the formula Yi Qi Gu Chong Tang Benefiting Qi and Consolidating the Penetrating Vessel Decoction which tonifies Qi and stops bleeding. The tongue presentation appropriate to this remedy is a Pale body. Summary Spleen not holding Blood
Clinical manifestations
Flooding at the beginning of the period which then stops and goes on with a trickle for a long time after the period proper, pale and watery blood, pale face, tiredness, slight dizziness, no appetite, loose stools. Tongue: Pale, teethmarks. Pulse: Weak. Treatment principle
Tonify Qi, strengthen the Spleen, nourish Blood, stop bleeding. Acupuncture
Ren-6 Qihai, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu, Du-20 Baihui, SP-8 Diji. Reinforcing method, moxa may be used. Herbal treatment
Pre scriptions
• GU BEN ZHI BENG TANG Consolidating the Root and Stopping Flooding Decoction • DANG GUI BU XUE TANG Angelica Tonifying Blood Decoction • GUI PI TANG Tonifying the Spleen Decoction • YI QI GU CHONG TANG Benefiting Qi and Consolidating the Penetrating Vessel Decoction • FU ZHENG ZHI BENG TANG Supporting the Upright Qi and Stopping Flooding Decoction Women’s Treasure remedy
• RESTRAIN THE FLOW
Case history A 31-year-old woman had been suffering from prolonged bleeding after the period for a year. Her periods came regularly and lasted only 5 days but, after stopping for 1 or 2 days, they started again for at least another 5 days. The amount of blood was scanty and the colour was bright red. She also felt very tired and depressed and slept badly, waking up several times during the night. On interrogation, it transpired that she also suffered from backache, dizziness, a slight tinnitus, chilliness and frequent and urgent urination. She was very pale and spoke with a low voice. Her tongue was very Pale and rather wet. Her pulse was Weak in general and more so on both Rear positions. Diagnosis This is a very clear example of Spleen-Qi deficient and sinking, unable to contain Blood. There is also a clear condition of Spleen- and Kidney-Yang
deficiency as evidenced by the Kidney deficiency symptoms (chilliness, frequent urination, backache, dizziness, tinnitus, wet tongue). The tiredness, Weak pulse, pale face, Pale tongue and low voice are clear symptoms of Spleen-Qi deficiency. Treatment principle The treatment principle in this case is very simple: tonify and raise Spleen-Qi, stop bleeding, tonify and warm Spleen- and Kidney-Yang. She was treated with both acupuncture and herbs. Acupuncture
As this patient was very fearful of needles, I had to keep the number of needles to a minimum and only used points selected from the following, with reinforcing method: • Ren-12 Zhongwan to tonify Spleen-Qi. • ST-36 Zusanli, with warm needle, to tonify Spleen-Qi. • KI-3 Taixi, with warm needle, to tonify Kidney-Yang. • Ren-4 Guanyuan, with direct moxa cones, to tonify the Kidneys and strengthen the Uterus. Herbal treatment
Since this patient suffered from Spleen- and Kidney-Yang deficiency (which includes Spleen-Qi sinking not holding Blood), I could have used one of the formulae for Kidney-Yang deficiency such as You Gui Wan Restoring the Right [Kidney] Pill. However, the fact that this woman suffered from insomnia and depression led me to choose a formula for bleeding from Spleen-Qi deficiency, modified to tonify Kidney-Yang, i.e. Gui Pi Tang Restoring the Spleen Decoction:
• Dang Shen Radix Codonopsis 9 g • Huang Qi Radix Astragali 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Dang Gui Radix Angelicae sinensis 4.5 g • Fu Shen Sclerotium Poriae pararadicis 6 g • Suan Zao Ren Semen Ziziphi spinosae 3 g • Long Yan Rou Arillus Longan 6 g • Yuan Zhi Radix Polygalae 6 g • Mu Xiang Radix Aucklandiae 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Hong Zao Fructus Jujubae 5 dates • Xu Duan Radix Dipsaci 4.5 g • Ai Ye Folium Artemisiae argyi 3 g • Xian He Cao Herba Agrimoniae 4.5 g • Fu Pen Zi Fructus Rubi 4.5 g
Explanation The first twelve herbs constitute the formula Gui Pi Tang, unchanged except for reduced dosages. • Xu Duan was added to tonify Kidney-Yang, strengthen the Uterus and consolidate the Penetrating Vessel.
• Ai Ye warms the Uterus and stops bleeding. • Xian He Cao stops uterine bleeding. • Fu Pen Zi tonifies Kidney-Yang and, being astringent, helps to stop bleeding.
After 3 months of fortnightly acupuncture sessions and daily decoctions of the above formula, her periods returned to normal and she felt a lot better in general, reporting more energy, better sleep, a better mood and a decrease in the Kidney-Yang deficiency symptoms. After a further 3 months, I stopped the acupuncture treatment and the decoction and prescribed the Three Treasures remedy Strengthen the Root to tonify and warm Kidney-Yang, which she was advised to take for at least 6 months.
Kidney-Yang deficiency
Clinical manifestations Prolonged bleeding with a trickle for a long time after the proper period, periods coming late, blood pale, feeling cold, sore back, cold limbs, pale complexion, weak knees, pale urine. Tongue: Pale and Swollen. Pulse: Deep and Weak. Treatment principle Tonify and warm the Kidneys, consolidate the Directing and Penetrating Vessels, stop bleeding. Acupuncture Ren-6 Qihai, BL-23 Shenshu, Ren-4 Guanyuan, ST-30 Qichong, KI-7 Fuliu, ST-36 Zusanli, SP-6 Sanyinjiao, KI-13 Qixue. Reinforcing method, moxa must be used. A prescription which is specific to raise Qi and consolidate the Penetrating Vessel to hold Blood is: SP-1 Yinbai with moxa cones, BL-20 Pishu, SP-6 Sanyinjiao, Du-20 Baihui, Ren-6 Qihai and Ren-4 Guanyuan, all with reinforcing method. Explanation
– Ren-6 tonifies Qi and stops bleeding. – BL-23 and Ren-4, with moxa, tonify and warm Kidney-Yang and
consolidate the Penetrating Vessel. – ST-30, with moxa, consolidates the Penetrating Vessel. – KI-7 tonifies Kidney-Yang. – ST-36 and SP-6 tonify Qi and Blood. – KI-13 tonifies the Kidneys, strengthens the Uterus and consolidates the Penetrating Vessel. Herbal treatment
Prescription
– YOU GUI WAN – Restoring the Right [Kidney] Pill Explanation This formula, which has already been explained, tonifies and warms KidneyYang. It is suitable to stop bleeding as Fu Zi can stop bleeding from Yang deficiency and Cold, Shan Zhu Yu is astringent and will help to stop bleeding, Lu Jiao Jiao will nourish and calm Blood, and Dang Gui enters the Blood portion to direct the formula to the Blood and stop bleeding. Modifications Some doctors advise removing Dang Gui and Rou Gui from the original
formula when this is used for menstrual bleeding. I personally use these two herbs but in a lower dose: 3 g of Dang Gui and 1.5 g of Rou Gui. To enhance the stopping-bleeding effect, add Xian He Cao Herba Agrimoniae. • If there are symptoms of deficiency and sinking of Qi, add Huang Qi Radix Astragali. • If there is a hereditary Kidney weakness in a young girl, add Zi He Che Placenta hominis and Yin Yang Huo Herba Epimedii. • If the Spleen is also deficient and there is oedema, add Fu Ling Poria, Sha Ren Fructus Amomi and Pao Jiang Rhizoma Zingiberis preparatum (fried). • If there are symptoms of stasis of Blood deriving from internal Cold, add Yi Mu Cao Herba Leonuri and Wu Ling Zhi Faeces Trogopteri. Women’s Treasure remedies
– STRENGTHEN THE ROOT This remedy is a variation of the above formula You Gui Wan. – UNICORN PEARL This remedy is a variation of Yu Lin Zhu which tonifies Kidney-Yang and nourishes Blood. Summary Kidney-Yang deficiency
Clinical manifestations
Prolonged bleeding with a trickle for a long time after the proper period, periods coming late, blood pale, feeling cold, sore back, cold limbs, pale complexion, weak knees, pale urine. Tongue: Pale and Swollen. Pulse: Deep and Weak. Treatment principle
Tonify and warm the Kidneys, consolidate the Directing and Penetrating Vessels, stop bleeding. Acupuncture
Ren-6 Qihai, BL-23 Shenshu, Ren-4 Guanyuan, ST-30 Qichong, KI-7 Fuliu, ST-36 Zusanli, SP-6 Sanyinjiao, KI-13 Qixue. Reinforcing method, moxa must be used. Herbal treatment
Pre scription
• YOU GUI WAN Restoring the Right [Kidney] Pill Women’s Treasure remedies
• STRENGTHEN THE ROOT • UNICORN PEARL
Case history
A 50-year-old woman had been suffering from heavy menstrual bleeding for 18 months. The menstrual blood was bright red with small dark clots. Her period was very painful and she felt very cold during it. Her uterus was prolapsed. She also suffered from backache, dizziness, exhaustion, poor memory and frequency of urination. Her tongue was slightly Pale and Swollen and her pulse was Deep and Weak, particularly so on both Rear positions. Diagnosis This is a rather complex condition. There is definitely a deficiency of Spleenand Kidney-Yang: this is evident from the prolapse of the uterus (Spleen-Qi sinking), the cold feeling, backache, dizziness, poor memory, Deep-Weak pulse and Pale tongue. The heavy menstrual bleeding is caused by deficient Spleen- and Kidney-Qi not holding Blood. However, the painful period and small dark clots indicate that there is also internal Cold in the Uterus. This presumably originated from the Kidney-Yang deficiency. Treatment principle This patient was being treated with acupuncture by another practitioner who referred her to me for herbal treatment. The treatment principle adopted was to scatter Cold and warm the Uterus and to tonify and warm Spleen- and Kidney-Yang. Herbal treatment
One could have chosen the formula indicated above, i.e. You Gui Wan Restoring the Right [Kidney] Pill to tonify and warm Kidney-Yang. However, since the condition is characterized by both deficiency (of Spleenand Kidney-Yang) and excess (Cold in the Uterus), I decided to place the emphasis on expelling Cold first. I often find in practice that it is preferable to
eliminate the excess before tonifying the deficiency. I therefore selected a variation of Ai Fu Nuan Gong Wan Artemisia Cyperus Warming the Uterus Pill (see Ch. 14): • Ai Ye Folium Artemisiae argyi 6 g • Wu Zhu Yu Fructus Evodiae 4.5 g • Rou Gui Cortex Cinnamomi 3 g • Xiang Fu Rhizoma Cyperi 6 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Bai Shao Radix Paeoniae alba 9 g • Huang Qi Radix Astragali 9 g • Sheng Di Huang Radix Rehmanniae 9 g • Xu Duan Radix Dipsaci 6 g • Xian He Cao Herba Agrimoniae 6 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Shan Zhu Yu Fructus Corni 4 g • Chai Hu Radix Bupleuri 3 g • Sheng Ma Rhizoma Cimicifugae 3 g
Explanation The first 10 herbs constitute the root formula which scatters Cold from the Uterus, nourishes Blood and tonifies Kidney-Yang. • Xian He Cao was added to stop bleeding.
• Shu Di Huang was added to strengthen the Kidneys. • Shan Zhu Yu was added to nourish the Liver and Kidneys and also as an astringent to help to stop bleeding. • Chai Hu and Sheng Ma were added to raise sinking Spleen-Qi.
As the main problem was the heavy menstrual bleeding, the formula was modified to stop bleeding according to the four aims of treatment outlined in the Treatment Principles (see beginning of this chapter): 1. Harmonize Blood: • stop bleeding: Xian He Cao • eliminate stasis: Chuan Xiong • calm Blood: Bai Shao, Sheng Di Huang • nourish Blood: Dang Gui, Shu Di Huang. 2. Treat the root cause of bleeding (Yang deficiency): Xu Duan, Rou Gui. 3. Astringe: Shan Zhu Yu. 4. Treat Qi (raise Spleen-Qi): Huang Qi, Chai Hu, Sheng Ma.
This patient was treated with this formula (with slight variations) for 6 months, after which the period became much lighter and less painful. Case history A 29-year-old woman had been suffering from constant uterine bleeding for 1 year. She bled every day, with the bleeding getting heavier around the period at which time the blood became dark with clots and she experienced period pain. During the rest of the month the bleeding was like a daily trickle. Her other symptoms and signs included exhaustion, backache, dizziness, tinnitus, slight night sweating, feeling very cold, nocturia, blurred vision, numbness of the limbs and poor memory. Her tongue was Pale and with teethmarks. Her pulse was Choppy and Weak on the right Rear and left Middle position. Diagnosis
This is a clear condition of deficiency of Kidneys and Liver with a secondary stasis of Liver-Blood. The primary deficiency is that of Kidney-Yang (as indicated by the Pale tongue) even though there is some overlapping KidneyYin deficiency (night sweating): in women, an overlap of Kidney-Yang and Kidney-Yin deficiency is very common. Treatment principle The treatment principle adopted was to tonify the Kidneys and nourish and invigorate Liver-Blood. She was treated with both acupuncture and herbs. Acupuncture
This included a selection of the following points: • LU-7 Lieque on the right and KI-6 Zhaohai on the left to regulate the Directing Vessel, strengthen the Uterus and tonify the Kidneys. • ST-36 Zusanli and SP-6 Sanyinjiao to tonify Qi in general. • SP-8 Diji to stop bleeding. • Ren-4 Guanyuan, BL-23 Shenshu and KI-3 Taixi to nourish the Kidneys. Herbal treatment
The herbal formula used was a variation of Gui Pi Tang Tonifying the Spleen Decoction: • Huang Qi Radix Astragali 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Dang Shen Radix Codonopsis 6 g • Fu Ling Poria 6 g
• Long Yan Rou Arillus Longan 6 g • Suan Zao Ren Semen Ziziphi spinosae 3 g • Mu Xiang Radix Aucklandiae 3 g • Dang Gui Radix Angelicae sinensis 9 g • Yi Mu Cao Herba Leonuri 4 g • Sheng Di Huang Radix Rehmanniae 6 g • Bai Shao Radix Paeoniae alba 6 g • Xian He Cao Herba Agrimoniae 6 g • Ai Ye Folium Artemisiae argyi 4 g • Xu Duan Radix Dipsaci 6 g • Chi Shao Radix Paeoniae rubra 4 g • Hong Zao Fructus Jujubae 3 dates
Explanation The prescription can be explained in the light of the four aims of treatment outlined above: 1. Harmonize Blood: • stop bleeding: Xian He Cao, Ai Ye • invigorate Blood and eliminate stasis: Yi Mu Cao, Chi Shao • calm Blood: Sheng Di Huang, Bai Shao • nourish Blood: Dang Gui, Sheng Di Huang, Hong Zao. 2. Treat the root (deficiency of Kidneys and Liver): Sheng Di Huang, Dang Gui, Xu Duan. 3. Astringe: Suan Zao Ren.
4. Treat Qi: Dang Shen, Huang Qi, Bai Zhu to tonify and raise Qi.
The bleeding stopped almost immediately for 20 days out of a 28-day cycle; during the other 8 days the amount of bleeding was much decreased. After 4 months of treatment her periods were restored to complete normality.
Kidney-Yin deficiency
Clinical manifestations Trickling of blood after the period proper, late cycle, fresh, red and watery blood, dizziness, tinnitus, weak knees, feeling of heat in the evening, night sweating, hot flushes, malar flush, mental restlessness. Tongue: without coating; also Red if there is Empty-Heat. Pulse: Floating-Empty. This pattern is more common in women towards the beginning of the menopause. Treatment principle Nourish Yin, strengthen the Kidneys, stop bleeding. Acupuncture Ren-6 Qihai, BL-23 Shenshu, Ren-4 Guanyuan, KI-3 Taixi, ST-36 Zusanli, SP-6 Sanyinjiao, KI-2 Rangu, KI-13 Qixue, KI-10 Yingu, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left). Reinforcing method on all points except KI-2 which should be needled with even method. No moxa. Explanation
– Ren-6 tonifies Qi and stops bleeding. – BL-23 and Ren-4 tonify the Kidneys and consolidate the Penetrating Vessel.
– KI-3 tonifies the Kidneys. – ST-36 and SP-6 tonify Qi and Blood. – KI-2 clears Empty-Heat from the Kidneys. – KI-13 nourishes the Kidneys and strengthens the Penetrating Vessel. – KI-10 nourishes Kidney-Yin. – LU-7 and KI-6 regulate the Directing Vessel and nourish Yin. Herbal treatment
a Prescription
– ZUO GUI WAN and ER ZHI WAN Variation – Restoring the Left [Kidney] Pill and Two Solstices Pill Variation Explanation This formula nourishes Kidney-Yin. – Niu Xi has been removed from the original prescription as it pulls Qi downwards and is therefore not suitable for uterine bleeding. – Nu Zhen Zi and Han Lian Cao form the prescription Er Zhi Wan which nourishes Kidney-Yin and clear Empty-Heat. Han Lian Cao also stops bleeding. Other herbs in the original prescription make it suitable to stop bleeding:
Shan Zhu Yu is astringent and will help to stop bleeding and Lu Jiao Jiao and Gui Ban Jiao calm Blood and stop bleeding. b. Prescription
– LIANG DI TANG and ER ZHI WAN – Two ‘Di’ Decoction and Two Solstices Pill Explanation These two formulae are selected if the symptoms of Empty-Heat are pronounced, i.e. feeling of heat in the evening, malar flush, hot flushes and Red tongue without any coating. The first six herbs constitute Liang Di Tang and the last two Er Zhi Wan. – Sheng Di Huang and Di Gu Pi cool Blood, clear Empty-Heat and nourish Yin. They both also stop bleeding. Sheng Di also calms Blood. – Xuan Shen and Mai Men Dong help the first two herbs to nourish Yin. – Bai Shao and E Jiao nourish Blood, which helps to nourish Yin. Bai Shao is also astringent and calms Blood. – Nu Zhen Zi and Han Lian Cao nourish Yin and clear Empty-Heat. Han Lian Cao also stops bleeding. c. Prescription
– BU SHEN FANG13
– Tonifying the Kidneys Formula Explanation
– Sheng Di Huang, Xuan Shen, Bai Shao, Nu Zhen Zi and Gui Ban nourish Kidney-Yin and consolidate the Directing and Penetrating Vessels. – Di Gu Pi, Han Lian Cao and Mu Dan Pi clear Empty-Heat and stop bleeding. – Huang Qin and Dong Gua Ren resolve Dampness. This formula is suitable if the deficiency of Yin is pronounced and is accompanied by Empty-Heat and some Damp-Heat. d. Prescription
– YU YIN ZHI BENG TANG14 – Generating Yin and Stopping Flooding Decoction Explanation
– Sheng Di Huang, Shan Yao, Bai Shao, Shan Zhu Yu and Gui Ban nourish Kidney-Yin and consolidate the Directing and Penetrating Vessels. – Xu Duan and Du Zhong consolidate the Governing Vessel: they are added to the formula even though they tonify Yang, in order to consolidate the Governing Vessel to stop bleeding. – Sang Ji Sheng and E Jiao nourish Blood. E Jiao also stops bleeding.
– Hai Piao Xiao and Mu Li are absorbent and stop bleeding. – Di Yu cools Blood and stops bleeding. – Pu Huang invigorates Blood and stops bleeding. This formula is suitable when the deficiency of Kidney-Yin is accompanied by that of Kidney-Yang and when there is some Blood-Heat. Women’s Treasure remedy
– NOURISH YIN AND RESTRAIN THE FLOW This remedy is a variation of the formula Zuo Gui Wan Restoring the Left [Kidney] Pill which nourishes Kidney-Yin. It has been modified with the addition of herbs to stop bleeding. The tongue presentation appropriate to this remedy is a Red body without coating. Summary Kidney-Yin deficiency
Clinical manifestations
Trickling of blood after the period proper, late cycle, fresh, red and watery blood, dizziness, tinnitus, weak knees, feeling of heat in the evening, night sweating, hot flushes, malar flush, mental restlessness. Tongue: without coating; also Red if there is Empty-Heat. Pulse: Floating-Empty. Treatment principle
Nourish Yin, strengthen the Kidneys, stop bleeding.
Acupuncture
Ren-6 Qihai, BL-23 Shenshu, Ren-4 Guanyuan, KI-3 Taixi, ST-36 Zusanli, SP-6 Sanyinjiao, KI-2 Rangu, KI-13 Qixue, KI-10 Yingu, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left). Reinforcing method on all points except KI-2 which should be needled with even method. No moxa. Herbal treatment
Pre scriptions
• ZUO GUI WAN and ER ZHI WAN Variation Restoring the Left [Kidney] Pill and Two Solstices Pill Variation • LIANG DI TANG and ER ZHI WAN Two ‘Di’ Decoction and Two Solstices Pill • BU SHEN FANG Tonifying the Kidneys Formula • YU YIN ZHI BENG TANG Generating Yin and Stopping Flooding Decoction Women’s Treasure remedy
• NOURISH YIN AND RESTRAIN THE FLOW
Case history A 39-year-old woman had been suffering from very heavy periods for 8 years, following the birth of her third child. The periods started with a flood, they lasted up to 10 days and the blood was bright red. There was no pain and the cycle was regular. She felt always very tired and she often sweated at night especially during her periods. She often felt thirsty. She also had a lower
backache and occasionally tinnitus. Her tongue was slightly Red, cracked and without coating in places, especially in the front right side and towards the root on the left. Her pulse was Rapid and Overflowing but Empty. Diagnosis This is a complex condition. The excessive menstrual bleeding is caused by three factors: deficient Spleen-Qi and Kidney-Yin failing to hold Blood, and Empty-Heat agitating Blood. The Spleen-Qi deficiency is evidenced by the tiredness and by the bleeding in a sudden flood (bleeding from Kidney-Yin deficiency only would be a trickle at the end of the period). The Kidney-Yin deficiency is evident from the backache, tinnitus, thirst and night sweating. The Empty-Heat is evident from the Red colour of the tongue without coating and the Rapid and Overflowing-Empty pulse. Treatment principle The treatment principle adopted was to tonify Spleen-Qi, nourish KidneyYin, clear Empty-Heat and stop bleeding. This patient was treated only with acupuncture. Acupuncture
The points used (with reinforcing method except for those to clear EmptyHeat which were needled with even method) were selected from the following: • LU-7 Lieque and KI-6 Zhaohai to regulate the Directing Vessel and tonify the Uterus. • Ren-6 Qihai, Ren-12 Zhongwan, ST-36 Zusanli and SP-6 Sanyinjiao to tonify Spleen-Qi.
• Du-20 Baihui to raise Qi in order to hold Blood. • KI-3 Taixi to nourish Kidney-Yin. • KI-2 Rangu to clear Empty-Heat. • SP-8 Diji, Accumulation point, to stop uterine bleeding. • BL-20 Pishu and BL-23 Shenshu to tonify Spleen and Kidneys.
This patient was treated once a week for the 2 weeks after her period and twice a week for the 2 weeks before her period. The period started to decrease in amount after 2 months and after 6 months it went back to normal.
Complex patterns In Flooding and Trickling, complex conditions are very common because of the very nature of this condition. In fact, due to the close relationships between Qi and Blood and that between Blood and Yin, one pathology may lead to another. For example, Qi deficiency may cause bleeding but prolonged loss of blood may cause also deficiency of Blood, which, in turn, will aggravate the Qi deficiency. On the other hand, prolonged loss of blood may induce Yin deficiency because Blood pertains to Yin. In bleeding from Qi deficiency, the prolonged deficiency of Qi may also cause stagnation of Qi, while a prolonged Blood deficiency induced by the bleeding itself may cause also Blood stasis. Generally speaking, most complex conditions can be treated with one of the formulae discussed above, opportunely modified. For example, if prolonged bleeding from Qi deficiency gives rise to Blood deficiency, one can simply add Blood tonics to the formula used; if Blood deficiency, in turn, causes Yin deficiency, one adds some Yin tonics. If there is also stagnation of Qi or stasis of Blood in bleeding from Qi deficiency, one simply adds some herbs to move Qi or invigorate Blood; and so forth. Complex conditions may be classified in three groups: 1. Combined Full with Full. 2. Combined Empty with Empty. 3. Combined Empty with Full. The following formulae are mere examples of prescriptions used in complex conditions and many others could also be used.
Full with Full
Blood stasis and Blood-Heat
Treatment principle
Clear Heat, invigorate Blood, eliminate stasis. Prescription
– SHI XIAO SAN Variation – Breaking into a Smile Powder Variation Explanation
– Pu Huang and Wu Ling Zhi invigorate Blood and stop bleeding. – Dang Gui invigorates and nourishes Blood. – Mu Dan Pi cools and invigorates Blood. – Yi Mu Cao invigorates Blood. – Ma Bian Cao clears Heat and invigorates Blood.
Empty with Empty
Qi and Yin deficiency
Treatment principle
Benefit Qi and nourish Yin. Prescription
– BAO YIN JIAN Variation – Protecting the Yin Decoction Variation Explanation
– Sheng Di Huang nourishes Yin and stops bleeding. – Shu Di Huang nourishes Blood (which helps to nourish Yin) and tonifies the Kidneys. – Shan Yao and Tai Zi Shen nourish Stomach-Yin. – Xu Duan strengthens the Kidneys and the Uterus and consolidates the Directing and Penetrating Vessels. – Gan Cao harmonizes.
– Di Yu cools Blood and stops bleeding. – Huang Qi and Huang Jing tonify Qi. Huang Jing tonifies also the Yin and the Essence. – Gui Ban nourishes Yin and strengthens the Directing and Penetrating Vessels.
Empty with Full
Qi deficiency, Kidney-Yang deficiency and stasis of Blood
Treatment principle
Tonify Kidney-Yang, benefit Qi, invigorate Blood and eliminate stasis. Prescription
– SHI XIAO SAN Variation – Breaking into a Smile Powder Variation Explanation
– Pu Huang and Wu Ling Zhi invigorate Blood and stop bleeding. – Dang Gui, Chi Shao and Yi Mu Cao invigorate Blood and eliminate stasis. – Huang Qi, Dang Shen and Huang Jing tonify Qi. Huang Jing also nourishes the Essence. – Xu Duan, Du Zhong and Lu Rong tonify and warm Kidney-Yang, strengthen the Uterus, nourish the Essence and consolidate the Governing, Directing and Penetrating Vessels.
Ancient acupuncture prescriptions for Flooding and Trickling15
1. LIV-3 Taichong for Flooding and Trickling; or SP-10 Xuehai for Flooding and Trickling with a feeling of distension from rebellious Qi (ABC of Acupuncture, Zhen Jiu Jia Yi Jing, AD 259). 2. KI-8 Jiaoxin, KI-10 Yingu, LIV-3 Taichong and SP-6 Sanyinjiao for persistent Flooding and Trickling (Experience of Acupuncture and Moxibustion, Zhen Jiu Zi Sheng Jing, 1220). 3. Ren-3 Zhongji and Zigong (extra point) for Flooding and Trickling; or LIV-3 Taichong and SP-6 Sanyinjiao; or Ren-6 Qiahi, LIV-1 Dadun, KI-10 Yingu, LIV-Taichong, KI-2 Rangu, SP-6 Sanyinjiao and Ren-3 Zhongji (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601). 4. LIV-3 Taichong, SP-10 Xuehai, KI-10 Yingu, KI-2 Rangu, SP-6 Sanyinjiao, BL-18 Ganshu and T.B.-6 Zhigou (Collection of Acupuncture and Moxibustion, Zhen Jiu Ji Cheng, 1874). 5. Ren-6 Qihai, LIV-1 Dadun, KI-10 Yingu, KI-2 Rangu, SP-6 Sanyinjiao and Ren-3 Zhongji (Miraculous Classic, Shen Ying Jing).
Prognosis and prevention Both acupuncture and herbs give good results in Flooding and Trickling. Treatment with herbs is slightly more successful especially for the deficiencytype conditions. The most difficult pattern to treat is that from Kidney-Yin deficiency and the easiest is that from Blood-Heat. In any case, Flooding and Trickling is not easy to treat and both the patient and the practitioner need to be patient: it may take several months to achieve results. Obviously, if the uterine bleeding has an organic cause such as carcinoma of the cervix or uterus, myoma or endometrial polyp, results will be much worse (see below). In the case of carcinoma of the cervix or uterus, the prognosis is the worst as, by the time bleeding appears, the carcinoma is quite advanced. Bleeding from myomas or polyps can be stopped but it will necessarily take much longer than in functional bleeding. As for prevention, any woman who has a tendency to, or has been cured of, Flooding and Trickling should take certain precautions. She should avoid overwork as this depletes the Kidneys and may lead to bleeding from Kidney-Qi not holding Blood, or from Kidney Empty-Heat agitating the Blood. It is also very important that she avoids excessive physical exercise and especially lifting as this weakens Spleen- and Kidney-Qi and can lead to bleeding from Qi not holding Blood. She should avoid excessive sexual activity as this also depletes the Kidneys and may lead to Flooding and Trickling in one of the two ways described above. In particular, she should avoid having sex the day immediately after the end of the period as this will trigger off the bleeding. She should abstain from spicy foods and alcohol (except occasionally) as these can create Blood-Heat which very easily causes bleeding. Finally, she should avoid emotional stress (if at all possible) as this may lead to Fire and therefore bleeding from Blood-Heat.
Western view Menorrhagia and metrorrhagia may be either functional or organic. In 50% of cases of objective menorrhagia, no pathology is found at hysterectomy.16 Practitioners of Chinese medicine need to be particularly aware of the possible organic causes of uterine bleeding, which are: • carcinoma of the cervix • endometriosis • carcinoma of the uterus • myomas • endometrial polyps.
Carcinoma of the cervix Carcinoma of the cervix is more common in women over 30. Bleeding is one of the first symptoms and it typically occurs in between periods. Bleeding may also be noticed after coitus, severe exertion or straining for defaecation. The contact bleeding after coitus or pelvic examination is especially characteristic. Unfortunately, by the time bleeding does occur, the disease is already quite advanced. Other symptoms may include a blood-tinged vaginal discharge and bladder irritability. The three symptoms and signs of sacral pain, unilateral lymphoedema and unilateral ureteral obstruction indicate a very advanced stage of the condition.
Endometriosis Endometriosis is discussed in detail in Chapter 65. Symptoms include painful periods with the pain radiating to the rectum or perineum, menorrhagia and dyspareunia (pain on intercourse). It is common to have Flooding and Trickling with endometriosis.
Carcinoma of the uterus Carcinoma of the uterus usually occurs after menopause with roughly 75% of women being post-menopausal, 15% perimenopausal and 10% still menstruating. This disease seems to be more common in women who have no children or only one child and also in women who are overweight or suffer from diabetes or hypertension. Abnormal uterine bleeding is the most important symptom of this disease often with a bloody vaginal discharge. In fact, this type of discharge and bleeding in a woman after the menopause should always be investigated and diagnosed by a gynecologist and never treated as just functional bleeding.
Myomas Myomas are the most common cause of prolonged or excessive menstrual bleeding. Between 20% and 25% of women over the age of 35 have myomas. They are usually painless and a mass would only be felt if the myoma is quite large. If the myoma is larger than about 2–3 cm, it is difficult for Chinese medicine to dissolve it. However, Chinese herbs and acupuncture can be effective to reduce or even stop excessive menstrual bleeding in the presence of very large myomas. Myoma is discussed in detail in Chapter 67.
Endometrial polyps Endometrial polyps cause bleeding only when they protrude into the cervical canal. Bleeding usually occurs in between periods and is scanty. Summary Western view
• Carcinoma of the cervix • Endometriosis • Carcinoma of the uterus • Myomas • Endometrial polyps
Clinical trials
Herbal treatment
A clinical study of Gu Chong Zhi Xue (Consolidate the Chong Mai and Stop Bleeding) decoction in treating anovulatory-dysfunctional uterine bleeding
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2006 26(2): 159–162. – Liu J X. – The Affiliated Hospital of Shandong University of TCM, Jinan, China. Objective
To observe the efficacy of Gu Chong Zhi Xue Decoction (GCZXD) in treating anovulatory-dysfunctional uterine bleeding caused by Qi deficiency and Blood stasis and to systematically explore the haemostatic mechanism of the decoction. Methods
Sixty patients were randomly divided into two groups: the treated group (n = 30) were treated by oral administration of GCZXD and the control group (n = 30), treated by oral administration of Yi Gong Zhi Xue Benefit the Uterus and Stop Bleeding liquid. The haemostatic effect of the treatment, improvements of clinical symptoms, thickness of the endometrium, prothrombin time (PT) and activated partial prothrombin time (APTT), serum level of Ca2+, endocrine hormone, levels of PGE2 and PGF2α in menstrual
blood serum, and contents of endometrial oestrogen receptor (ER) and progestin receptor (PR) before and after treatment were observed. Results
The total haemostatic effective rate of GCZXD was 93.3% in the treated group, which was significantly better than that in the control group (70.0%, P < 0.05). Significant differences were shown in improving clinical symptoms, the thickness of the endometrium, PT and APTT, serum level of Ca2+, endocrine hormone, levels of PGE2 and PGF2α in menstrual blood serum, and contents of endometrial ER and PR in the treated group compared with baseline levels and also when compared with the control group after treatment (P < 0.05). Conclusion
Gu Chong Zhi Xue decoction has a favourable haemostatic effect in treating dysfunctional uterine bleeding caused by Qi deficiency and Blood stasis, and it may also significantly improve the accompanying symptoms. A study on the clinical efficacy and mechanism of Xiao Yan Zhi Xue Resolve Inflammation and Stop Bleeding capsules in treating menorrhagia caused by intra-uterine device use
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2004 24(7): 605–609. – Ren J F, Qu Q H, Yu B, Liu Z. – Gynaecological and Obstetric Department, Second Hospital, Shanxi Medical University, Taiyuan, China.
Objective
To observe the efficacy and mechanism of Xiao Yan Zhi Xue capsules (XYZXC) in treating abnormal menorrhagia caused by intra-uterine devices (IUD). Methods
IUD users with menorrhagia were randomly divided into two groups, the XYZXC treated group and adrenosoem (AC-17) control group. A biopsy of endometrial tissue of the XYZXC treated group, at baseline and after treatment, was carried out and any morphologic changes in the tissue observed through optical and electron microscopes. Results
The total effective rate of the treated group versus the control group was 90.3% versus 43.5%, showing a significant difference (P < 0.01). Morphological examination of endometrial tissue showed the inflammation in the treated group abated after treatment as the contractible function of the helicine branches of the uterine artery improved. Conclusion
Xiao Yan Zhi Xue capsules have obvious anti- inflammatory and haemostatic effects. They have a marked effect in treating IUD-caused pre- and postmenstruation menorrhagia. The possible mechanism may be: (1) modulation of the synthesis of prostaglandin; (2) antagonization of the IUD-caused fibrinolytic hyperfunction; (3) promotion of the synthesis of endometrial tissue; and (4) increase of the contractility and activity of uterine smooth
muscle. The prevention and treatment with Huan-an powder of abnormal menstruation caused by intra-uterine device use
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 1994 14(6): 3402. – Liu R F. – Affiliated Hospital of Shandong College of TCM, Jinan, China. Objective
To observe the efficacy of Huan-an powder (HA) in preventing and treating abnormal menstruation caused by intra-uterine device (IUD) use. Methods
One-hundred and fifty-five women were allocated to one of two groups: group A was the prevention group (n = 70) and group B was the treatment group (n = 85) and both were given HA. Outcome measures were: changes in the menstrual cycle length, length of bleeding, amount of bleeding and haemoglobin levels. Results
In the prevention group, there were no obvious differences in the amounts of menstrual blood, menstrual period length, menstrual cycle length and haemoglobin before and after inserting the IUD (P > 0.05). In the treatment
group, of whom 30 had hypermenorrhoea, 30 had menostaxis and 25 had preceded menstrual cycle, the total effective rate was 90%, 93% and 88% respectively. The amount of the menstrual blood was significantly reduced, the menstrual period markedly shortened (P < 0.01), while the menstrual cycle was prolonged and haemoglobin significantly increased (P < 0.01). Conclusion
The results showed that Huan-an powder is effective in preventing and treating abnormal menstruation caused by IUD use, without any side effects and contraindications. End notes 1. 1979 The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen
), People’s Health Publishing House, Beijing, p. 56. First published c. 100 BC..
2. He Ren 1981 A New Explanation of the Synopsis of Prescriptions from the Golden Cabinet (Jin Gui Yao Lue Xin Jie
), Zhejiang Science Publishing House, P. 189. The Synopsis of Prescriptions from the Golden Cabinet was written by Zhang Zhong Jing c. AD200..
3. Shen Jin Hao 1774 Jade Rule of Gynaecology (Fu Ke Yu Chi) cited in Luo Yuan Kai 1986 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Shanghai Science and Technology Press, Shanghai, p. 69..
4. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian
), People’s Health Publishing House, Beijing, Vol. 3, p. 7. First published in 1742..
5. Chao Yuan Fang AD 610 General Treatise on the Aetiology and Symptoms of Diseases (Zhu Bing Yuan Hou Zong Lun) cited in Nanjing College of Traditional Chinese Medicine 1979 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Nanjing College of Traditional Chinese Medicine, Nanjing, p. 47..
6. Giovanni Maciocia 1994 The Practice of Chinese Medicine, Churchill Livingstone, Edinburgh, Chapter 30..
7. Kuang Yi Huang 1996 Invigorating Blood and Eliminating Stasis is the Basic Treatment Principle for Flooding and Trickling (Huo Xue Hua Yu Fa Shi Zhi Liao Beng Lou De Ji Ben Fa Ze) in Journal of Chinese Medicine (Zhong Yi Za Zhi
) 37(7): 402–403..
8. 1981 Spiritual Axis (Ling Shu Jing
), People’s Health Publishing House, Beijing, p. 153. First published c. 100 BC..
9. Heilongjiang Province National Medical Research Group 1984 An Explanation of the Great Compendium of Acupuncture (Zhen Jiu Da Cheng Jiao Shi
), People’s Health Publishing House, Beijing, p. 1107. The Great Compendium of Acupuncture itself was published in 1601..
10. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p. 11. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
11. Mei Jiang Han 1993 The Extraordinary Channel Chong Mai and its Clinical Applications. Journal of Chinese Medicine 43:27..
12. Hu Xi Ming 1990 Great Treatise of Secret Formulae in Chinese Medicine (Zhong Guo Zhong Yi Mi Fang Da Quan
), Culture Publishing House, Shanghai, Vol. 2, p. 158..
13. Ibid., p. 158..
14. Ibid., p. 156..
15. Wang Xue Tai 1995 Great Treatise of Chinese Acupuncture (Zhong Guo Zhen Jiu Da Quan
), Henan Science and Technology Publishing House, p. 455..
16. Ann McPherson 1993 Women’s Problems in General Practice, Oxford University Press, Oxford, pp 176–177..
CHAPTER 18 Pre-Menstrual Syndrome
AETIOLOGY 357 PATHOLOGY 358 IDENTIFICATION OF PATTERNS AND TREATMENT 358 FULL CONDITIONS 358 Liver-Qi stagnation 358 Liver-Heat 362 Liver-Qi stagnation with Phlegm 363 Lung-Qi stagnation with Phlegm 364 Heart-Heat 365 Phlegm-Fire harassing upwards 365 EMPTY CONDITIONS 369 Liver-Blood deficiency 369 Liver- and Kidney-Yin deficiency 371 Spleen- and Kidney-Yang deficiency 373 Ancient acupuncture prescription for Pre-Menstrual Syndrome 376 PROGNOSIS AND PREVENTION 376 WESTERN VIEW 376 Western treatment of Pre-Menstrual Syndrome 377 The term Pre-Menstrual Syndrome (PMS) broadly describes emotional
and physical symptoms occurring before a period. These may include depression, sadness, irritability, anxiety, lethargy, loss of concentration, aggressiveness, changes in libido, changes in bowel habit, skin eruptions, food cravings, crying, propensity to outbursts of anger, clumsiness, distension of abdomen and breasts, and insomnia. These symptoms can vary in intensity from very mild to extremely serious; a woman suffering severe Pre-Menstrual Syndrome may actually injure a member of her family or some other person. The symptoms vary in duration as well as in intensity, ranging from 1 day to 2 weeks before the period. Rarely, these symptoms may be experienced after the period. Pre-Menstrual Syndrome is more common in the 30–40 age group.
Aetiology
Emotional strain Emotional strain is the most important aetiological factor for Pre-Menstrual Syndrome. Anger, worry, guilt, frustration and resentment may all, in the long run, cause stagnation of Liver-Qi which is a major cause of Pre-Menstrual Syndrome. Liver-Qi should move in phase 4: the movement of Liver-Qi moves the Blood in preparation for the period. When Liver-Qi stagnates, its influence is felt most in phase 4 (i.e. the pre-menstrual phase), hence the premenstrual symptoms. Prolonged stagnation of Liver-Qi may also give rise to Liver-Heat which may cause pre-menstrual symptoms in itself: when there is Heat, there will be more irritability and anxiety. Irregular diet Excessive consumption of dairy products and greasy foods leads to the formation of Phlegm. Phlegm easily combines with Qi stagnation to cause pre-menstrual symptoms: when there is Phlegm, the breasts will be particularly distended and swollen. If stagnation of Liver-Qi leads to Heat, this combines with Phlegm to form Phlegm-Fire which accumulates in the chest and breasts and obstructs the Mind’s orifices. This results in breast distension and swelling, a feeling of oppression in the chest and severe mental changes. In severe cases, PhlegmFire obstructs the Mind’s orifices and may lead to more serious mental– emotional disturbances, verging on psychotic behaviour. Overwork
Overwork weakens Kidney- and Liver-Yin and when these are deficient they can cause stagnation of Liver-Qi. In this case, the stagnation of Liver-Qi is secondary to Liver- and Kidney-Yin deficiency.
Pathology In order to understand the pathology of Pre-Menstrual Syndrome, we must recall the physiology and pathology of phase 4 (i.e. the pre-menstrual phase). During phase 4, Liver-Qi moves in preparation for the period and Yang rises to reach a maximum just before the onset of the period. This means that excess of Yang may also give rise to pre-menstrual symptoms and so can deficiency of Yang. As for the organs involved, the Liver is not the only organ causing premenstrual symptoms. Other organs may be involved and especially the Lungs, Heart, Spleen and Kidneys. For example, pre-menstrual symptoms may be due to Heat in the Heart or Lungs, or to Lung-Qi stagnation. Deficiency of Yang of the Spleen and Kidneys may also cause pre-menstrual symptoms. In my opinion, Liver-Qi stagnation is grossly overemphasized as a cause of pre-menstrual symptoms and, as a consequence, Xiao Yao San Free and Easy Wanderer Powder is overused. To summarize, the following are the main pathological conditions causing Pre-Menstrual Syndrome together with the clinical manifestations: • Liver-Qi stagnation: breast and abdominal distension, irritability, depression. • Lung-Qi stagnation: breast distension, sighing, crying. • Liver-Heat: irritability, anxiety, depression, propensity to outbursts of anger. • Heart-Heat: irritability, anxiety, insomnia. • Spleen- and Kidney-Yang deficiency: depression, crying, tiredness. • Phlegm: swelling and discomfort of the breasts. The most important thing to establish is whether the Pre-Menstrual
Syndrome derives from a Full or Empty condition. In case of Liver-Qi stagnation, if it arises independently from emotional problems it is a purely Full condition. In this case, the pulse will be Wiry, either in all positions or only on the left. If it is secondary to a deficiency of Liver-Blood, Liver-Yin or Liver- and Kidney-Yin, the condition is primarily Empty. In such a case, the pulse will be Fine and Weak, at least on one side. In women, Liver-Qi stagnation often derives from Liver-Blood or Liver-Yin deficiency. In fact, Liver-Qi and Liver-Blood/Yin are the Yang and Yin aspects of the Liver. Liver-Blood and Liver-Yin are the root and the material basis of Liver-Qi. If Liver-Blood/Yin are deficient, Liver-Qi is deprived of its root and stagnates.
Identification of patterns and treatment
Full conditions
Liver-Qi stagnation
Clinical manifestations
Abdominal and breast distension before the period, irritability, clumsiness, moodiness, depression, hypochondrial pain and distension. Tongue: in light cases, the tongue body may be unchanged. In chronic cases, the sides may be Red. Pulse: Wiry all over or only on the left. Treatment principle Soothe the Liver, eliminate stagnation, calm the Mind, settle the Ethereal Soul. Acupuncture LIV-3 Taichong, G.B.-34 Yanglingquan, G.B.-41 Zulinqi, SP-6 Sanyinjiao, T.B.-6 Zhigou, P-6 Neiguan. Reducing or even method. Explanation
– LIV-3 and G.B.-34 soothe the Liver and eliminate stagnation. G.B.-34 specifically treats the hypochondrial region. – G.B.-41 is used if the breast distension is very pronounced and the
breasts are also painful. – SP-6 helps to soothe the Liver and calm the Mind. – T.B.-6 moves Liver-Qi and affects the lateral side of the upper body. – P-6 moves Liver-Qi, calms the Mind and settles the Ethereal Soul. It also affects the chest and breasts and is a very important point for this condition. Herbal treatment
a Prescription
– XIAO YAO SAN – Free and Easy Wanderer Powder Explanation This formula, which has already been explained, is very widely used for PreMenstrual Syndrome from Liver-Qi stagnation. It is especially suitable if there is a deficiency of Liver-Blood and the pulse is not too Wiry. It is particularly effective for distension of the breasts. b Prescription
– YUE JU WAN
– Gardenia-Chuanxiong Pill Explanation This formula is selected if the stagnation of Qi is more intense, there is some Heat and the pulse is definitely Wiry in all positions. Very effective for emotional depression, it was devised by Zhu Dan Xi (1281–1358) for mental depression. It contains five herbs for the ‘Six Stagnations’, i.e. stagnation of Qi, Blood, Food, Heat, Dampness and Phlegm. However, it is primarily for Qi stagnation. – Xiang Fu, the Emperor herb, resolves stagnation of Qi. – Cang Zhu resolves stagnation of Dampness and Phlegm. – Chuan Xiong resolves stasis of Blood. – Shan Zhi Zi resolves stagnation of Heat. – Shen Qu resolves stagnation of Food. c Prescription
– CHAI HU SHU GAN TANG – Bupleurum Pacifying the Liver Decoction Explanation This formula, already explained, is selected if the stagnation of Liver-Qi is severe and there is breast and abdominal pain as well as distension. Table 18.1 compares and contrasts the above three formulae for Pre-Menstrual
Syndrome from Qi stagnation. Table 18.1 Comparison of Xiao Yao San, Yue Ju Wan and Chai Hu Shu Gan Tang for Pre-Menstrual Syndrome
Modifications The following are variations applying to all three previous formulae. • If the breast distension is very pronounced, add Qing Pi Pericarpium Citri reticulatae viride and Yu Jin Radix Curcumae. • If abdominal distension is pronounced, add (or increase) Xiang Fu Rhizoma Cyperi. • If there is mental depression, add He Huan Pi Cortex Albiziae and Yuan Zhi Radix Polygalae. • If there is irritability and propensity to outbursts of anger, add Suan Zao Ren Semen Ziziphi spinosae. • If there is irritability, restlessness and insomnia, add Long Chi Fossilia
Dentis mastodi and Zhen Zhu Mu Concha Margaritiferae usta. • If there is insomnia and anxiety from Blood deficiency, add Long Yan Rou Arillus Longan and Bai Zi Ren Semen Platycladi. • If there is a headache before each period, add Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus Uncariae cum Uncis and Fang Feng Radix Saposhnikoviae. • If there is pronounced water retention, add Zhu Ling Polyporus, Yi Yi Ren Semen Coicis, Ze Xie Rhizoma Alismatis and Gui Zhi Ramulus Cinnamomi. • If stagnant Liver-Qi has given rise to Heat, add Shan Zhi Zi Fructus Gardeniae and Mu Dan Pi Cortex Moutan. • If there is stasis of Blood, add Wang Bu Liu Xing Semen Vaccariae, Yu Jin Radix Curcumae and Dan Shen Radix Salviae miltiorrhizae. • If the breasts are swollen and hot (or if there is mastitis), add Xia Ku Cao Spica Prunellae and Pu Gong Ying Herba Taraxaci. • If there are skin eruptions, add Bai Xian Pi Cortex Dictami. • If the breasts are painful, add Mo Yao Myrrha. Women’s Treasureremedies
– FREEING THE MOON This remedy is a variation of Xiao Yao San Free and Easy Wanderer Powder: it nourishes Liver-Blood, pacifies the Liver, moves Qi, calms the Mind and settles the Ethereal Soul. The tongue presentation appropriate to this remedy is either a normal-coloured or a Pale tongue body: it may also be
Pale only on the sides. The pulse corresponding to this remedy is Choppy or Fine and slightly Wiry on one side only (typically the left side). – FREEING CONSTRAINT This remedy is a variation of the formula Yue Ju Wan GardeniaChuanxiong Pill which pacifies the Liver, moves Qi and eliminates stagnation. The tongue presentation appropriate to this remedy is a body with Red sides: the whole body might be Red as well. The pulse appropriate to this remedy is Wiry on all positions. The difference in action and indications between this remedy and Freeing the Moon is the same as that between Yue Ju Wan and Xiao Yao San indicated above. Summary Liver-Qi stagnation
Clinical manifestations
Abdominal and breast distension before the period, irritability, clumsiness, moodiness, depression, hypochondrial pain and distension. Tongue: in light cases, the tongue body may be unchanged. In chronic cases, the sides may be Red. Pulse: Wiry all over or only on the left. Treatment principle
Soothe the Liver, eliminate stagnation, calm the Mind, settle the Ethereal Soul. Acupuncture
LIV-3 Taichong, G.B.-34 Yanglingquan, G.B.-41 Zulinqi, SP-6 Sanyinjiao, T.B.-6 Zhigou, P-6 Neiguan. Reducing or even method.
Herbal treatment
Pre scriptions
• XIAO YAO SANFree and Easy Wanderer Powder • YUE JU WANGardenia-Chuanxiong Pill • CHAI HU SHU GAN TANGBupleurum Pacifying the Liver Decoction Women’s Treasure remedies
• FREEING THE MOON • FREEING CONSTRAINT
Case history A 38-year-old woman had been suffering from pre-menstrual tension for 10 years, starting after the birth of her first child; the problem got worse after the birth of the second child. For 1 week before the periods she experienced irritability, aggressiveness, anger, and abdominal and breast distension. Her cycle was often short, the period lasted 5 days and the menstrual blood was dark red without clots. She often felt hot and frequently had lower backache. Her tongue was slightly Red and her pulse was Weak on the left Rear position and slightly Wiry in general. Diagnosis This is a clear case of Liver-Qi stagnation with some Heat, occurring against a background of Kidney deficiency (weak Kidney pulse and backache). The Heat is evident from the slightly Red colour of the tongue body and the
feeling of heat. Treatment principle The treatment principle adopted was to pacify the Liver, clear Liver-Heat, move Qi, calm the Mind, settle the Ethereal Soul and tonify the Kidneys. She was treated with both acupuncture and herbs. Acupuncture
The points used were selected from the following: • LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to regulate the Directing Vessel and move Qi. • P-6 Neiguan, with even method, to pacify the Liver, calm the Mind and settle the Ethereal Soul. • LIV-3 Taichong, with reducing method, to pacify the Liver, move Qi and settle the Ethereal Soul. • KI-3 Taixi to tonify the Kidneys (with reinforcing method).
It is not necessary to use any points to clear Heat when this derives from Qi stagnation. Herbal treatment
The formula used was a variation of Dan Zhi Xiao Yao San MoutanGardenia Free and Easy Wanderer Powder: • Shan Zhi ZiFructus Gardeniae 4.5 g • Mu Dan PiCortex Moutan 4.5 g • Bo HeHerba Menthae haplocalycis 3 g • Chai HuRadix Bupleuri 6 g
• Dang GuiRadix Angelicae sinensis 6 g • Bai ShaoRadix Paeoniae alba 6 g • Bai ZhuRhizoma Atractylodis macrocephalae 6 g • Fu LingPoria 6 g • Yuan ZhiRadix Polygalae 6 g • Suan Zao RenSemen Ziziphi spinosae 4.5 g • Tu Si ZiSemen Cuscutae 6 g • He Huan PiCortex Albiziae 6 g • Zhi Gan CaoRadix Glycyrrhizae preparata 3 g
Explanation The first eight herbs constitute the formula Dan Zhi Xiao Yao San which clears Liver-Heat deriving from Liver-Qi stagnation. • Yuan Zhi, Suan Zao and He Huan Pi were added to pacify the Liver, calm the Mind and settle the Ethereal Soul. • Tu Si Zi was added to tonify the Kidneys.
This patient was treated with variations of this formula for about 5 months after which her pre-menstrual tension disappeared nearly completely. Case history A 19-year-old woman had been suffering from pre-menstrual tension ever since her menarche at 14. For about 1 week before the period she felt very irritable and depressed and had severe abdominal and breast distension. During this time she also experienced papular skin eruptions on her face. Her periods were regular, lasted 7 days but were not too heavy. She felt hot in
general and thirsty. She also experienced headaches on the temples and her eyes were blood-shot. Her tongue was slightly Red with a redder tip and with many Red points on the sides and tip. Her pulse was very Rapid (100). Diagnosis This is another example of Pre-Menstrual Syndrome from stagnant Liver-Qi turning into Heat: in this case, the Heat symptoms and signs are more pronounced as the tongue shows clearly. Also, the Heat has affected the Heart as well as the Liver (the Red tip of the tongue shows this). Treatment principle The treatment principle adopted was to pacify the Liver, clear Liver-Heat, move Qi, clear Heart-Fire, calm the Mind and settle the Ethereal Soul. She was treated only with herbal medicine as she did not like the idea of needles. Herbal treatment
The prescription used was a variation of Dan Zhi Xiao Yao San MoutanGardenia Free and Easy Wanderer Powder: • Mu Dan PiCortex Moutan 4.5 g • Shan Zhi ZiFructus Gardeniae 4.5 g • Bo HeHerba Menthae haplocalycis 3 g • Chai HuRadix Bupleuri 6 g • Dang GuiRadix Angelicae sinensis 6 g • Bai ZhuRhizoma Atractylodis macrocephalae 6 g • Fu LingPoria 6 g
• Bai ShaoRadix Paeoniae alba 6 g • Gan CaoRadix Glycyrrhizae uralensis 3 g • Suan Zao RenSemen Ziziphi spinosae 4.5 g • Yuan ZhiRadix Polygalae 6 g • Qing PiPericarpium Citri reticulatae viride 4.5 g • Xia Ku CaoSpica Prunellae 4.5 g
Explanation The first nine herbs constitute the formula Dan Zhi Xiao Yao San which pacifies the Liver, moves Qi and clears Liver-Heat. • Suan Zao Ren and Yuan Zhi were added to calm the Mind and settle the Ethereal Soul. These two herbs combine well because the former is sour and absorbing and the latter pungent and somewhat scattering. • Qing Pi moves Liver-Qi. • Xia Ku Cao clears Liver-Heat and affects the breasts.
This young woman experienced a reduction in her pre-menstrual tension after 2 months of taking this formula. She is still being treated at the time of writing. Case history A 27-year-old woman had been suffering from pre-menstrual tension for 13 years (more or less ever since her menarche). She had two children and the pre-menstrual tension became worse after each birth. Her main symptoms were abdominal distension, severe irritability, anger and aggressiveness. She had been given a progesterone pill but this had not helped and had only given her headaches. Her periods were regular, lasted 4
days and were heavy; the menstrual blood was bright red. She also suffered from constipation and, on interrogation, it transpired that she experienced backache and dizziness, she often felt cold, she had cold feet and her urination was frequent and pale. She did not sleep well and occasionally experienced some tingling of her limbs. Her tongue was Pale and slightly Thin with teethmarks. Her pulse was Wiry. Diagnosis The main pattern at the root of the pre-menstrual tension is Liver-Qi stagnation manifesting with the typical pre-menstrual symptoms and a Wiry pulse. This occurred against a background of Kidney-Yang deficiency (feeling cold, cold feet, frequent urination, backache, dizziness) and some Blood deficiency (insomnia, tingling and a Pale-Thin tongue). Treatment principle The main emphasis should be on pacifying the Liver, moving Qi and calming the Mind. However, one should also attend to the deficiency by tonifying Kidney-Yang and nourishing Blood. She was treated with acupuncture and herbal remedies. Acupuncture
The points used were selected from the following, using even method on the points to pacify the Liver and reinforcing method on those to tonify the Kidneys and nourish Blood: • L.I.-4 Hegu to calm the Mind and regulate the ascending and descending of Qi. This will help the distension caused by the stagnation of Qi. • P-6 Neiguan to pacify the Liver, calm the Mind and settle the Ethereal Soul. • Ren-15 Jiuwei to calm the Mind and free the chest and breasts.
• SP-6 Sanyinjiao to pacify the Liver, move Qi and Blood and calm the Mind. • LIV-3 Taichong to pacify the Liver, move Qi and settle the Ethereal Soul. • KI-3 Taixi, with warm needle, to tonify Kidney-Yang. Herbal treatment
I prescribed the Three Treasures remedies Strengthen the Root to tonify Kidney-Yang (to be taken for about 12 days after the period) and Freeing the Moon to pacify the Liver and move Qi (to be taken for about 12 days before the period). After 3 months of treatment (with fortnightly acupuncture sessions), her pre-menstrual tension was very much reduced. This patient is still under treatment at the time of writing.
Liver-Heat
Clinical manifestations Pre-menstrual tension, irritability, anxiety, agitation, depression, abdominal and breast distension, thirst, feeling of heat, red eyes, headache, dizziness. Tongue: Red sides. Pulse: Wiry-Rapid. This is a condition of Liver-Heat deriving from longstanding Liver-Qi stagnation. Treatment principle Move Qi, pacify the Liver, clear Liver-Heat, calm the Mind, settle the Ethereal Soul. Acupuncture LIV-3 Taichong, G.B.-34 Yanglingquan, G.B.-41 Zulinqi, SP-6 Sanyinjiao, T.B.-6 Zhigou, P-6 Neiguan, LIV-2 Xingjian, P-7 Daling. Reducing or even method. Explanation
– LIV-3 and G.B.-34 soothe the Liver and eliminate stagnation. G.B.-34 specifically treats the hypochondrial region. – G.B.-41 is used if the breast distension is very pronounced and the breasts are also painful.
– SP-6 helps to soothe the Liver and calm the Mind. – T.B.-6 moves Liver-Qi and affects the lateral side of the upper body. – P-6 moves Liver-Qi, calms the Mind and settles the Ethereal Soul. It also affects the chest and breasts and is a very important point for this condition. – LIV-2 clears Liver-Heat. – P-7 calms the Mind and settles the Ethereal Soul. Herbal treatment
Prescription
– DAN ZHI XIAO YAO SAN Variation – Moutan-Gardenia Free and Easy Wanderer Powder Variation Explanation
– The root formula moves Liver-Qi and clears Liver-Heat. – Qing Pi and Xiang Fu move Liver-Qi. – Suan Zao Ren calms the Mind and settles the Ethereal Soul. Women’s Treasure remedy
– FREEING THE SUN This remedy is a variation of Dan Zhi Xiao Yao San Moutan-Gardenia Free and Easy Wanderer Powder. Summary Liver-Heat
Clinical manifestations
Pre-menstrual tension, irritability, anxiety, agitation, depression, abdominal and breast distension, thirst, feeling of heat, red eyes, headache, dizziness. Tongue: Red sides. Pulse: Wiry-Rapid. Treatment principle
Move Qi, pacify the Liver, clear Liver-Heat, calm the Mind, settle the Ethereal Soul. Acupuncture
LIV-3 Taichong, G.B.-34 Yanglingquan, G.B.-41 Zulinqi, SP-6 Sanyinjiao, T.B.-6 Zhigou, P-6 Neiguan, LIV-2 Xingjian, P-7 Daling. Reducing or even method. Herbal treatment
Pre scription
• DAN ZHI XIAO YAO SAN Variation Moutan-Gardenia Free and Easy Wanderer Powder Variation Women’s Treasure remedy
• FREEING THE SUN
Liver-Qi stagnation with Phlegm
Clinical manifestations Premenstrual tension, irritability, depression, crying, sadness, worry, swollen, distended and painful breasts, abdominal distension, a feeling of oppression or tightness of the chest, slight breathlessness, sighing, expectoration of sputum in the mornings, possibly benign breast lumps. Tongue: Swollen, sticky coating. Pulse: Wiry-Slippery. Treatment principle Move Qi, pacify the Liver, resolve Phlegm, tonify the Spleen. Acupuncture LIV-3 Taichong, G.B.-34 Yanglingquan, G.B.-41 Zulinqi, SP-6 Sanyinjiao, T.B.-6 Zhigou, P-6 Neiguan, Ren-12 Zhongwan, Ren-9 Shuifen, ST-28 Shuidao, BL-22 Sanjiaoshu, ST-40 Fenglong. Reducing or even method except Ren-12 which should be reinforced. Explanation
– LIV-3 and G.B.-34 soothe the Liver and eliminate stagnation. G.B.-34 specifically treats the hypochondrial region. – G.B.-41 is used if the breast distension is very pronounced and the breasts are also painful.
– SP-6 helps to soothe the Liver and calm the Mind. – T.B.-6 moves Liver-Qi and affects the lateral side of the upper body. – P-6 moves Liver-Qi, calms the Mind and settles the Ethereal Soul. It also affects the chest and breasts and is a very important point for this condition. – Ren-12, Ren-9, ST-28, BL-22 and ST-40 resolve Phlegm. Herbal treatment
Prescription
– WEN DAN TANG Variation – Warming the Gall Bladder Decoction Variation Explanation
– The root formula resolves Phlegm. – Qing Pi and Xiang Fu move Liver-Qi. – Yuan Zhi and Yu Jin move Qi and open the Mind’s orifices. – He Huan Pi and Mei Gui Hua move Liver-Qi and relieve depression. Women’s Treasureremedy
– CLEAR THE MOON This remedy moves Qi, calms the Mind, settles the Ethereal Soul and resolves Phlegm. Summary Liver-Qi stagnation with Phlegm
Clinical manifestations
Pre-menstrual tension, irritability, depression, crying, sadness, worry, swollen, distended and painful breasts, abdominal distension, a feeling of oppression or tightness of the chest, slight breathlessness, sighing, expectoration of sputum in the mornings, possibly benign breast lumps. Tongue: Swollen, sticky coating. Pulse: Wiry-Slippery. Treatment principle
Move Qi, pacify the Liver, resolve Phlegm, tonify the Spleen. Acupuncture
LIV-3 Taichong, G.B.-34 Yanglingquan, G.B.-41 Zulinqi, SP-6 Sanyinjiao, T.B.-6 Zhigou, P-6 Neiguan, Ren-12 Zhongwan, Ren-9 Shuifen, ST-28 Shuidao, BL-22 Sanjiaoshu, ST-40 Fenglong. Reducing or even method except Ren-12 which should be reinforced. Herbal treatment
Pre scription
• WEN DAN TANG Variation Warming the Gall Bladder Decoction Variation Women’s Treasure remedy
• CLEAR THE MOON
Lung-Qi stagnation with Phlegm
Clinical manifestations Pre-menstrual tension, worrying, crying, breast distension, sighing, depression, a feeling of tightness or oppression of the chest, expectoration of phlegm, obesity. Tongue: Swollen. Pulse: Slippery, slightly Tight on the Lung position. Treatment principle Move Lung-Qi, restore the descending of Lung-Qi, resolve Phlegm, calm the Mind. Acupuncture LU-7 Lieque, L.I.-4 Hegu, Ren-17 Shanzhong, HE-7 Shenmen, P-6 Neiguan, Ren-12 Zhongwan, Ren-9 Shuifen, ST-28 Shuidao, BL-22 Sanjiaoshu, ST-40 Fenglong. All with reducing or even method except Ren12 which should be reinforced. Explanation
– LU-7, L.I.-4 and Ren-17 move Lung-Qi and restore the descending of Lung-Qi. – HE-7 and P-6 move Lung-Qi and calm the Mind. – Ren-12, Ren-9, ST-28, BL-22 and ST-40 resolve Phlegm.
Herbal treatment
Prescription
– BAN XIA HOU PO TANG Variation – Pinellia-Magnolia Decoction Variation Explanation
– The root formula moves Lung- and Heart-Qi and calms the Mind. – Bai He moves Lung-Qi, restores the descending of Lung-Qi, calms the Mind, settles the Corporeal Soul and treats sadness. – Chen Pi and Gua Lou resolve Phlegm. – He Huan Pi calms the Mind, settles the Ethereal Soul and treats depression. Three Treasures remedy
– OPEN THE HEART This remedy is a variation of Ban Xia Hou Po Tang Pinellia-Magnolia Decoction. Summary
Lung-Qi stagnation with Phlegm
Clinical manifestations
Pre-menstrual tension, worrying, crying, breast distension, sighing, depression, a feeling of tightness or oppression of the chest, expectoration of phlegm, obesity. Tongue: Swollen. Pulse: Slippery, slightly Tight on the Lung position. Treatment principle
Move Lung-Qi, restore the descending of Lung-Qi, resolve Phlegm, calm the Mind. Acupuncture
LU-7 Lieque, L.I.-4 Hegu, Ren-17 Shanzhong, HE-7 Shenmen, P-6 Neiguan, Ren-12 Zhongwan, Ren-9 Shuifen, ST-28 Shuidao, BL-22 Sanjiaoshu, ST-40 Fenglong. All with reducing or even method except Ren12 which should be reinforced. Herbal treatment
Pre scription
• BAN XIA HOU PO TANG Variation Pinellia-Magnolia Decoction Variation Three Treasures remedy
• OPEN THE HEART
Heart-Heat
Clinical manifestations Pre-menstrual tension, irritability, anxiety, insomnia, depression, agitation, thirst, a feeling of heat, tongue ulcers, palpitations. Tongue: Red tip. Pulse: Rapid-Overflowing. Treatment principle Clear Heart-Heat, calm the Mind. Acupuncture HE-7 Shenmen, Ren-15 Jiuwei, Du-24 Shenting, P-6 Neiguan, P-7 Daling. All with reducing or even method. Explanation
– HE-7 clears Heart-Heat and calms the Mind. – Ren-15 and Du-24 calm the Mind. – P-6 makes Heart-Qi descend. – P-7 calms the Mind. Herbal treatment
Prescription
– DAO CHI SAN Variation – Eliminating Redness Powder Variation Explanation
– The root formula clears Heart-Heat. I eliminate Mu Tong from it due to safety concerns (possible presence of aristolochic acid). – Huang Qin and Huang Lian clear Heart-Heat. – Suan Zao Ren, Deng Xin Cao and Lian Zi Xin clear Heat-Heat and calm the Mind. Summary Heart-Heat
Clinical manife stations
Pre-menstrual tension, irritability, anxiety, insomnia, depression, agitation, thirst, a feeling of heat, tongue ulcers, palpitations. Tongue: Red tip. Pulse: Rapid-Overflowing. Tre atme nt principle
Clear Heart-Heat, calm the Mind. Acupuncture
HE-7 Shenmen, Ren-15 Jiuwei, Du-24 Shenting, P-6 Neiguan, P-7 Daling. All with reducing or even method. He rbal tre atme nt
Prescription
• DAO CHI SAN Variation Eliminating Redness Powder Variation
Phlegm-Fire harassing upwards
Clinical manifestations Agitation, depression, slightly manic behaviour, aggressiveness, a feeling of oppression of the chest, a red face, blood-shot eyes. Tongue: Red with a sticky-yellow coating. Pulse: Overflowing-Slippery-Rapid. Treatment principle Clear Heat, resolve Phlegm, calm the Mind, settle the Ethereal Soul. Acupuncture P-7 Daling, ST-40 Fenglong, ST-8 Touwei, Du-24 Shenting, L.I.-11 Quchi, SP-9 Yinlingquan, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), Ren-12 Zhongwan, BL-20 Pishu. Reducing or even method on all except for Ren-12 and BL-20 which should be reinforced. Explanation
– P-7 and ST-40 resolve Phlegm and calm the Mind. – ST-8 and Du-24 calm the Mind and resolve Phlegm from the head. – L.I.-11 clears Heat. – SP-9 helps to resolve Phlegm. – SP-4 and P-6 regulate the Penetrating Vessel and subdue rebellious Qi.
Subduing Qi will help to resolve Phlegm which harasses upwards with rebellious Qi. – Ren-12 and BL-20 tonify the Spleen to resolve Phlegm. Special empirical treatment
If there is mastitis, which is especially likely to occur with this pattern, look for a bright red rash on the upper back between C-7 and D-12, with macular spots which do not stick out on touch, and which do not change colour on finger pressure. Prick all the spots with a triangular needle and bleed them slightly. Herbal treatment
a Prescription
– SHENG TIE LUO YIN – Frusta Ferri Decoction Explanation This formula clears Heat, resolves Phlegm and subdues Liver-Yang. It is appropriate in this case to treat the Liver because of the influence it has on the menstrual function. Phlegm harassing upwards is often associated with Liver-Yang or Liver-Wind rising. Note that the original formula contains Zhu Sha which is toxic (when used over a long period of time) and can be omitted without altering the action of the formula substantially: in fact, it is
there to open the Mind’s orifices, a function performed also by Shi Chang Pu and Yuan Zhi within the prescription. – Sheng Tie Luo subdues Liver-Yang. – Nan Xing and Bei Mu resolve Phlegm. – Xuan Shen, Tian Dong and Mai Dong nourish Yin. – Lian Qiao clears Heat. – Dan Shen enters the Pericardium and helps to subdue Liver-Yang, calm the Mind and settle the Ethereal Soul. – Fu Ling and Chen Pi help to resolve Phlegm. – Shi Chang Pu, Yuan Zhi and Zhu Sha calm the Mind and open the Mind’s orifices. Please note that Zhu Sha should be removed due to its toxicity. b Prescription
– WEN DAN TANG Variation – Warming the Gall Bladder Decoction Variation Explanation This formula resolves Phlegm-Heat from the chest area, calms the Mind and opens the Mind’s orifices. The first eight herbs constitute the formula Wen Dan Tang. – Qing Pi moves Liver-Qi and relieves breast distension.
– Xiang Fu moves Liver-Qi and relieves abdominal distension. – He Huan Pi moves Liver-Qi, subdues Liver-Yang, calms the Mind and lifts depression. Modifications These variations are applicable to both formulae. • If Phlegm is very pronounced, add (or increase the dosage of) Ban Xia Rhizoma Pinelliae preparatum and Gua Lou Fructus Trichosanthis. Gua Lou specifically affects the breasts. • If the breasts are very swollen, add Zhu Ling Polyporus, Yi Yi Ren Semen Coicis and Lu Lu Tong Fructus Liquidambaris. • If the breast distension is very pronounced, add (or increase the dosage of) Qing Pi Pericarpium Citri reticulatae viride and Yu Jin Radix Curcumae. • If abdominal distension is pronounced, add (or increase) Xiang Fu Rhizoma Cyperi. • If there is mental depression, add (or increase the dosage of) He Huan Pi Cortex Albiziae and Yuan Zhi Radix Polygalae. • If there is irritability and a propensity to outbursts of anger, add Suan Zao Ren Semen Ziziphi spinosae. • If there is irritability, restlessness and insomnia, add Long Chi Fossilia Dentis mastodi and Zhen Zhu Mu Concha Margaritiferae usta. • If there is great anxiety, agitation, anger and obstruction of the Mind’s orifices, add the formula Gan Mai Da Zao Tang Glycyrrhiza-TriticumJujuba Decoction.
Women’s Treasure remedy
– CLEAR THE MOON This remedy is a variation of the formula Wen Dan Tang Warming the Gall Bladder Decoction: it resolves Phlegm-Heat, calms the Mind and settles the Corporeal and Ethereal Souls. The tongue presentation appropriate to this remedy is a Red and Swollen body with a sticky-yellow coating. The most typical presentation would be a Swollen body with a central Stomach crack with a rough-sticky-yellow coating inside it. Summary Phlegm-Fire harassing upwards
Clinical manifestations
Agitation, depression, slightly manic behaviour, aggressiveness, a feeling of oppression of the chest, a red face, blood-shot eyes. Tongue: Red with a sticky-yellow coating. Pulse: Overflowing-Slippery-Rapid. Treatment principle
Clear Heat, resolve Phlegm, calm the Mind, settle the Ethereal Soul. Acupuncture
P-7 Daling, ST-40 Fenglong, ST-8 Touwei, Du-24 Shenting, L.I.-11 Quchi, SP-9 Yinlingquan, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), Ren-12 Zhongwan, BL-20 Pishu. Reducing or even method on all except for Ren-12 and BL-20 which should be reinforced.
Herbal treatment
Pre scriptions
• SHENG TIE LUO YINFrusta Ferri Decoction • WEN DAN TANG Variation Warming the Gall Bladder Decoction Variation Women’s Treasure remedy
• CLEAR THE MOON
Case history A 45-year-old woman had been suffering from pre-menstrual tension for a long time. For 7 days before the period she felt very irritable and experienced a pronounced swelling, distension and soreness of her breasts. Her periods were regular and normal in amount and colour. She felt tired in general and experienced a pronounced feeling of heaviness and oppression of the chest. Her tongue was Reddish-Purple and Swollen and her pulse Wiry and Slippery. Diagnosis In this case there is both stagnation of Liver-Qi and Phlegm-Heat, each of them contributing to causing the pre-menstrual tension. The symptoms of Phlegm are: feeling of heaviness and oppression of the chest, Swollen tongue, Slippery pulse and the pronounced swelling and soreness of the breasts. There is also some stasis of Blood as evidenced by the purple colour of the tongue body.
Treatment principle This patient had been referred by her acupuncture practitioner and was already receiving acupuncture. I therefore treated her only with herbs and used a variation of Wen Dan Tang Warming the Gall Bladder Decoction: • Zhu RuCaulis Bambusae in taeniam 6 g • Zhi ShiFructus Aurantii immaturus 6 g • Ban XiaRhizoma Pinelliae preparatum 6 g • Fu LingPoria 6 g • Chen PiPericarpium Citri reticulatae 3 g • Dan ShenRadix Salviae miltiorrhizae 6 g • Qing PiPericarpium Citri reticulatae viride 3 g • Yuan ZhiRadix Polygalae 6 g
Explanation The first five herbs constitute the formula Wen Dan Tang which resolves Phlegm-Heat, calms the Mind, opens the mind’s orifices and affects the chest and breasts. • Dan Shen invigorates Blood and calms the Mind. • Qing Pi pacifies the Liver, moves Qi and affects the breasts. • Yuan Zhi calms the Mind and opens its orifices.
After 2 months of taking this formula, this patient’s pre-menstrual tension was greatly reduced. She is still under treatment at the time of writing.
Case history A 37-year-old woman had been suffering from Pre-Menstrual Syndrome for 10 years. Her condition was very severe and characterized by anger, violent behaviour, depression, anxiety, crying, swelling of the right breast, abdomen, face and fingers. All these symptoms lasted for 2 weeks before the period and occasionally went on even after it. Her periods were regular, lasted 3–4 days, were bright red in colour and had a few clots. On interrogation, it transpired that she also suffered from blurred vision, poor memory, itchy eyes, night sweating and a dry throat at night. Her face had a malar flush. Two years previously she had developed a malignant tumour of the left breast which had been removed. She had also been diabetic for 17 years. Her tongue was slightly Red with a Red tip, slightly Purple in the chest area on the right, Swollen and with a sticky but rootless coating. Her pulse was Slippery on the right side and Deep, Weak and Choppy on the left. Diagnosis The Pre-Menstrual Syndrome is caused primarily by Phlegm-Heat harassing upwards: the symptoms of Phlegm are the pronounced swelling of the breasts, the swelling of the tongue, the sticky coating and the Slippery pulse. Phlegm-Heat harasses and clouds the Mind and causes the severe anger, violent behaviour and depression. In addition to this, there was also Blood deficiency (blurred vision, poor memory, Choppy pulse, itchy eyes) and Kidney-Yin deficiency (Red tongue with rootless coating, night sweating, dry throat at night, malar flush, Deep, Weak pulse). The Yin deficiency is consistent with diabetes and the slightly Purple patch in the chest area on the right does not bode well because, in women, that area of the tongue corresponds to the breasts: a Purple colour on the right side, indicating stasis of Blood, may therefore indicate the possibility of her developing cancer in her right breast as well. From a mental–emotional point of view, this is a case of Mind Obstructed, Weakened and Unsettled all at the same time: the obstruction of the Mind manifests with the violent behaviour towards her
family members; its weakened state, with depression; and its unsettling, with anxiety and anger. Treatment principle This is a very complex case with several different patterns which cannot all be treated simultaneously. As I often do, I preferred to treat the excess patterns first to eliminate pathogenic factors: in this case, this was necessary also because the Phlegm-Heat was causing the most distressing problem for her, i.e. the pre-menstrual tension. After resolving Phlegm-Heat, I went on to tonify Kidney-Yin, nourish Blood and invigorate Blood in the chest. She was treated with both acupuncture and herbal medicine. Acupuncture
Since she was rather wary of acupuncture, I used very few simple points to resolve Phlegm and calm the Mind such as: • Ren-12 Zhongwan to resolve Phlegm and tonify the Spleen. • L.I.-4 Hegu to regulate the ascending and descending of Qi and calm the Mind. Regulating the ascending and descending of Qi will help to resolve Phlegm and relieve stagnation in the chest area. • LIV-3 Taichong, in conjunction with L.I.-4, calms the Mind and settles the Ethereal Soul. • ST-40 Fenglong resolves Phlegm. • SP-6 Sanyinjiao resolves Phlegm, calms the Mind and invigorates Blood. Herbal treatment
I adopted the treatment principle of resolving Phlegm-Heat and therefore decided to use the formula Wen Dan Tang Warming the Gall-Bladder Decoction Variation:
• Zhu RuCaulis Bambusae in taeniam 6 g • Zhi ShiFructus Aurantii immaturus 6 g • Ban XiaRhizoma Pinelliae preparatum 6 g • Fu LingPoria 6 g • Chen PiPericarpium Citri reticulatae 3 g • Yuan ZhiRadix Polygalae 6 g • He Huan PiCortex Albiziae 6 g • Shi Chang PuRhizoma Acori tatarinowii 4 g • Dan ShenRadix Salviae miltiorrhizae 4.5 g • Qing PiPericarpium Citri reticulatae viride 3 g • Long ChiFossilia Dentis mastodi 12 g
Explanation The first five herbs constitute the formula Wen Dan Tang which resolves Phlegm-Heat, calms the Mind, opens the Mind’s orifices and relaxes the chest. In pre-menstrual tension, it will calm the Mind and reduce swelling of the breasts. • Yuan Zhi opens the Mind’s orifices (necessary because this is a case of Mind Obstructed) and calms the Mind. • He Huan Pi and Shi Chang Pu open the Mind’s orifices, calm the Mind, settle the Ethereal Soul and move Qi. • Dan Shen invigorates Blood in the chest area and calms the Mind. I added this herb because the right side of the tongue was Purple in the breast area. • Qing Pi moves Qi in the breast area and eliminates stagnation.
• Long Chi settles the Ethereal Soul and calms the Mind. I added a heavy, sinking substance because of the extreme unsettlement of the Mind.
After taking this decoction for 21 days (spanning a period), she reported a great decrease in all the pre-menstrual tension symptoms. I repeated the same formula with some slight variations by adding: • Huang Qin Radix Scutellariae to clear Heart-Heat and calm the Mind. • Zhi Mu Rhizoma Anemarrhenae to clear Heat and nourish Yin. • Bai He Bulbus Lilii and Mai Men Dong Radix Ophiopogonis to nourish Yin. Also, Bai He, together with Zhi Mu, forms a prescription that calms the Mind, settles the Corporeal Soul and soothes the Liver: it is especially indicated for depression.
After 3 months of taking this decoction and having fortnightly acupuncture treatments, her pre-menstrual tension was greatly diminished and she had not had any fits of violent temper. This patient is still under treatment and the next step is to change the focus of the treatment from resolving Phlegm-Heat to nourishing Blood and Kidney-Yin.
Empty conditions
Liver-Blood deficiency
Clinical manifestations Depression and weepiness before the period, slight abdominal and breast distension, scanty periods, tiredness, poor memory, poor sleep, slight dizziness and a dull, pale complexion. Tongue: Pale, possibly only on the sides. Pulse: Choppy or Fine and possibly slightly Wiry on the left. Treatment principle Nourish Liver-Blood, move Liver-Qi. Acupuncture Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-6 Sanyinjiao, ST-36 Zusanli, G.B.-34 Yanglingquan, P-6 Neiguan, Ren-6 Qihai, LIV-8 Ququan, BL-20 Pishu, BL-18 Ganshu. Reinforcing method except for G.B.-34, P-6 and Ren-6 which should be needled with even method. Moxa can be used. Explanation
– Ren-4 nourishes Blood and regulates the Directing Vessel. – LU-7 and KI-6 regulate the Directing Vessel and move Qi. – SP-6 and ST-36 nourish Blood. SP-6 also moves Liver-Qi and calms the Mind.
– G.B.-34 moves Liver-Qi. – P-6 moves Liver-Qi, calms the Mind and settles the Ethereal Soul. – Ren-6, in combination with G.B.-34, moves Qi in the lower abdomen. – LIV-8 and BL-18 nourish Liver-Blood. – BL-20 tonifies the Spleen to produce Blood. Herbal treatment
a Prescription
– XIAO YAO SAN Variation – Free and Easy Wanderer Powder Variation Explanation This formula, which has already been explained above, moves Liver-Qi and nourishes Liver-Blood. – Shu Di Huang and Gou Qi Zi were added to nourish Liver-Blood. b Prescription
– GUI SHAO DI HUANG TANG Variation – Angelica-Paeonia-Rehmannia Decoction Variation
Explanation
– Dang Gui and Bai Shao nourish Blood. – Shu Di Huang, Shan Yao, Shan Zhu Yu, Fu Ling, Ze Xie and Mu Dan Pi constitute the formula Liu Wei Di Huang Tang Six Ingredients Rehmannia Decoction which tonifies the Kidneys. Shu Di Huang also nourishes Blood. – Qing Pi moves Liver-Qi and affects the breasts. – Chai Hu moves Liver-Qi. – He Huan Pi moves Liver-Qi, subdues Liver-Yang and lifts depression. Women’s Treasure remedy
– FREE-FLOWING SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood. This formula nourishes Blood, tonifies the Kidneys and secondarily moves Liver-Qi: it is specific for Pre-Menstrual Syndrome from stagnation of Liver-Qi occurring against a background of Blood and Kidney deficiency. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Liver-Blood deficiency
Clinical manifestations
Depression and weepiness before the period, slight abdominal and breast distension, scanty periods, tiredness, poor memory, poor sleep, slight dizziness and a dull, pale complexion. Tongue: Pale, possibly only on the sides. Pulse: Choppy or Fine and possibly slightly Wiry on the left. Treatment principle
Nourish Liver-Blood, move Liver-Qi. Acupuncture
Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-6 Sanyinjiao, ST-36 Zusanli, G.B.-34 Yanglingquan, P-6 Neiguan, Ren-6 Qihai, LIV-8 Ququan, BL-20 Pishu, BL-18 Ganshu. Reinforcing method except for G.B.-34, P-6 and Ren-6 which should be needled with even method. Moxa can be used. Herbal treatment
Pre scriptions
• XIAO YAO SAN Variation Free and Easy Wanderer Powder Variation • GUI SHAO DI HUANG TANG Variation Angelica-Paeonia-Rehmannia Decoction Variation Women’s Treasure remedy
• FREE-FLOWING SEA
Case history
A 37-year-old woman had been suffering from pre-menstrual tension for 8 years. It had started when she suffered post-natal depression following the birth of her first child. She had another bout of post-natal depression after the birth of her second child. During the pre-menstrual period she felt very irritable, was irrational and cried a lot. On a physical level, she had a pronounced feeling of distension of the breasts and abdomen. Apart from her pre-menstrual problem, she also suffered from constipation, headaches, insomnia, excessive dreaming and palpitations. Her pulse was Fine in general, slightly Wiry only on the left Middle position (Liver) and Weak on the left Front position (Heart). Her tongue was Pale and slightly Thin but also slightly Red on the sides. Diagnosis This is a condition of both deficiency and excess. There is a deficiency of Liver-Blood manifesting with constipation, excessive dreaming, Pale tongue and Fine pulse. This deficiency has also induced a deficiency of Heart-Blood manifesting with insomnia and palpitations. The deficiency of Blood most probably started with the loss of blood occurring after childbirth and was the original cause of post-natal depression. The deficiency of Liver-Blood, over the years, gave rise to stagnation of Liver-Qi and therefore the pre-menstrual tension. The fact that, besides feeling irritable before the periods, she also wept a lot, indicates a deficiency condition. Treatment principle The principle of treatment adopted was to nourish Liver- and Heart-Blood, pacify the Liver, eliminate stagnation, calm the Mind and settle the Ethereal Soul. She was treated with acupuncture and prepared remedies. Acupuncture
The acupuncture points used (with reinforcing method to nourish Liver- and Heart-Blood and even method to pacify the Liver) were selected from the following: • LIV-3 Taichong and G.B.-34 Yanglingquan to pacify the Liver and eliminate stagnation. • P-7 Daling to pacify the Liver, calm the Mind and settle the Ethereal Soul. • P-6 Neiguan on the right and SP-4 Gongsun on the left to open the Yin Linking Vessel, nourish Blood and calm the Mind. • ST-36 Zusanli and SP-6 Sanyinjiao to tonify Qi and Blood. • BL-20 Pishu, BL-15 Xinshu and BL-18 Ganshu to nourish Liver- and HeartBlood.
She was treated once a week. Herbal treatment
The prepared remedies used were Xiao Yao Wan Free and Easy Wanderer Pill to pacify the Liver and eliminate stagnation and Bai Zi Yang Xin Wan Platycladi Nourishing the Heart Pill to nourish Liver and Heart-Blood and calm the Mind. By the end of 9 months, this patient’s condition showed about 80% improvement. Case history A 35-year-old woman suffered from Pre-Menstrual Syndrome, complaining of breast distension, irritability and depression. She also suffered from severe abdominal distension and, on a mental level, she lacked confidence and a sense of direction in life, could not concentrate, found it difficult to take decisions and feared change. She also complained of poor memory, insomnia, blurred vision, dizziness and numbness of the feet. Her
tongue was Pale on the sides and the pulse was Fine and slightly Wiry on the left side and Choppy on the right. Diagnosis This is a clear case of stagnation of Liver-Qi which is secondary to LiverBlood deficiency. She had many symptoms of Liver-Blood deficiency: poor memory and concentration, blurred vision, insomnia, dizziness, numbness, Pale tongue, and Fine and Choppy pulse. Also on a mental level, many of her problems were due to deficient Liver-Blood not rooting the Ethereal Soul: lack of confidence, lack of a sense of direction in life, fear of change, depression. Fear was a marked aspect of her mental make-up, and it should be remembered here that this emotion is not always due to the Kidneys but can also be related to a Liver-Blood deficiency. The pre-menstrual symptoms were characteristic of Liver-Qi stagnation. Treatment principle The treatment principle adopted was to nourish Liver-Blood, root the Ethereal Soul and move Liver-Qi. She was treated with acupuncture and herbal remedies. Acupuncture
The acupuncture points were selected from the following: • P-6 Neiguan, on the right, to regulate the Liver, calm the Mind and settle the Ethereal Soul. • LIV-3 Taichong, on the left, to pacify the Liver, eliminate stagnation and settle the Ethereal Soul. • ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan (all bilateral) and Ren-4 Guanyuan to nourish Liver-Blood.
• Du-20 Baihui to clear the brain and lift mood. Herbal treatment
The remedy used was Freeing the Moon from the Women’s Treasure. This patient made a complete recovery in 9 months and felt much better mentally. In particular, it was interesting to note that she acquired a sense of direction in her life, by taking a new training course.
Liver- and Kidney-Yin deficiency
Clinical manifestations Slight breast distension and irritability before the period and occasionally after it, sore back and knees, dizziness, blurred vision, poor memory, night sweating, dry eyes and throat. Tongue: without coating; Red if there is Empty -Heat. Pulse: Floating-Empty. Treatment principle Nourish Liver- and Kidney-Yin and move Liver-Qi. Acupuncture LIV-8 Ququan, Ren-4 Guanyuan, SP-6 Sanyinjiao, LIV-3 Taichong. Reinforcing method on all except LIV-3 which should be needled with even method. Explanation
– LIV-8 nourishes Liver-Yin. – Ren-4 nourishes Liver- and Kidney-Yin. – SP-6 nourishes Liver- and Kidney-Yin and calms the Mind. – LIV-3 moves Liver-Qi. Herbal treatment
Prescription
– YI GUAN JIAN Variation – One Linking Decoction Variation Explanation The first six herbs constitute the formula Yi Guan Jian which nourishes LiverYin. – Mei Gui Hua and Fo Shou move Liver-Qi without damaging Yin. Modifications
• If Liver- and Kidney-Yin deficiency leads to Liver-Yang rising, add Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus Uncariae cum Uncis and Shi Jue Ming Concha Haliotidis. • If there is mental restlessness and insomnia, add Suan Zao Ren Semen Ziziphi spinosae and Ye Jiao Teng Caulis Polygoni multiflori. Three Treasures remedy
– NOURISH THE ROOT This remedy has the same actions and indications as the formula Zuo Gui Wan Restoring the Left [Kidney] Pill, of which it is a variation: it
nourishes Liver- and Kidney-Yin. The tongue presentation appropriate to this remedy is a Red body without coating. Summary Liver- and Kidney-Yin deficiency
Clinical manifestations
Slight breast distension and irritability before the period and occasionally after it, sore back and knees, dizziness, blurred vision, poor memory, night sweating, dry eyes and throat. Tongue: without coating; Red if there is Empty Heat. Pulse: Floating-Empty. Treatment principle
Nourish Liver- and Kidney-Yin and move Liver-Qi. Acupuncture
LIV-8 Ququan, Ren-4 Guanyuan, SP-6 Sanyinjiao, LIV-3 Taichong. Reinforcing method on all except LIV-3 which should be needled with even method. Herbal treatment
Pre scription
• YI GUAN JIAN Variation One Linking Decoction Variation Three Treasures remedy
• NOURISH THE ROOT
Case history A 40-year-old woman had been suffering from Pre-Menstrual Syndrome for 7 years. Before the period she felt depressed and irritable and had a headache on the vertex. Her periods were regular, lasted 3 days, were rather scanty and not painful. Apart from this, she suffered from constipation, backache, a feeling of heat and dry mouth in the evening, sore eyes and blurred vision. Her hair was dry and had been falling out. Her tongue was slightly Red with a rootless coating. Her pulse was Weak on the left Rear position. Diagnosis This is a clear condition of Liver-Yin deficiency leading to some stagnation of Liver-Qi causing the pre-menstrual tension. The symptoms of Liver-Yin deficiency are a feeling of heat and dry mouth at night, sore eyes, blurred vision and dry and falling hair. There is also some deficiency of Kidney-Yin as evidenced by the backache. Treatment principle The treatment principle adopted was to nourish Liver-Yin, pacify the Liver, eliminate stagnation, calm the Mind and settle the Ethereal Soul. As she was receiving acupuncture from another practitioner who referred her to me for herbal treatment, she was treated only with herbs. Herbal treatment
The decoction used was a variation of Yi Guan Jian One Linking Decoction
which nourishes Liver-Yin: • Mai Men DongRadix Ophiopogonis 6 g • Bei Sha ShenRadix Glehniae 6 g • Gou Qi ZiFructus Lycii 9 g • Sheng Di HuangRadix Rehmanniae 9 g • Dang GuiRadix Angelicae sinensis 9 g • Chuan Lian ZiFructus Toosendan 4 g • Xiang FuRhizoma Cyperi 6 g • Bai ShaoRadix Paeoniae alba 9 g • Ju HuaFlos Chrysanthemi 6 g • Zhi Gan CaoRadix Glycyrrhizae preparata 3 g
Explanation
• Mai Dong, Sha Shen, Gou Qi Zi, Sheng Di and Dang Gui nourish Liver-Yin. • Chuan Lian Zi and Xiang Fu pacify the Liver and eliminate stagnation. • Bai Shao nourishes Liver-Yin and pacifies the Liver. • Ju Hua subdues Liver-Yang (headache) and calms the Mind. • Gan Cao harmonizes.
This patient made a gradual improvement over 6 months after which she had no signs of pre-menstrual tension.
Spleen- and Kidney-Yang deficiency
Clinical manifestations Slight pre-menstrual tension with depression and weeping, slight abdominal and breast distension, tiredness, sore back, feeling cold, frequent and pale urination, low sexual desire. Tongue: Pale. Pulse: Deep and Weak. Treatment principle Tonify Yang, strengthen the Kidneys. Acupuncture BL-23 Shenshu, BL-20 Pishu, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left). Reinforcing method, moxa should be used. Explanation
– BL-23 and BL-20 tonify Kidneys and Spleen. – Ren-4, with direct moxa, tonifies Kidney-Yang. – ST-36 and SP-6 tonify Qi and Blood. – KI-3, with moxa, tonifies Kidney-Yang. – LU-7 and KI-6 regulate the Directing Vessel, regulate the Uterus and tonify the Kidneys.
Herbal treatment
Prescription
– YOU GUI WAN – Restoring the Right [Kidney] Pill Explanation This formula, which has already been explained, tonifies Kidney-Yang. It is particularly suited to this pattern as it also contains Shu Di Huang, Dang Gui and Gou Qi Zi which nourish Blood and benefit the Directing Vessel. Modifications
• If the symptoms of Liver-Qi stagnation are pronounced and there is breast distension, add Qing Pi Pericarpium Citri reticulatae viride. • If there is abdominal distension, add Xiang Fu Rhizoma Cyperi. Three Treasures remedy
– STRENGTHEN THE ROOT This remedy, a variation of You Gui Wan Restoring the Right [Kidney] Pill, tonifies and warms Spleen- and Kidney-Yang. The tongue presentation appropriate to this remedy is a Pale and wet body.
Summary Spleen- and Kidney-Yang deficiency
Clinical manifestations
Slight pre-menstrual tension with depression and weeping, slight abdominal and breast distension, tiredness, sore back, feeling cold, frequent and pale urination, low sexual desire. Tongue: Pale. Pulse: Deep and Weak. Treatment principle
Tonify Yang, strengthen the Kidneys. Acupuncture
BL-23 Shenshu, BL-20 Pishu, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left). Reinforcing method, moxa should be used. Herbal treatment
Pre scription
• YOU GUI WANRestoring the Right [Kidney] Pill Three Treasures remedy
• STRENGTHEN THE ROOT
Case history A 33-year-old woman had been suffering from Pre-Menstrual Syndrome for 4 years. Before the period she was depressed and anxious. The period itself was painful, the menstrual blood had some small dark clots and she felt very cold during it. Other symptoms included a general cold feeling, backache, achy knees, dizziness, tinnitus, urgent and slightly dribbling urination, poor memory, numbness of the limbs, restless sleep and tiredness. Her tongue was Pale but had slightly Red sides. The root of the tongue had no spirit. Her pulse was generally Weak, particularly on the Rear positions. Diagnosis This patient has clear symptoms of Kidney-Yang deficiency: backache, cold feeling, achy knees, dizziness, tinnitus, poor memory, dribbling urination, Pale tongue and pulse Weak on the Kidney positions. There is also some deficiency of Blood evidenced by the numbness of limbs and restless sleep. The deficiency of the Kidneys leads to Liver deficiency and stagnation of Liver-Qi which causes the pre-menstrual tension. Treatment principle The treatment principle adopted was to tonify and warm Kidney-Yang, nourish and pacify the Liver, eliminate stagnation, calm the Mind and settle the Ethereal Soul. As she had been referred by a fellow acupuncturist for herbal treatment, I treated her only with herbs. Herbal treatment
I started by using a variation of the decoction You Gui Wan Restoring the Right [Kidney] Pill: • Rou GuiCortex Cinnamomi 2 g
• Du ZhongCortex Eucommiae 6 g • Shan Zhu YuFructus Corni 4.5 g • Tu Si ZiSemen Cuscutae 6 g • Lu Jiao JiaoColla Cornu Cervi 6 g • Shu Di HuangRadix Rehmanniae preparata 12 g • Shan YaoRhizoma Dioscoreae 6 g • Gou Qi ZiFructus Lycii 6 g • Dang GuiRadix Angelicae sinensis 6 g • Xiang FuRhizoma Cyperi 6 g • Bai ShaoRadix Paeoniae alba 6 g
Explanation All the herbs, except for the last two, make up the You Gui Wan which tonifies Kidney-Yang and nourishes Liver-Blood. Fu Zi was removed from the original prescription because its internal use is illegal in Europe. • Xiang Fu was added to move Liver-Qi and eliminate stagnation. • Bai Shao nourishes and pacifies the Liver and calms the Mind.
After taking this prescription for 3 weeks, she said that, although she had more energy, she felt angry, still had pre-menstrual tension, did not sleep well and was confused. I concluded that the treatment emphasis should have been, as is often the case, on eliminating first rather than tonifying. In this case, the premature tonification had probably created more stagnation affecting the Mind and Ethereal Soul, hence the anger, insomnia and mental confusion. I therefore changed the treatment principle to concentrate on pacifying the Liver, eliminating stagnation, calming the Mind, opening the orifices and settling the Ethereal Soul, and chose to use a variation of Xiao
Yao San Free and Easy Wanderer Powder: • Bo HeHerba Menthae haplocalycis 3 g • Chai HuRadix Bupleuri 9 g • Dang GuiRadix Angelicae sinensis 9 g • Bai ShaoRadix Paeoniae alba 12 g • Bai ZhuRhizoma Atractylodis macrocephalae 9 g • Fu LingPoria 15 g • Gan CaoRadix Glycyrrhizae 6 g • Sheng JiangRhizoma Zingiberis recens 3 slices • Shu Di HuangRadix Rehmanniae preparata 9 g • Xiang FuRhizoma Cyperi 6 g • He Huan PiCortex Albiziae 6 g • Shi Chang PuRhizoma Acori tatarinowii 6 g
Explanation The first eight herbs constitute the Xiao Yao San which pacifies the Liver and nourishes Liver-Blood. • Shu Di Huang was added to tonify the Kidneys. • Xiang Fu, He Huan Pi and Shi Chang Pu pacify the Liver, eliminate stagnation, lift depression and open the Mind’s orifices.
This decoction had a much better effect, improving the pre-menstrual tension, calming her and dispelling the confusion. She continued to be treated with variations of this decoction for about 3 months, after which the treatment principle was changed again to tonify Kidney-Yang primarily. After another 4
months, she felt much better all round and her pre-menstrual tension had gone. Case history A 34-year-old woman had been suffering from pre-menstrual tension since she was 20, after the death of her mother. Her main pre-menstrual symptoms were: fatigue, a bearing-down sensation in the abdomen, a feeling of distension, loss of confidence, mood swings, irritability, depression, frequent urination, sore chest, insomnia, a feeling of heaviness of the legs, poor memory, lack of coordination, feeling faint and sore breasts. The period was regular but painful and the menstrual blood was dark with clots. Her tongue was of a normal colour but with a Red tip and it had a Heart crack. Her pulse was Deep, Weak and Slow (60). She was pale and looked depressed with eyes lacking shen. Diagnosis The main pattern appearing is overwhelmingly that of Kidney-Yang deficiency: frequent urination, fatigue, loss of confidence, depression, poor memory, lack of coordination, faint feeling, a Deep, Weak and Slow pulse. As a consequence of the severe deficiency of Kidney-Yang, there is also Qi sinking which causes the bearing-down sensation in the abdomen. As a result of Yang deficiency, there is some Dampness manifesting with the feeling of heaviness of the legs. Finally, as a result of Kidney-Yang deficiency, there is internal Cold leading to some stasis of Blood (period painful with dark blood and clots). In addition, there is some Liver-Qi stagnation manifesting with distension and irritability. However, the condition is overwhelmingly overshadowed by the Kidney-Yang deficiency as the pulse clearly shows: in fact, although there is some Dampness and stasis of Blood, these do not show on the pulse at all. Treatment principle
The treatment principle adopted was to tonify and warm Kidney-Yang primarily. Secondary aims were to move Liver-Qi, resolve Dampness and invigorate Blood. She was treated with both acupuncture and herbs. Acupuncture
The points used were selected from the following (with reinforcing method for the points to tonify the Spleen and Kidneys and even method on the others): • LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to regulate the Directing Vessel, strengthen the Uterus and tonify the Kidneys. • ST-36 Zusanli and SP-6 Sanyinjiao, with warm needle, to tonify Qi in general. • BL-20 Pishu and BL-23 Shenshu, with direct moxa cones, to tonify Spleenand Kidney-Yang. • Ren-4 Guanyuan, with direct moxa cones, to tonify Kidney-Yang and strengthen the Uterus. • P-6 Neiguan and Ren-15 Jiuwei to nourish the Heart. This is necessary as the tongue has a Heart crack indicating the tendency to emotional problems and also because the pre-menstrual tension was triggered off by the grief and loss following the death of her mother. Herbal treatment
The formula used at first was a variation of You Gui Wan Restoring the Right [Kidney] Pill: • Rou GuiCortex Cinnamomi 2 g • Du ZhongCortex Eucommiae 6 g • Shan Zhu YuFructus Corni 4.5 g
• Tu Si ZiSemen Cuscutae 6 g • Lu Jiao JiaoColla Cornu Cervi 6 g • Shu Di HuangRadix Rehmanniae preparata 12 g • Shan YaoRhizoma Dioscoreae 6 g • Gou Qi ZiFructus Lycii 6 g • Dang GuiRadix Angelicae sinensis 6 g • Xiang FuRhizoma Cyperi 6 g • Chai HuRadix Bupleuri 6 g • Chi ShaoRadix Paeoniae rubra 4.5 g • Fu LingPoria 6 g
Explanation The first nine herbs constitute the formula You Gui Wan (minus Fu Zi Radix Aconiti lateralis preparata) to tonify and warm Kidney-Yang. • Xiang Fu and Chai Hu pacify the Liver and move Qi. • Chi Shao was added to invigorate Blood. • Fu Ling was added to resolve Dampness.
She was treated with this formula for 3 months after which the premenstrual problems were greatly reduced and the menstrual blood was no longer dark and clotted. After this time, she stopped taking the herbs for some 2 months and she started experiencing pronounced breast distension and irritability before the period. Her pulse was now much stronger in general and it appeared that, as the Kidneys got stronger, the symptoms of Qi distension acquired more prominence. I therefore changed the formula to Xiao Yao San Free and Easy Wanderer Powder plus:
• Yuan Zhi Radix Polygalae and He Huan Pi Cortex Albiziae to calm the Mind and open the Mind’s orifices.
After she had taken this formula for about 2 months, her periods were completely regulated and her pre-menstrual tension and distension greatly reduced. However, I considered that the treatment had still not come to an end because I felt the emotional sadness and grief should be addressed. In fact, although her condition had greatly improved, she still felt anxious and rather depressed in general. I therefore prescribed three courses (of 3 weeks each) of Gui Pi Tang Restoring the Spleen Decoction which, together with some psychological counselling, greatly helped her mental state.
Ancient acupuncture prescription for Pre-Menstrual Syndrome 1
– KI-6 Zhaohai 0.4 cun deep followed by 2 moxa cones for hesitant start to the period, aches, anxiety, sadness, depression with a sinking feeling (Thousand Golden Ducat Prescriptions, Qian Jin Yao Fang, AD 652).
Prognosis and prevention Both acupuncture and herbs, singly or in combination, give excellent results for Pre-Menstrual Syndrome. It could be said that there is hardly a case that cannot be helped, although those caused by Phlegm-Fire harassing upwards will take longest to treat. As with all menstrual problems, it will take a minimum of three menstrual periods to regulate the cycle completely, although some improvement can often be seen even after a month.
Western view Pre-menstrual syndrome is a subject shrouded in controversy in Western medicine as there is no widely accepted definition of what it really is. For example, the following are four different definitions of pre-menstrual syndrome in Western medicine: 1. Changes in certain mental and physical symptoms relative to the menstrual cycle with increasing intensity and frequency of these symptoms pre-menstrually. 2. A condition with cyclic mood changes whose symptom development is closely related to the luteal phase. 3. The collective name given to the problems that occur during the 2-week period before menstruation. 4. A cluster of symptoms, both psychological and physical, that appear episodically in relation to the phases of the menstrual cycle.2 There are several theories trying to explain the causes of pre-menstrual syndrome in Western medicine but all of them are controversial and clinical trials have given no conclusive evidence supporting any of these theories. The main ones are discussed below. Progesterone deficiency According to this hypothesis, women suffering from pre-menstrual syndrome have a progesterone deficiency (and therefore a relative oestrogen excess). The symptoms of pre-menstrual tension intensify as progesterone levels fall late in the luteal phase. Unopposed oestrogen could cause water retention and breast hyperplasia. However, many studies of women with pre-menstrual syndrome and control groups showed no significant difference in the
circulating progesterone between the two groups.3 Indeed, progestogens themselves can cause pre-menstrual syndrome-type symptoms in some women.4 Deficiency of vitamin B6 Lack of vitamin B6 , possibly caused by excess of oestrogen, may lead to decreased synthesis of dopamine and serotonin which causes pre-menstrual depression. Elevated prolactin Women with pre-menstrual tension have elevated levels of prolactin in the luteal phase. Prolactin is important for the fluid balance and prolactin antagonists usually help pre-menstrual fluid retention but have no influence on other symptoms. Prostaglandins Prostaglandins have been suggested as a cause of pre-menstrual syndrome but clinical trials have yielded contradictory results. Aldosterone Excessive levels of aldosterone cause fluid retention but this would not explain all the other symptoms present in pre-menstrual syndrome.
Western treatment of Pre-Menstrual Syndrome The Western medical therapy of Pre-Menstrual Syndrome is based on the above hypotheses and it includes the agents discussed below. Diuretics
Diuretics are widely prescribed to deal with pre-menstrual fluid retention. However, they obviously have no effect on the other symptoms and their prolonged use is fraught with side effects. From a Chinese perspective, longterm use (or abuse) of diuretics may lead to Yin deficiency. The diuretic normally used is spironolactone as it is an aldosterone antagonist. Progesterone
The administration of progesterone is based on the hypothesis that premenstrual symptoms are caused by a deficiency of this hormone. Doubleblind, controlled studies of progesterone therapy for pre-menstrual syndrome did not show progesterone to be better than a placebo.5 Oral contraceptives
The use of oral contraceptives is based on the hypothesis that pre-menstrual tension may be caused by a relative excess of oestrogen compared to progesterone. Reports indicate that the incidence of Pre-Menstrual Syndrome in oral contraceptive users is 29% lower than in non-users. Bromocriptine
Bromocriptine is a prolactin antagonist and, if it has any effect at all, this would be only on the breast distension and swelling. Prostaglandin synthetase inhibitors
Synthetase inhibitors reduce the levels of prostaglandins: their use in PreMenstrual Syndrome is still experimental. Vitamin B6
The use of vitamin B6 is based on the hypothesis that it is deficient in PreMenstrual Syndrome. This vitamin would stimulate serotonin, thus treating the pre-menstrual irritability and depression. Summary Western view
• Progesterone deficiency • Deficiency of vitamin B6 • Elevated prolactin • Prostaglandins • Aldosterone
Western treatment
• Diuretics
• Progesterone • Oral contraceptives • Bromocriptine • Prostaglandin synthetase inhibitors • Vitamin B6
End notes 1. Chen You Bang 1990 Chinese Acupuncture Therapy (Zhong Guo Zhen Jiu Zhi Liao Xue
), China Scientific Publishing House, Beijing, p. 865..
2. Clarke-Pearson D L, Yusoff Dawood M 1990 Green’s Gynaecology, Little, Brown and Company, Boston, p. 186..
3. Ibid., p. 187..
4. McPherson A 1993 Women’s Problems in General Practice, Oxford University Press, Oxford, p. 164..
5. Ibid., p. 192..
SECTION 5 Problems at Period Time
Introduction 19. PRE-MENSTRUAL BREAST DISTENSION 381 20. HEADACHES DURING PERIODS 395 21. OEDEMA DURING PERIODS 405 22. DIARRHOEA AT PERIOD TIME 411 23. BODY ACHES AT PERIOD TIME 415 24. FEVER AT PERIOD TIME 421 25. EPISTAXIS OR HAEMOPTYSIS AT PERIOD TIME 429 26. MOUTH ULCERS AT PERIOD TIME 433 27. SKIN ERUPTIONS AT PERIOD TIME 439 28. DIZZINESS AT PERIOD TIME 445
This section will discuss the treatment of various symptoms and signs occurring around the period time: this may be before, during or immediately after the period. ‘Problems at period time’ refers to problems that occur strictly only just before, during or just after the period. For example, if a woman suffers from pre-menstrual headaches every month and at no other time, this would qualify as ‘pre-menstrual headaches’; but if she suffered from headaches that occur sometimes before the period and sometimes at other times, then this would not be treated as a gynecological disease category. The distinction is relatively important as problems that occur at period times must be treated by regulating the periods and adapting the treatment to the four phases. Thus the treatment of problems occurring around the period time must be based on a dual approach: on the one hand, they are treated by
reference to the patterns of general internal medicine; on the other hand, they must be treated by regulating the periods, regulating Blood and treating according to the four phases. From the acupuncture perspective, it also means that these problems must often be treated by using the Extraordinary Vessels.
CHAPTER 19 Pre-Menstrual Breast Distension
AETIOLOGY 381 PATHOLOGY 382 CHANNELS INFLUENCING THE BREAST 382 IDENTIFICATION OF PATTERNS AND TREATMENT 383 Liver-Qi stagnation 383 Lung-Qi stagnation 386 Heart-Qi stagnation 387 Liver-Blood stasis 388 Damp-Heat 389 Phlegm with Qi stagnation 390 Kidney- and Liver-Yin deficiency 392 PROGNOSIS AND PREVENTION 393 Pre-menstrual breast distension is a very common problem occurring mostly before the onset of a period, although occasionally it may occur after a period. It can vary from mild to a very severe distension, with swelling, enlargement, hardness and pain. In many cases, pre-menstrual breast distension is also accompanied by small lumps in the breast which may become larger before and during the period and smaller afterwards. This corresponds to benign fibrocystic breast disease and will be discussed separately under the chapter on benign breast lumps (Ch. 59). The common problem of pre-menstrual tension has been discussed in the chapter on Pre-
Menstrual Syndrome (Ch. 18).
Aetiology
Emotional stress Anger, repressed anger, worry, guilt, frustration and resentment may lead to Liver-Qi stagnation, and if stagnant Liver-Qi invades the Stomach, this affects the breast because the Liver channel influences the nipple, and the Stomach channel the breast itself. This will cause distension and swelling of the breasts before the periods because, during this phase, Liver-Qi rises. Please note that the Lung channel also affects the breast and therefore emotional problems that affect the Lungs (e.g. worry, sadness and grief) may also cause breast distension. Overwork Overwork in the sense of working long hours under stressful conditions without adequate rest is the most common cause of Liver- and Kidney-Yin deficiency in modern, industrialized societies. Kidney- and Liver-Yin deficiency often lead to a secondary stagnation of Liver-Qi: this happens because the deficient Yin fails to ‘embrace’ or root the Yang, which therefore stagnates. The stagnation of Qi leads to pre-menstrual breast distension. In such cases of Yin deficiency leading to Qi stagnation, the breast distension may occasionally occur after the periods. In other cases, Kidney- and Liver-Yin deficiency may give rise to Liver-Yang rising, the latter causing not only breast distension but also some pain and a feeling of burning of the skin (over the breasts). Irregular diet Irregular diet and the excessive consumption of dairy foods, raw, cold foods
and greasy foods may lead to the formation of Phlegm. When emotional strain is also present leading to stagnation of Qi, there is an interaction between these two pathogenic factors. Stagnant Qi contributes to the formation of Phlegm because there is no free flow of Qi to transform fluids, and Phlegm obstructs the free movement of Qi augmenting the stagnation. Thus, in women, when Phlegm coexists with stagnation of Qi, the breast becomes not only distended but also very swollen and enlarged.
Pathology The main pathological factors in pre-menstrual breast distension are: • Liver-Qi stagnation • Lung-Qi stagnation • Heart-Qi stagnation • Liver-Blood stasis • Damp-Heat • Phlegm with Qi stagnation • Kidney- and Liver-Yin deficiency. Liver-Qi stagnation The key symptom of Qi stagnation is distension and Liver-Qi stagnation is a very common cause of breast distension. This typically occurs in the premenstrual phase when Liver-Qi should move: if it does not, it causes distension. Lung-Qi stagnation It is important to remember that Qi stagnation does not affect only the Liver: many other organs are affected by Qi stagnation. In particular, Lung-Qi stagnation affects the breast because the Lung channel flows on the lateral side of the breast. Relating aetiology to pathology, it is also important to note that it is not
only anger and repressed anger that cause Qi stagnation. Emotions that affect the Lungs also cause Qi stagnation: these are worry, sadness and grief. Heart-Qi stagnation Like the Lungs, the Heart is also subject to Qi stagnation. This is caused by emotional problems related to fear, worry, sadness or guilt. The Heart and Pericardium Muscle channels flow to the lateral side of the breast. Heart-Qi stagnation also causes distension. ! Remember that Liver-Qi stagnation is not the only pattern to affect the breasts and that Qi stagnation of Heart and Lungs also affects the breasts. Liver-Blood stasis Liver-Blood stasis often develops from longstanding Liver-Qi stagnation. The change from Liver-Qi stagnation is reflected in a shift from distension to pain: in fact, while Qi stagnation typically causes distension, Blood stasis causes pain. Of course, the two can coexist so that a woman may suffer from premenstrual breast distension and pain. Damp-Heat Dampness (with or without Heat) may affect the breast, particularly through the Liver and Stomach channels. Damp-Heat in the Liver and/or Stomach may cause breast pain and possibly a discharge from the nipple. Phlegm with Qi stagnation
Phlegm in the breasts causes swelling (as opposed to distension) and it may also cause some pain. Thus, pre-menstrually, the breasts feel swollen and slightly painful. Often, these women will tend to obesity. However, as there is also Qi stagnation, the breasts will feel distended too. Phlegm in the breasts may also cause benign breast lumps such as those see in fibrocystic breast disease. Kidney- and Liver-Yin deficiency Kidney- and Liver-Yin deficiency will cause only a mild feeling of distension. This is due to the secondary Liver-Qi stagnation that may accompany LiverYin deficiency.
Channels influencing the breast Many channels influence the breast as indicated in Figure 19.1.
Figure 19.1 Channels flowing over the breasts.
Liver channel
The Liver channel has an important influence on the female breast and particularly on the outer quadrants. However, although the Liver channel flows on the lateral side of the breasts, most Chinese diagnosis books relate the nipple to the Liver. I personally think the nipple is influenced by the Liver and the Stomach channels. In pathology, Liver-Qi stagnation is a very common cause of breast distension.
Lung channel
The Lung channel flows on the lateral side of the breast and its Qi stagnation is a cause of breast distension. The distension deriving from Lung-Qi stagnation is less severe than that caused by Liver-Qi stagnation. The Lung Muscle channel also flows over the breasts. Stomach channel
The Stomach channel flows in the centre of the breast and goes over the nipple. The Stomach channel in the breast is often affected by Damp-Heat. The Stomach Muscle channel also flows over the breast, on the medial side. Penetrating Vessel (Chong Mai)
The Penetrating Vessel disperses over the female breasts on its way up to the chest and throat. The Penetrating Vessel is affected by Qi stagnation or rebellious Qi, both of which may cause breast distension. Heart Muscle channel
The Heart Muscle channel flows to the medial side of the breast and it may cause breast distension when the Heart is affected by Qi stagnation. Pericardium Muscle channel
The Pericardium Muscle channel flows over the lateral inferior side of the breast and it may cause breast distension when the Heart is affected by Qi stagnation.
Gall Bladder Muscle channel
The Gall Bladder Muscle channel flows over the lateral side of the breast and it may cause breast distension when the Liver is affected by Qi stagnation. The pathway of the Gall Bladder Muscle channel probably accounts for the effect of the point G.B.-41 Zulinqi on the female breast.
Identification of patterns and treatment
Liver-Qi stagnation
Clinical manifestations Pre-menstrual breast distension from 3 to 7 days before or even up to 15 days before the period, intolerance if the breasts are touched, irritability, sighing, a feeling of oppression of the chest. Tongue: normal body colour or slightly Red sides. Pulse: Wiry. Treatment principle Pacify the Liver, move Qi, eliminate stagnation, dissipate accumulation. Acupuncture LIV-3 Taichong, G.B.-34 Yanglingquan, G.B.-41 Zulinqi, LIV-14 Qimen, ST-18 Rugen, T.B.-6 Zhigou, G.B.-21 Jianjing, P-6 Neiguan. All with reducing or even method. Explanation
– LIV-3 moves Liver-Qi and eliminates stagnation. It has also a powerful mental effect in calming the Mind and settling the Ethereal Soul. – G.B.-34 also moves Liver-Qi and it affects specifically the area below the breasts. Compared with LIV-3, G.B.-34 is milder in effect and does not work on the Mind as much; it does, however, affect the general area of the breasts and rib-cage.
– G.B.-41 specifically affects the breasts and also moves Liver-Qi. This point has a long history of use to affect the breasts and relieve stagnation and pain, being mentioned for this problem in most acupuncture classics from all ages from the ABC of Acupuncture (AD 259) to the Great Compendium of Acupuncture (1601).1 – LIV-14 is used as a local point, but it also moves Liver-Qi and calms the Mind. – ST-18 is used as a local point but it is also chosen as a point from the Stomach channel because this channel affects the breast tissues. – T.B.-6 is another possible distal point that moves Qi and affects the ribcage area. – G.B.-21 moves Liver-Qi, makes Qi descend and specifically affects the breasts. It would be particularly indicated if, besides Liver-Qi stagnation, there were also Liver-Yang rising. – P-6 pacifies the Liver, eliminates stagnation and settles the Ethereal Soul. It is an excellent point for this condition because, besides the above actions, it also opens and relaxes the chest area and therefore the breasts. Herbal treatment
a Prescription
– XIAO YAO SAN – Free and Easy Wanderer Powder Explanation
This is, of course, a very well-known formula, especially effective for women, to move Liver-Qi and eliminate stagnation with a particular effect on the breasts. This formula is in fact specific for breast pathology. – Bo He and Chai Hu move Liver-Qi. Chai Hu reaches the upper part of the body and therefore the breasts. – Dang Gui and Bai Shao nourish Liver-Blood: this helps to pacify the Liver and eliminate stagnation. – Bai Zhu and Fu Ling tonify the Spleen. – Gan Cao and Sheng Jiang harmonize. b Prescription
– CHAI HU SHU GAN TANG – Bupleurum Pacifying the Liver Decoction Explanation This formula can be chosen in preference to the previous one when the stagnation of Qi is more pronounced and there is also some pain which may be in the breast or the abdomen. – Chai Hu, Zhi Ke and Xiang Fu pacify the Liver, move Qi and eliminate stagnation. – Bai Shao nourishes Blood, harmonizes the Liver and stops pain. – Zhi Gan Cao harmonizes and, together with Bai Shao, it stops pain.
– Chen Pi moves Qi, resolves Dampness and harmonizes the Centre. – Chuan Xiong moves Qi and Blood. c Prescription
– XIAO ZHANG SHU YU TANG – Dissolving Distension and Relaxing Stagnation Decoction Explanation
– Xiang Fu, Chai Hu, Qing Pi, Ju He, Chuan Lian Zi and Zhi Ke move Qi, eliminate stagnation, pacify the Liver and free the breasts. – Lu Lu Tong removes obstructions from the Connecting channels of the breast. – Mu Gua nourishes and pacifies the Liver. This formula is used if there is a tendency to Liver-Blood or Liver-Yin deficiency. Modifications
• If the breasts are painful and there are small nodules, add (or increase the dosage of) Qing Pi Pericarpium Citri reticulatae viride, Ju He Semen Citri reticulatae, Xia Ku Cao Spica Prunellae and Bai Zhi Radix Angelicae dahuricae. • If the patient is depressed and unhappy, add (or increase the dosage of)
Xiang Fu Rhizoma Cyperi, He Huan Pi Cortex Albiziae, Yu Jin Radix Curcumae and Su Luo Zi Semen Aesculi. • If there is abdominal distension and pain, add (or increase the dosage of) Chuan Lian Zi Fructus Toosendan, Yan Hu Suo Rhizoma Corydalis and Wu Yao Radix Linderae. • If there is stabbing pain in the breasts and the tongue is Red (indicating that stagnant Liver-Qi has given rise to Fire), add Mu Dan Pi Cortex Moutan and Shan Zhi Zi Fructus Gardeniae. Women’s Treasure remedy
– FREEING THE MOON This remedy is a variation of Xiao Yao San Free and Easy Wanderer Powder aimed at pacifying the Liver, eliminating stagnation and nourishing Liver-Blood. It is therefore for stagnation of Liver-Qi occurring against a background of Liver-Blood deficiency, in much the same way as Xiao Yao San. It can be used to treat breast distension as it contains herbs that specifically affect the breast such as Qing Pi and Yuan Zhi. The tongue presentation appropriate to this remedy is a body that is either Pale or normal-coloured. Summary Liver-Qi stagnation
Clinical manifestations
Pre-menstrual breast distension from 3 to 7 days before or even up to 15
days before the period, intolerance if the breasts are touched, irritability, sighing, a feeling of oppression of the chest. Tongue: normal body colour or slightly Red sides. Pulse: Wiry. Treatment principle
Pacify the Liver, move Qi, eliminate stagnation, dissipate accumulation. Acupuncture
LIV-3 Taichong, G.B.-34 Yanglingquan, G.B.-41 Zulinqi, LIV-14 Qimen, ST-18 Rugen, T.B.-6 Zhigou, G.B.-21 Jianjing, P-6 Neiguan. All with reducing or even method. Herbal treatment
Pre scriptions
• XIAO YAO SAN Free and Easy Wanderer Powder • CHAI HU SHU GAN TANG Bupleurum Pacifying the Liver Decoction • XIAO ZHANG SHU YU TANG Dissolving Distension and Relaxing Stagnation Decoction Women’s Treasure remedy
• FREEING THE MOON
Case history A 32-year-old woman had been suffering from pre-menstrual breast and
abdomen distension for several years. This lasted for 2 weeks immediately prior to the onset of the period, and she also complained of irritability. She had been prescribed a progesterone pill which had not helped at all. The period itself was painful, with a heavy flow of slightly dark blood. The cycle was regular at 28 days and the period lasted 4–6 days. These were her presenting symptoms. On questioning, it transpired that her vision was sometimes blurred and she experienced dizziness and some tingling of the limbs. Her pulse was Fine on the right and Fine and slightly Wiry on the left. Her tongue was unremarkable apart from slightly orangey sides. Her complexion was dull and pale. Diagnosis This is a clear case of Liver-Qi stagnation occurring against a background of Blood deficiency. The clear symptoms of Liver-Qi stagnation are the premenstrual distension, the painful period and the slightly Wiry pulse. The symptoms and signs of Liver-Blood deficiency are: blurred vision, tingling of limbs, dull, pale complexion, dizziness, orangey sides of the tongue and the Fine pulse. Her pulse shows very clearly the dual conditions of deficiency and excess: in fact the Fine quality denotes Blood deficiency, while the Wiry quality (albeit slight) indicates stagnation. Treatment principle The treatment principle adopted was to nourish Liver-Blood and pacify the Liver. Acupuncture
The points used at various times were selected from the following: • LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to open and regulate the Directing Vessel.
• T.B.-6 Zhigou to move Liver-Qi and affect the sides of the chest and breast. • SP-6 Sanyinjiao and LIV-3 Taichong to pacify the Liver. Herbal treatment
I used only the Women’s Treasure remedy Freeing the Moon (one tablet three times a day) which pacifies the Liver and nourishes Liver-Blood. This patient was treated for 6 months, after which both the breast distension and the painful period were reduced by about 80%. Case history A 21-year-old woman had been suffering from pre-menstrual breast distension and pain ever since her periods first started. The problem lasted for about a week before the period. She also complained of irritability and depression. Her cycle was regular; the period lasted 7 days; it was not heavy but it took a long time to come to an end. In addition to these symptoms she also suffered from a feeling of heat, thirst, headaches and blood-shot eyes. Her pulse was slightly Wiry and Rapid. Her tongue was slightly Red, with a Red tip and many Red points on the sides. Diagnosis In this case, prolonged Liver-Qi stagnation has given rise to Liver-Fire. Compared with the previous case of Liver-Qi stagnation, this patient suffers from a purely excess condition (Liver-Qi stagnation and Fire) while the former patient suffers from a mixed excess and deficiency condition (of Liver-Qi stagnation and Liver-Blood deficiency). Her breast distension indicates Liver-Qi stagnation, while the pain in the breasts tends to denote the presence of Fire. This is clearly confirmed by the feeling of heat, the thirst, the blood-shot eyes, the Rapid pulse and the Red tongue. Treatment principle
The treatment principle adopted was to pacify the Liver, eliminate stagnation, drain Liver-Fire, calm the Mind and settle the Ethereal Soul. Herbal treatment
This patient did not want acupuncture and was treated only with herbs. The prescription used was Dan Zhi Xiao Yao San Moutan-Gardenia Free and Easy Wanderer Powder. • Bo He Herba Menthae haplocalycis 3 g • Chai Hu Radix Bupleuri 4 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 4 g • Fu Ling Poria 6 g • Shan Zhi Zi Fructus Gardeniae 4 g • Mu Dan Pi Cortex Moutan 6 g • Long Dan Cao Radix Gentianae 4 g • Suan Zao Ren Semen Ziziphi spinosae 4 g • Xia Ku Cao Spica Prunellae 4 g • Yuan Zhi Radix Polygalae 6 g • Qing Pi Pericarpium Citri reticulatae viride 3 g • Gan Cao Radix Glycyrrhizae 3 g
Explanation
The first eight herbs constitute the Dan Zhi Xiao Yao San which pacifies the Liver, eliminates stagnation and drains Liver-Fire. • Long Dan Cao and Xia Ku Cao were added to strengthen the Fire-draining effect. Xia Ku Cao specifically enters the breast and relieves swelling and pain. • Suan Zao Ren and Yuan Zhi calm the Mind and settle the Ethereal Soul. • Qing Pi moves Liver-Qi and specifically affects the breast. • Gan Cao harmonizes.
As this patient was very young, treatment was easier and she improved considerably within 3 months.
Lung-Qi stagnation
Clinical manifestations Pre-menstrual breast distension, pre-menstrual tension, worrying, crying, sighing, depression, a feeling of tightness or oppression of the chest. Tongue: normal body colour. Pulse: slightly Tight on the Lung position. Treatment principle Move Lung-Qi, settle the Corporeal Soul, calm the Mind. Acupuncture LU-7 Lieque, L.I.-4 Hegu, LU-3 Tianfu, Ren-17 Shanzhong. Reducing or even method. Explanation
– LU-7 and L.I.-4 regulate the ascending and descending of Qi and restore the descending of Lung-Qi. – LU-3 moves Lung-Qi, settles the Corporeal Soul and calms the Mind. – Ren-17 moves Lung-Qi in the chest. Herbal treatment
Prescription
– BAN XIA HOU PO TANG Variation – Pinellia-Magnolia Decoction Variation Explanation
– The root formula moves Heart- and Lung-Qi in the chest. – Bai He moves Lung-Qi and treats sadness. – He Huan Pi calms the Mind. – Qing Pi moves Qi in the breast. Three Treasures remedy
– OPEN THE HEART This remedy is a variation of Ban Xia Hou Po Tang. Summary Lung-Qi stagnation
Clinical manifestations
Pre-menstrual breast distension, pre-menstrual tension, worrying, crying,
sighing, depression, a feeling of tightness or oppression of the chest. Tongue: normal body colour. Pulse: slightly Tight on the Lung position. Treatment principle
Move Lung-Qi, settle the Corporeal Soul, calm the Mind. Acupuncture
LU-7 Lieque, L.I.-4 Hegu, LU-3 Tianfu, Ren-17 Shanzhong. Reducing or even method. Herbal treatment
Pre scription
• BAN XIA HOU PO TANG Variation Pinellia-Magnolia Decoction Variation Three Treasures remedy
• OPEN THE HEART
Heart-Qi stagnation
Clinical manifestations Pre-menstrual breast distension, palpitations, a feeling of distension or oppression of the chest, depression, a slight feeling of lump in the throat, slight shortness of breath, sighing, poor appetite, chest and upper epigastric distension, dislike of lying down, weak and cold limbs, slightly purple lips, pale complexion. Tongue: normal body colour or slightly Pale-Purple on the sides in the chest area. Pulse: Empty but very slightly Overflowing on the left Front position. Treatment principle Move Heart-Qi, calm the Mind. Acupuncture HE-5 Tongli, HE-7 Shenmen, P-6 Neiguan, Ren-15 Jiuwei, Ren-17 Shanzhong, LU-7 Lieque, ST-40 Fenglong. All with reducing or even method. Explanation
– HE-5 and P-6 move Heart-Qi. – HE-7 calms the Mind. – Ren-15 moves Heart-Qi and calms the Mind.
– Ren-17 moves Qi in the chest and breasts. – LU-7 helps to move Qi in the chest as the Lungs govern Qi. – ST-40 is used here not to resolve Phlegm but to assist the Heart in moving Qi in the chest. Herbal treatment
a Prescription
– MU XIANG LIU QI YIN – Aucklandia Flowing Qi Decoction Explanation This formula moves Heart-Qi and calms the Mind. – Mu Xiang, Ban Xia, Chen Pi, Hou Po, Qing Pi, Gan Cao. Xiang Fu and Zi Su Ye move Heart-Qi, calm the Mind and move Qi in the chest and breast. – Mu Gua regulates the Liver. – Shi Chan Pu opens the Mind’s orifices and contributes to calming the Mind. – Bai Zhu tonifies Qi. – Bai Zhi is used here to promote the descending of Qi.
– Mai Men Dong nourishes the Heart and Lungs and calms the Mind. – Cao Guo moves Qi. – Rou Gui warms Yang to help to move Qi. – E Zhu invigorates Blood. – Da Fu Pi and Bing Lang move Qi. – Ding Xiang and Huo Xiang help to move Qi. – Mu Tong penetrates the Connecting channels of the breast. As its use is illegal, it should be replaced with Tong Cao Medulla Tetrapanacis. b Prescription
– BAN XIA HOU PO TANG – Pinellia-Magnolia Decoction. Explanation This formula, already explained, moves Heart-Qi in the chest and breast. Three Treasures remedy
– OPEN THE HEART This remedy is a variation of Ban Xia Hou Po Tang. Summary
Heart-Qi stagnation
Clinical manifestations
Pre-menstrual breast distension, palpitations, a feeling of distension or oppression of the chest, depression, a slight feeling of lump in the throat, slight shortness of breath, sighing, poor appetite, chest and upper epigastric distension, dislike of lying down, weak and cold limbs, slightly purple lips, pale complexion. Tongue: normal body colour or slightly Pale-Purple on the sides in the chest area. Pulse: Empty but very slightly Overflowing on the left Front position. Treatment principle
Move Heart-Qi, calm the Mind. Acupuncture
HE-5 Tongli, HE-7 Shenmen, P-6 Neiguan, Ren-15 Jiuwei, Ren-17 Shanzhong, LU-7 Lieque, ST-40 Fenglong. All with reducing or even method. Herbal treatment
Pre scriptions
• MU XIANG LIU QI YIN Aucklandia Flowing Qi Decoction • BAN XIA HOU PO TANG Pinellia-Magnolia Decoction Three Treasures remedy
• OPEN THE HEART
Liver-Blood stasis
Clinical manifestations Pre-menstrual breast distension and pain which is greatly alleviated by the onset of the period, hardness of the breasts, irregular periods, period starting and stopping, dark blood with clots, abdominal pain, mental restlessness. Tongue: Purple. Pulse: Wiry or firm. Treatment principle Invigorate Blood, eliminate stasis, pacify the Liver and regulate the periods. Acupuncture LIV-3 Taichong, G.B.-34 Yanglingquan, G.B.-41 Zulinqi, LIV-14 Qimen, ST-18 Rugen, T.B.-6 Zhigou, G.B.-21 Jianjing, P-6 Neiguan, SP-10 Xuehai, BL-17 Geshu, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left). All with reducing or even method. Explanation The first eight points are the same as those given for Qi stagnation and have already been explained. All points that move Qi also move Blood. – SP-10 and BL-17 invigorate Blood. – SP-4 and P-6 open the Penetrating Vessel which is the Sea of Blood: these two points can therefore move Blood, pacify the Liver and penetrate the Connecting channels, thus relieving breast distension.
Herbal treatment
a Prescription
– WU XIANG WAN and TONG YU JIAN – Five Aromatic Pill and Eliminating Stasis Decoction Explanation
– Wu Ling Zhi, Dang Gui and Hong Hua move Blood and eliminate stasis. – Xiang Fu, Wu Yao, Qing Pi and Mu Xiang pacify the Liver and move Qi. – Ze Xie resolves Dampness and Phlegm and is added because there is an interaction between Body Fluids and Blood and between Phlegm and stasis of Blood. – Shan Zha moves Blood and eliminates stasis. b. Prescription
– SHU QI HUO LUO TANG – Pacifying Qi and Invigorating the Connecting Channels Decoction Explanation
– Dan Shen, Yu Jin, Ze Lan, Wang Bu Liu Xing and Chuan Shan Jia invigorate Blood and eliminate stasis. Yu Jin, Wang Bu Liu Xing and Chuan Shan Jia specifically affect the breast. – Xiang Fu and Chai Hu move Qi and eliminate stagnation. – Gua Lou resolves Phlegm and softens the breasts. Compared with the previous formula, this prescription has a stronger Blood-invigorating effect and it also resolves Phlegm. It is therefore suitable if the breasts are swollen and painful and the tongue body is Swollen. Three Treasures remedy
– RED STIRRING This remedy is a variation of Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction which invigorates Blood in the Upper Burner. Summary Liver-Blood stasis
Clinical manifestations
Pre-menstrual breast distension and pain which is greatly alleviated by the onset of the period, hardness of the breasts, irregular periods, period starting and stopping, dark blood with clots, abdominal pain, mental restlessness. Tongue: Purple. Pulse: Wiry or firm. Treatment principle
Invigorate Blood, eliminate stasis, pacify the Liver and regulate the periods. Acupuncture
LIV-3 Taichong, G.B.-34 Yanglingquan, G.B.-41 Zulinqi, LIV-14 Qimen, ST-18 Rugen, T.B.-6 Zhigou, G.B.-21 Jianjing, P-6 Neiguan, SP-10 Xuehai, BL-17 Geshu, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left). All with reducing or even method. Herbal treatment
Pre scriptions
• WU XIANG WAN and TONG YU JIAN Five Aromatic Pill and Eliminating Stasis Decoction • SHU QI HUO LUO TANG Pacifying Qi and Invigorating the Connecting Channels Decoction Three Treasures remedy
• RED STIRRING
Damp-Heat
Clinical manifestations Pre-menstrual breast distension, nipple tenderness, possibly discharge from the nipple, a feeling of fullness of the epigastrium, sticky taste, a feeling of heaviness, excessive vaginal discharge. Tongue: sticky-yellow coating. Pulse: Slippery-Rapid. Treatment principle Resolve Dampness, clear Heat, clear the Liver. Acupuncture G.B.-41 Zulinqi on the right with T.B.-5 Waiguan on the left, ST-18 Rugen, G.B.-21 Jianjing, LIV-14 Qimen, LIV-3 Taichong, Ren-9 Shuifen, SP-9 Yinlingquan. All with even or reducing method. Explanation
– G.B.-41 and T.B.-5 regulate the Girdle Vessel (Dai Mai) which resolves Dampness from the Liver and Gall Bladder channels. – ST-18 and G.B.-21 resolve Dampness from the breast. – LIV-14 and LIV-3 resolve Dampness from the Liver channel. – Ren-9 and SP-9 resolve Dampness.
Herbal treatment
Prescription
– SAN REN TANG – Three Seeds Decoction Explanation This formula resolves Damp-Heat from the Liver, Gall Bladder and Spleen. It is suitable to treat Damp-Heat in the breast due to the presence of Xing Ren, Tong Cao and Hou Po. – Xing Ren enters the Lung channel which affects the breasts. By making Qi descend, it helps to resolve Dampness. – Bai Dou Kou, Yi Yi Ren and Hua Shi resolve Dampness. – Tong Cao penetrates the Connecting channels of the breast. – Zhu Ye clears Heat. – Ban Xia helps to resolve Dampness. – Hou Po moves Qi and resolves Dampness. Summary Damp-Heat
Clinical manife stations
Pre-menstrual breast distension, nipple tenderness, possibly discharge from the nipple, a feeling of fullness of the epigastrium, sticky taste, a feeling of heaviness, excessive vaginal discharge. Tongue: sticky-yellow coating. Pulse: Slippery-Rapid. Tre atme nt principle
Resolve Dampness, clear Heat, clear the Liver. Acupuncture
G.B.-41 Zulinqi (on the right) with T.B.-5 Waiguan (on the left), ST-18 Rugen, G.B.-21 Jianjing, LIV-14 Qimen, LIV-3 Taichong, Ren-9 Shuifen, SP-9 Yinlingquan. All with even or reducing method. He rbal tre atme nt
Prescription
• SAN REN TANG Three Seeds Decoction
Phlegm with Qi stagnation
Clinical manifestations Pre-menstrual breast distension, very swollen and enlarged breasts, there may be nodules on palpation, a feeling of oppression of the chest, a sticky taste, irritability, irregular periods, obesity. Tongue: Swollen with a sticky coating. Pulse: Slippery or Wiry or both Slippery and Wiry. Treatment principle Pacify the Liver, eliminate stagnation, penetrate the Connecting channels, resolve Phlegm. Acupuncture LIV-3 Taichong, T.B.-6 Zhigou, G.B.-41 Zulinqi, G.B.-34 Yanglingquan, P6 Neiguan, Ren-12 Zhongwan, SP-9 Yinlingquan, ST-40 Fenglong, SP-6 Sanyinjiao, ST-18 Rugen, BL-22 Sanjiaoshu, BL-20 Pishu. All with reducing or even method except for Ren-12 and BL-20 which should be reinforced. Explanation
– LIV-3, T.B.-6, G.B.-41 and G.B.-34 all pacify the Liver and eliminate stagnation. In particular, T.B.-6 affects the general area to the sides of the breast and G.B.-41 affects the breast itself. – P-6 indirectly moves Liver-Qi (due to its connection with the Liver channel within the Terminal Yin), it affects the chest area and therefore the
breast, it calms the Mind and it settles the Ethereal Soul. – Ren-12, SP-9, ST-40, SP-6, BL-22 and BL-20 resolve Dampness and Phlegm. In particular, ST-40 will affect the chest area and therefore the breast. – ST-18 resolves Phlegm and specifically affects the chest. Herbal treatment
a Prescription
– JIA WEI XIAO YAO SAN – Augmented Free and Easy Wanderer Powder Explanation
– Chai Hu, Yu Jin and Qing Pi pacify the Liver and eliminate stagnation. Qing Pi and Yu Jin enter the breast. – Chen Pi, Ju He, Ban Xia and Gua Lou resolve Dampness and Phlegm. Chen Pi and Ju He also move Qi. – Dang Gui and Bai Shao nourish Blood. b Prescription
– JIAN PI SHU YU TANG – Strengthening the Spleen and Pacifying Stagnation Decoction Explanation
– Bai Zhu, Fu Ling and Chen Pi tonify the Spleen, resolve Dampness and move Qi. – Yi Yi Ren drains Dampness and softens the breasts. – Xiang Fu and Chuan Lian Zi move Qi, eliminate stagnation and pacify the Liver. – He Huan Pi moves Qi, eliminates stagnation, calms the Mind and settles the Ethereal Soul. – Tong Cao removes obstructions from the Connecting channels of the breast. Compared with the previous formula, this prescription tonifies SpleenQi and therefore addresses also the underlying cause for the development of Phlegm. It is therefore indicated when there are symptoms of Spleen deficiency such as tiredness, poor appetite and loose stools and the pulse is Weak on the whole (albeit also slightly Slippery). Summary Phlegm with Qi stagnation
Clinical manife stations
Pre-menstrual breast distension, very swollen and enlarged breasts, there
may be nodules on palpation, a feeling of oppression of the chest, a sticky taste, irritability, irregular periods, obesity. Tongue: Swollen with a sticky coating. Pulse: Slippery or Wiry or both Slippery and Wiry. Tre atme nt principle
Pacify the Liver, eliminate stagnation, penetrate the Connecting channels, resolve Phlegm. Acupuncture
LIV-3 Taichong, T.B.-6 Zhigou, G.B.-41 Zulinqi, G.B.-34 Yanglingquan, P6 Neiguan, Ren-12 Zhongwan, SP-9 Yinlingquan, ST-40 Fenglong, SP-6 Sanyinjiao, ST-18 Rugen, BL-22 Sanjiaoshu, BL-20 Pishu. All with reducing or even method except for Ren-12 and BL-20 which should be reinforced. He rbal tre atme nt
Prescriptions
• JIA WEI XIAO YAO SAN Augmented Free and Easy Wanderer Powder • JIAN PI SHU YU TANG Strengthening the Spleen and Pacifying Stagnation Decoction
Case history A 35-year-old woman had been suffering from very intense breast distension, swelling and enlargement for many years. She also developed a pustular rash before the period which then took a long time to clear up. She also complained of a feeling of heaviness and oppression of the chest. She was quite overweight. The cycle was usually short (24–25 days) and the period lasted 4 days. She suffered from lower backache. Her pulse was very Weak on the left Kidney position and her tongue was Swollen (Plate 6). In the previous 2 years, she had experienced several bereavements with the loss
of several close friends. Diagnosis
In this case there is both stagnation of Liver-Qi and Phlegm, the former causing the breast distension and the latter the breast enlargement and swelling. Phlegm is also evidenced by the obesity, the pustular rash on the breast, the feeling of heaviness and oppression of the chest, and the Swollen tongue. Besides these two pathogenic factors there is also an underlying Kidney deficiency (Weak pulse on Kidney position and backache). Given the long duration of the problem, the Kidney deficiency is at the root of the Liver-Qi stagnation and must be dealt with at some stage of the treatment. Treatment principle
The treatment principle adopted was to pacify the Liver, eliminate stagnation and resolve Phlegm first. At a later stage, the Kidneys should be tonified. This patient was treated only with herbal medicine because she had been referred by her acupuncturist and was therefore already receiving acupuncture. I used a variation of the formula Jia Wei Xiao Yao San: • Chai Hu Radix Bupleuri 6 g • Qing Pi Pericarpium Citri reticulatae viride 4 g • Chen Pi Pericarpium Citri reticulatae 3 g • Yu Jin Radix Curcumae 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Gua Lou Fructus Trichosanthis 5 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g
• He Huan Pi Cortex Albiziae 6 g • Yuan Zhi Radix Polygalae 6 g Explanation
The first eight herbs constitute the formula Jia Wei Xiao Yao San minus Ju He to pacify the Liver, eliminate stagnation and resolve Phlegm. • He Huan Pi and Yuan Zhi were added to calm the Mind and settle the Ethereal Soul, due to her many bereavements.
After a few courses this prescription was changed, removing some herbs and adding others such as Bai Xian Pi Cortex Dictamni to treat the breast rash, Xia Ku Cao Spica Prunellae and Pu Gong Ying Herba Taraxaci to resolve Phlegm from the breast and Xu Duan Radix Dipsaci to tonify Kidney-Yang. After 9 months of treatment, the breast distension and swelling were very much reduced and I continued the treatment by tonifying KidneyYang with a variation of You Gui Wan Restoring the Right [Kidney] Pill: • Rou Gui Cortex Cinnamomi 2 g • Du Zhong Cortex Eucommiae 6 g • Shan Zhu Yu Fructus Corni 4.5 g • Tu Si Zi Semen Cuscutae 6 g • Lu Jiao Jiao Colla Corni Cervi 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Gou Qi Zi Fructus Lycii 6 g • Dang Gui Radix Angelicae sinensis 4.5 g • Qing Pi Pericarpium Citri reticulatae viride 3 g
• Yuan Zhi Radix Polygalae 6 g • He Huan Pi Cortex Albiziae 4 g • Gua Lou Fructus Trichosanthis 6 g Explanation
The first nine herbs constitute the formula You Gui Wan minus Fu Zi Radix Aconiti lateralis preparata to tonify Kidney-Yang and strengthen the back. • Qing Pi was added to move Liver-Qi and treat the breast specifically. • Yuan Zhi and He Huan Pi were added to calm the Mind and settle the Ethereal Soul. • Gua Lou was added to resolve Phlegm.
After another 3 months with treatment along these lines, the breast distension and swelling did not recur and treatment could be stopped.
Kidney- and Liver-Yin deficiency
Clinical manifestations Breast distension that is less severe than that in the previous pattern and may occasionally (but rarely) occur after the period, malar flush, mental restlessness, insomnia, night sweating, dry throat. Tongue: without coating; also Red if there is Empty-Heat. Pulse: Fine but also slightly Wiry often on one side only. This pattern is likely to occur in older women. Treatment principle Nourish Liver and Kidneys, nourish Yin, pacify the Liver. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-7 Yinjiao, SP-6 Sanyinjiao, KI-3 Taixi, LIV-3 Taichong, P-7 Daling, HE-6 Yinxi and KI-2 Rangu. Reinforcing method on all points except LIV-3 and P-7 which should be needled with reducing or even method. No moxa. Explanation
– LU-7 and KI-6 open the Directing Vessel, tonify the Kidneys, nourish Yin and regulate the Uterus. – Ren-4 and Ren-7 nourish Yin and tonify the Kidneys.
– SP-6 and KI-3 tonify the Kidneys and Liver. – LIV-3 and P-7 in combination pacify the Liver, eliminate stagnation, calm the Mind and settle the Ethereal Soul. – HE-6 and KI-2 need only be used if there are pronounced Empty-Heat signs. Herbal treatment
a Prescription
– YI GUAN JIAN – One Linking Decoction Explanation
– Bei Sha Shen and Mai Men Dong nourish Yin. – Dang Gui nourishes Liver-Blood. – Sheng Di Huang and Gou Qi Zi nourish Kidney- and Liver-Yin. – Chuan Lian Zi moves Liver-Qi without injuring Yin (unlike most other Qi-moving herbs, due to their pungent-warm taste). Modifications
• If there is a pronounced Kidney-Yang deficiency and the breasts are soft, add some Kidney-Yang tonics such as Tu Si Zi Semen Cuscutae, Fu Pen Zi Fructus Rubi, Xu Duan Radix Dipsaci, Lu Jiao Shuang Cornu Cervi degelatinatum, Rou Gui Cortex Cinnamomi, Xian Ling Pi Herba Epimedii, and Xiang Fu Rhizoma Cyperi and He Huan Pi Cortex Albiziae to pacify the Liver. b Prescription
– ROU GAN ZHI TONG TANG – Softening the Liver and Stopping Pain Decoction Explanation
– Dang Gui, Shou Wu, Nu Zhen Zi and Wu Mei nourish the Liver and nourish Yin. – Lu Lu Tong removes obstructions from the Connecting channels of the breast. – Hou Po moves Qi, eliminates stagnation and relaxes the chest and breast. – Gan Cao harmonizes. The formula Yi Guan Jian only nourishes Liver-Yin while the present formula Rou Gan Zhi Tong Tang nourishes Liver-Yin and also moves LiverQi and removes obstructions from the breast Connecting channels. Three Treasures remedy
– NOURISH THE ROOT This remedy is a variation of Zuo Gui Wan Restoring the Left [Kidney] Pill to nourish Kidney- and Liver-Yin. It is particularly suitable in gynecology because it contains Gui Ban Jiao which nourishes the Directing and Penetrating Vessels. The tongue presentation appropriate to this remedy is a Red body without coating. Summary Kidney- and Liver-Yin deficiency
Clinical manifestations
Breast distension that is less severe than that in the previous pattern and may occasionally (but rarely) occur after the period, malar flush, mental restlessness, insomnia, night sweating, dry throat. Tongue: without coating; also Red if there is Empty-Heat. Pulse: Fine but also slightly Wiry often on one side only. Treatment principle
Nourish Liver and Kidneys, nourish Yin, pacify the Liver. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-7 Yinjiao, SP-6 Sanyinjiao, KI-3 Taixi, LIV-3 Taichong, P-7 Daling, HE-6 Yinxi and KI-2 Rangu. Reinforcing method on all points except LIV-3 and P-7 which should be needled with reducing or even method. No moxa. Herbal treatment
Pre scriptions
• YI GUAN JIAN One Linking Decoction • ROU GAN ZHI TONG TANG Softening the Liver and Stopping Pain Decoction Three Treasures remedy
• NOURISH THE ROOT
Prognosis and prevention Generally speaking, acupuncture and herbal medicine are equally effective in treating pre-menstrual breast distension. The pattern that will take the longest to treat is probably that of Phlegm with Stagnation of Liver-Qi because Phlegm is notoriously difficult to resolve. As with every menstrual irregularity, it will take a very minimum of three menstrual cycles to see any result. Breast distension that has occurred from menarche time is more difficult to treat. As for prevention and lifestyle advice, the most important aspect is the mental–emotional attitude. The patient should obviously deal with any emotional stress and try to relax. If she is suffering from emotional stress which has rather deep roots in childhood patterns (which often manifest with a Heart crack on the tongue), she might benefit from enlisting the help of a good counsellor or psychotherapist. It is especially important for women suffering from Phlegm to avoid eating dairy foods, raw, cold foods and greasy foods. Women suffering from Kidney- and Liver-Yin deficiency should learn to rest more and not work too long hours. End note 1. Chen You Bang 1990 Chinese Acupuncture Therapy (Zhong Guo Zhen Jiu Zhi Liao Xue
), China Scientific Publishing House, Beijing, p. 868..
CHAPTER 20 Headaches During Periods
AETIOLOGY 395 PATHOLOGY 395 IDENTIFICATION OF PATTERNS AND TREATMENT 396 Blood deficiency 396 Liver-Fire blazing 398 Liver-Yang rising 398 Blood stasis 401 PROGNOSIS AND PREVENTION 402 Headache occurring at period time is an extremely common problem. When chronic headache is linked to the menstrual cycle it must be treated by regulating the menses and the Uterus, plus any other treatment that may be called for. Headaches at period time may occur before, during or after the period; the incidence is more or less equal. As a rough guide, headaches occurring before the period are due to Qi or Blood stagnation; headaches during the period, to Liver-Yang rising; headaches after the period, to Blood deficiency. However, this is only a rough diagnostic guide and, in practice, there may be deviations from the above rule.
Aetiology
Excessive physical work Excessive physical work, including sports, may injure the Spleen and lead to Qi and Blood deficiency. Blood deficiency is aggravated after the period because at this time the Penetrating Vessel, which is the Sea of Blood, is in a state of relative emptiness. Deficient Blood fails to nourish the Brain and this results in deficient-type headaches which usually occur during or after the period. Emotional stress Anger, repressed anger, resentment, frustration, worry and guilt may lead to Liver-Qi stagnation which may turn into Fire. Liver-Fire has the tendency to flare upwards, all the more so during the periods when the Qi of the Penetrating Vessel may rebel upwards. This causes headaches before or during the period. Another possibility is that emotional strain leads to deficiency of LiverBlood and/or Liver-Yin and the ensuing uprising of Liver-Yang. This also leads to headaches before or during the period. Yet another possibility is that Liver-Qi stagnation gives rise to LiverBlood stasis; when this happens, Blood accumulates and does not flow into the Uterus and Penetrating Vessel properly at period time. Since the Liver channel enters the Brain, this condition of Blood stasis may cause headaches before or during the period.
Pathology The main pathological conditions causing headaches at period time are: • Blood deficiency • Liver-Fire blazing • Liver-Yang rising • Blood stasis. Blood deficiency and Liver-Yang rising tend to occur in women with a background of deficiency, i.e. deficiency of Blood and/or Yin, while LiverFire and Blood stasis tend to occur in women with a Yang constitution and a tendency to Full conditions.
Identification of patterns and treatment
Blood deficiency
Clinical manifestations Dull headaches on the vertex during or after the period, dizziness, palpitations, insomnia, blurred vision, tiredness, dull, pale complexion. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle Strengthen the Liver and Heart, nourish Blood. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, BL-20 Pishu, BL-18 Ganshu, BL-23 Shenshu. All with reinforcing method; moxa can be used on Ren-4, ST-36 and SP-6. Explanation
– LU-7 and KI-6 open and regulate the Directing Vessel and the Uterus. They also nourish Blood and Yin. – Ren-4 nourishes Blood and strengthens the Uterus. It is very effective when used with direct moxa cones. – ST-36 and SP-6 tonify Qi and Blood. When needled with warm needle, they are extremely effective.
– LIV-8 nourishes Liver-Blood. – BL-20 and BL-23 tonify Spleen and Kidney to produce Blood. – BL-18, in conjunction with the above points, nourishes Liver-Blood. Herbal treatment
Prescription
– BA ZHEN TANG Variation – Eight Precious Decoction Variation Explanation The first eight herbs constitute the Ba Zhen Tang which tonifies Qi and Blood. – Gou Qi Zi and Shou Wu strengthen the Blood-nourishing effect. – Ju Hua and Gou Teng subdue Liver-Yang. I add these two herbs even if there are no signs of Liver-Yang rising to alleviate the headaches and direct the formula to the head and eyes. Modifications
• If there are pronounced signs of Qi deficiency, add Huang Qi Radix Astragali.
• If the headaches are chronic and have been present for many years, in an older woman, add (Zhi) Lu Jiao Cornu Cervi (toasted) and Gui Ban Plastrum Testudinis to fill the Marrow and Essence and tonify the Brain. Three Treasures remedy
– BRIGHTEN THE EYES This remedy aims at treating eye problems deriving from Blood deficiency. However, it is also suitable to treat deficiency-type headaches from Blood deficiency as some of the herbs that reach the eyes also treat headaches, e.g. Ju Hua, Man Jing Zi and Bai Ji Li. Women’s Treasure remedy
– PRECIOUS SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. It has been modified with the addition of Kidney tonics. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Blood deficiency
Clinical manifestations
Dull headaches on the vertex during or after the period, dizziness, palpitations, insomnia, blurred vision, tiredness, dull, pale complexion.
Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle
Strengthen the Liver and Heart, nourish Blood. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, BL-20 Pishu, BL-18 Ganshu, BL-23 Shenshu. All with reinforcing method; moxa can be used on Ren-4, ST-36 and SP-6. Herbal treatment
Pre scription
• BA ZHEN TANG Variation Eight Precious Decoction Variation Three Treasures remedy
• BRIGHTEN THE EYES Women’s Treasure remedy
• PRECIOUS SEA
Case history A 52-year-old woman suffered from headaches occurring after the period. Her periods were still coming regularly but were rather scanty. Her
hair was falling out and her skin was dry. She had never been able to conceive although she tried for many years. She also felt very weary and depressed, especially so after her period. She also lacked any motivation and ‘everything was an effort’. She found it difficult to fall asleep and had had a lump in her left breast for 20 years. Her iron storage level was very low (3). Her pulse was very Weak and Empty on the deep level but also slightly Fine and Wiry on the left. Her tongue was Pale on the sides, had a Heart crack and a rootless coating. Diagnosis This is quite a complex condition. The main pattern that emerges is that of Liver-Blood deficiency manifesting with scanty periods, hair falling out, dry skin, infertility, insomnia, a Fine pulse and a Pale tongue on the sides. There are, however, other patterns that manifest with only a few symptoms. The Wiry quality of the pulse indicates that there is some stagnation of Liver-Qi from emotional stress, also evidenced by the Heart crack on the tongue. The stagnation of Liver-Qi was a contributory factor to the development of the breast lump, another being Phlegm (as the lump felt soft to the touch). Yet another pattern is a Kidney-Yin deficiency, again manifesting with few symptoms and principally the emptiness of the pulse at the deep level, the rootless tongue coating and the lack of motivation and exhaustion. The falling hair and dry skin attributed to Liver-Blood deficiency may also be caused by Kidney-Yin deficiency, or this may contribute to them. To sum up, there are two excess conditions (stagnation of Liver-Qi and Phlegm) and two deficiency ones (Liver-Blood and Kidney-Yin deficiency). In addition, this may be classified as a case of Mind Weakened, i.e. low spirits, depression, lack of motivation and physical and mental exhaustion. Treatment principle The headaches occurring after the period were her main presenting symptom and they were due to Liver-Blood deficiency. I therefore started by treating
her with a variation of the formula Ba Zhen Tang Eight Precious Decoction: • Dang Gui Radix Angelicae sinensis 10 g • Chuan Xiong Rhizoma Chuanxiong 5 g • Bai Shao Radix Paeoniae alba 8 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 10 g • Fu Ling Poria 8 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Gou Qi Zi Fructus Lycii 6 g • Gui Ban Plastrum Testudinis 10 g • Ju Hua Flos Chrysanthemi 4 g • He Huan Pi Cortex Albiziae 4 g • Gua Lou Fructus Trichosanthis 6 g
Explanation The first eight herbs constitute the formula Ba Zhen Tang. • Gou Qi Zi and Gui Ban were added to nourish the Liver and Kidneys. Gui Ban also nourishes the Directing and Penetrating Vessels. • Ju Hua was added to relieve the headaches. • He Huan Pi moves Liver-Qi and calms the Mind. • Gua Lou resolves Phlegm and affects the breast.
After one course (30 days) of this formula, this patient felt a lot better in herself and her headaches disappeared. Her iron storage levels also climbed to 13. The patient is still under treatment and I foresee that she will probably eventually need to change to a formula to nourish Kidney-Yin and Blood.
Liver-Fire blazing
Clinical manifestations Severe throbbing headaches in the temples, eyes or sides of the head before or during the period, heavy menstrual flow, dizziness, flashes in the eyes, bitter taste, thirst, red face, dry stools, dark urine, irritability. Tongue: Red with yellow coating and redder sides. Pulse: Wiry and Rapid. Treatment principle Clear the Liver, drain Fire, nourish Yin, subdue Yang. Acupuncture LIV-2 Xingjian, T.B.-5 Waiguan, G.B.-43 Xiangu, LIV-3 Taichong, L.I.-4 Hegu, L.I.-11 Quchi, SP-6 Sanyinjiao, KI-3 Taixi, Taiyang, G.B.-5 Xuanlu, G.B.-6 Xuanli, G.B.-9 Tianchong. All with reducing or even method. No moxa. Explanation
– LIV-2 is the main point to drain Liver-Fire. – T.B.-5 subdues Yang and is excellent for headaches from a Liver pathology occurring on the Gall Bladder channel, due to its relationship with this channel within the Lesser Yang. – G.B.-43 subdues Yang and treats headaches occurring along the Gall
Bladder channel in the temple or in the eye. – LIV-3 subdues Yang, calms the Mind and settles the Ethereal Soul. – L.I.-4 regulates the ascending and descending of Qi and therefore helps to subdue ascending Liver-Fire. In combination with LIV-3, it subdues Yang and calms the Mind. – L.I.-11 is used if there are pronounced signs of Heat. – SP-6 and KI-3 are used to nourish Yin to protect it from injury from Fire. – Taiyang, G.B.-5, G.B.-6 and G.B.-9 are local points to be selected according to the location of the headaches. Herbal treatment
Prescription
– LONG DAN XIE GAN TANG Variation – Gentiana Draining the Liver Decoction Variation Explanation The first 10 herbs constitute the formula Long Dan Xie Gan Tang which drains Liver-Fire. – Gou Teng and Bai Ji Li subdue Liver-Yang and alleviate headaches.
Three Treasures remedy
– DRAIN FIRE This remedy is a variation of the formula Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction which drains Liver-Fire. The tongue presentation appropriate to this remedy is a Red body with redder sides and with a dry, yellow coating. Summary Liver-Fire blazing
Clinical manifestations
Severe throbbing headaches in the temples, eyes or sides of the head before or during the period, heavy menstrual flow, dizziness, flashes in the eyes, bitter taste, thirst, red face, dry stools, dark urine, irritability. Tongue: Red with yellow coating and redder sides. Pulse: Wiry and Rapid. Treatment principle
Clear the Liver, drain Fire, nourish Yin, subdue Yang. Acupuncture
LIV-2 Xingjian, T.B.-5 Waiguan, G.B.-43 Xiangu, LIV-3 Taichong, L.I.-4 Hegu, L.I.-11 Quchi, SP-6 Sanyinjiao, KI-3 Taixi, Taiyang, G.B.-5 Xuanlu, G.B.-6 Xuanli, G.B.-9 Tianchong. All with reducing or even method. No moxa.
Herbal treatment
Pre scription
• LONG DAN XIE GAN TANG VariationGentiana Draining the Liver Decoction Variation Three Treasures remedy
• DRAIN FIRE
Liver-Yang rising
Clinical manifestations Throbbing headache in the temples, eyes or sides of the head before or during the period, irritability, dizziness, flashing lights in the eyes. Tongue: the body colour may be unchanged or Pale if Liver-Yang rising derives from Liver-Blood deficiency. Pulse: Wiry, or Wiry on the left and Fine on the right. Treatment principle Nourish Liver-Blood and Liver-Yin, subdue Liver-Yang. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-3 Taixi, LIV-8 Ququan, T.B.-5 Waiguan, P-6 Neiguan, G.B.-43 Xiangu, LIV-3 Taichong, Taiyang, G.B.-5 Xuanlu, G.B.-6 Xuanli, G.B.-9 Taichong. Ren-4, SP-6, KI-3 and LIV-8 should be needled with reinforcing method; all the others with reducing or even method. Explanation
– LU-7 and KI-6 open and regulate the Directing Vessel and the Uterus. They also nourish Blood and Yin. – Ren-4 nourishes Liver-Blood. – SP-6, KI-3 and LIV-8 nourish Liver-Blood and Liver-Yin.
– T.B.-5 subdues Wind and Liver-Yang and is excellent for headaches from a Liver pathology occurring on the Gall Bladder channel, due to its relationship with this channel within the Lesser Yang. – P-6 helps to subdue Liver-Yang (due to its relationship with the Liver channel within the Terminal Yin), calms the Mind and settles the Ethereal Soul. – G.B.-43 is the main distal point to treat headache in the temple deriving from Liver-Yang rising. – LIV-3 is the main distal point to subdue Liver-Yang rising. – Taiyang, G.B.-5, G.B.-6 and G.B.-9 are local points to be selected according to the location of the headaches. Herbal treatment
a Prescription
– TIAN MA GOU TENG YIN – Gastrodia-Uncaria Decoction Explanation This a modern formula that is used frequently for headaches from Liver-Yang rising. – Tian Ma, Gou Teng and Shi Jue Ming subdue Liver-Yang and alleviate headaches.
– Sang Ji Sheng and Du Zhong tonify Liver and Kidneys to help to anchor Liver-Yang downwards. – Chuan Niu Xi is used as a messenger to attract Qi downwards and thus help to subdue Liver-Yang. – Shan Zhi Zi and Huang Qin clear any Liver-Heat that there might be. – Yi Mu Cao moves Liver-Blood and reduces the blood pressure. – Ye Jiao Teng and Fu Shen calm the Mind, settle the Ethereal Soul and promote sleep. This is important as, if the patient does not sleep well, it will be very difficult to make any progress on the headaches. b Prescription
– QI JU DI HUANG WAN Variation – Lycium-Chrysanthemum-Rehmannia Pill Variation Explanation This formula is used in preference to the previous one when there is a pronounced deficiency of Liver-Yin and Kidney-Yin. It is, of course, a variation of the famous Liu Wei Di Huang Wan Six Ingredients Rehmannia Pill. The first eight herbs constitute the formula Qi Ju Di Huang Tang. – Gou Teng, Tian Ma and Bai Ji Li are added to subdue Liver-Yang and treat the headaches. Three Treasures remedy
– BEND BAMBOO This remedy is specific to treat headaches from Blood deficiency and Liver-Yang rising. The tongue presentation appropriate to this remedy is a Pale and Thin body indicating Blood deficiency. If there is a tendency to Yin deficiency, the body might be slightly Red and with insufficient coating. Summary Liver-Yang rising
Clinical manifestations
Throbbing headache in the temples, eyes or sides of the head before or during the period, irritability, dizziness, flashing lights in the eyes. Tongue: the body colour may be unchanged or Pale if Liver-Yang rising derives from Liver-Blood deficiency. Pulse: Wiry, or Wiry on the left and Fine on the right. Treatment principle
Nourish Liver-Blood and Liver-Yin, subdue Liver-Yang. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-3 Taixi, LIV-8 Ququan, T.B.-5 Waiguan, P-6 Neiguan, G.B.-43 Xiangu, LIV-3 Taichong, Taiyang, G.B.-5 Xuanlu, G.B.-6 Xuanli, G.B.-9 Taichong. Ren-4, SP-6, KI-3 and LIV-8 should be needled with reinforcing method; all the others with reducing or even method. Herbal treatment
Pre scriptions
• TIAN MA GOU TENG YIN Gastrodia-Uncaria Decoction • QI JU DI HUANG WAN Variation Lycium-Chrysanthemum-Rehmannia Pill Variation Three Treasures remedy
• BEND BAMBOO
Case history A 45-year-old woman had been suffering from severe headaches since the age of 16. These occurred with regularity at mid-cycle and were of a throbbing character. They occurred over the eyes and were accompanied by dizziness, blurred vision and nausea. She tried hormone replacement therapy for 18 months but this only made the headaches worse. She also suffered from backache, tinnitus and night sweating. Her periods came regularly every 26 days and lasted about 4–5 days; they were not painful and the blood was not particularly dark. Her urination was frequent and the urine pale and she suffered from cold feet. Her pulse was very Weak on both Rear positions and her tongue was Pale and Swollen. Diagnosis This is a clear example of headache from Liver-Yang rising: the throbbing character of the headache, the dizziness, blurred vision, nausea and location of the headache, all clearly indicate this pattern. In this case, Liver-Yang rising originates from a Kidney deficiency: although it may seem strange, it was in this case a Kidney-Yang deficiency. This can happen because, as was
pointed out several times, the Yin and Yang aspects of the Kidneys are not separate but an indivisible whole; thus when they are deficient, especially in women over 40, nearly always both Yin and Yang are deficient, albeit in different degrees. That it is Kidney-Yang deficiency is clear from the Pale colour of the tongue, the frequent urination and the chilliness. Treatment principle The treatment principle adopted was to tonify the Kidneys and subdue LiverYang. She was treated with acupuncture and prepared remedies. With acupuncture, I selected points from the following: • LU-7 Lieque (on the right) and KI-6 (on the left) to open and regulate the Directing Vessel. I did this because of the occurrence of the headaches at midcycle with regularity. • Ren-4 Guanyuan to nourish the Kidneys and strengthen the Directing Vessel. • T.B.-5 Waiguan to subdue Liver-Yang and treat the headaches. • ST-36 Zusanli, SP-6 Sanyinjiao and KI-3 Taixi to tonify the Liver and Kidneys. • LIV-3 Taichong to subdue Liver-Yang. • G.B.-20 Fengchi to subdue Liver-Yang.
As a prepared remedy, I prescribed the Three Treasures’ Bend Bamboo which nourishes the Liver and Kidneys and subdues Liver-Yang. After four treatments, the headaches were reduced in intensity and did not occur at mid-cycle any longer. When menstrual headaches lose their relation with the periods, I usually interpret this as a good sign: it means that the menstrual function is regulated and the residual headaches, although still occurring because the basic pattern is still there (in this case Liver-Yang rising), no longer occur in conjunction with the period. After another 30 treatments (at 2-week intervals), her headaches all but disappeared.
Case history A 40-year-old woman had been suffering from headaches before and after the period: interestingly, the headaches had started after an operation for sterilization (tube ligation). The headaches were located behind the eyes, on either side, and were throbbing in nature; they were accompanied by nausea, blurred vision, a bitter taste, thirst and dizziness. Her periods were regular and rather scanty. On interrogation, it transpired that she also suffered from palpitations, dizziness, tingling of her limbs, poor memory, blurred vision and night sweating. Her tongue was Pale and Swollen and her pulse was Choppy and Weak, particularly on both Rear positions. Diagnosis The headaches are typical of Liver-Yang rising with their throbbing character, dizziness, blurred vision and nausea. The bitter taste and thirst also indicated some Liver-Fire. The origin of Liver-Yang rising was primarily Liver-Blood deficiency as was clearly shown by the blurred vision, dizziness, poor memory, tingling, scanty periods, Pale tongue, Choppy pulse and palpitations (this last symptom due to Liver-Blood deficiency affecting Heart-Blood). There was a slight Kidney deficiency as evidenced by the night sweating and Weak pulse on both Rear positions. Finally, there was also some Phlegm and Spleen-Qi deficiency as evidenced by the Swollen tongue. Treatment principle The treatment principle adopted was to nourish Liver-Blood, tonify the Spleen, subdue Liver-Yang and tonify the Kidneys. I treated her with herbal medicine and acupuncture. Acupuncture
I used a simple treatment with few points such as:
• LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to regulate the Directing Vessel, regulate the periods and strengthen the Uterus. • T.B.-5 Waiguan to subdue Liver-Yang and treat the headaches. • ST-36 Zusanli and SP-6 Sanyinjiao, with warm needle to tonify the Spleen and nourish Blood. Herbal treatment
I used a decoction based on the Three Treasures remedy Bend Bamboo: • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Bai Shao Radix Paeoniae alba 6 g • Ju Hua Flos Chrysanthemi 6 g • Man Jing Zi Fructus Viticis 4.5 g • Gou Teng Ramulus Uncariae cum Uncis 6 g • Bai Ji Li Fructus Tribuli 3 g • Gou Qi Zi Fructus Lycii 6 g • Fu Ling Poria 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g
Explanation
• Dang Gui, Shu Di Huang, Bai Shao and Chuan Xiong form the Si Wu Tang Four Substances Decoction which nourishes and invigorates Blood. • Man Jing Zi, Bai Ji Li, Ju Hua and Gou Teng subdue Liver-Yang and treat headaches. • Gou Qi Zi nourishes Blood and tonifies the Kidneys. • Fu Ling, Bai Zhu and Ban Xia tonify Spleen-Qi and resolve Phlegm. • Zhi Gan Cao harmonizes.
After the first decoction, I added Xia Ku Cao Spica Prunellae 4.5 g remembering that there was also some Liver-Fire (bitter taste and thirst). After four courses of decoctions (of 15 days each), she was completely free of headaches.
Blood stasis
Clinical manifestations Stabbing headache in the temples, eyes or sides of the head before the periods, dark menstrual blood with clots, painful period, abdominal pain. Tongue: Purple. Pulse: Wiry or Choppy. Treatment principle Invigorate Blood, harmonize the Penetrating Vessel, remove obstructions from the Connecting channels. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), P-6 Neiguan, SP-10 Xuehai, BL-17 Geshu, ST-29 Guilai, SP-6 Sanyinjiao, KI-14 Siman, LIV-3 Taichong, Du-20 Baihui, G.B.-17 Zhengying. All with reducing or even method. Explanation
– SP-4 and P-6 open and regulate the Penetrating Vessel. This vessel is the Sea of Blood and it fills the Uterus before and during the period. For this reason, when Qi rebels within the Penetrating Vessel, Blood stagnates and headaches occur before the period. – P-6 and SP-6 invigorate Blood and calm the Mind.
– SP-10 and BL-17 invigorate Blood. – ST-29 and KI-14 invigorate Blood in the lower abdomen. KI-14, in particular, is a point of the Penetrating Vessel and relieves stagnation in this vessel. – LIV-3 invigorates Liver-Blood, relieves headaches, calms the Mind and settles the Ethereal Soul. – Du-20 and G.B.-17 are local points to invigorate Blood in the head and remove obstructions from the Connecting channel of the head. Herbal treatment
Prescription
– TONG QIAO HUO XUE TANG Variation – Opening the Orifices and Invigorating Blood Decoction Variation Explanation
– Chi Shao, Chuan Xiong, Tao Ren and Hong Hua invigorate Blood and eliminate stasis. – She Xiang opens the orifices of the head and penetrates the Connecting channels. Please note that the use of this substance is prohibited in some countries and, in any case, it is extremely expensive. Shi Chang Pu Rhizoma Acori tatarinowii can replace She Xiang.
– Cong Bai opens the orifices. – Hong Zao and Sheng Jiang harmonize. – Rice wine helps to open the orifices and directs the other herbs to the head. – Ge Gen relaxes the sinews and therefore alleviates the headache by relaxing the neck muscles and tendons. – Chuan Niu Xi invigorates Blood and nourishes the sinews. Three Treasures remedy
– RED STIRRING This remedy is a variation of Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction. It invigorates Blood and eliminates stasis and it can be used for headaches because it is directed at the Upper Burner. The tongue presentation appropriate to this remedy is a Purple body. Summary Blood stasis
Clinical manifestations
Stabbing headache in the temples, eyes or sides of the head before the periods, dark menstrual blood with clots, painful period, abdominal pain. Tongue: Purple. Pulse: Wiry or Choppy. Treatment principle
Invigorate Blood, harmonize the Penetrating Vessel, remove obstructions from the Connecting channels. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), P-6 Neiguan, SP-10 Xuehai, BL-17 Geshu, ST-29 Guilai, SP-6 Sanyinjiao, KI-14 Siman, LIV-3 Taichong, Du-20 Baihui, G.B.-17 Zhengying. All with reducing or even method. Herbal treatment
Pre scription
• TONG QIAO HUO XUE TANG Variation Opening the Orifices and Invigorating Blood Decoction Variation Three Treasures remedy
• RED STIRRING
Prognosis and prevention Menstrual headaches respond very well to treatment with acupuncture or herbs used singly or in combination. The most difficult pattern to treat is that from stasis of Blood and the easiest is that from deficiency of Blood. Usually the combination of both acupuncture and herbs gives quicker results. As for prevention, it is essential that a woman who suffers from menstrual headaches should not consume excessive amounts of tea or coffee or, preferably, should not drink them at all. With the patterns of Liver-Yang rising and Liver-Fire, she should also abstain from consuming sour foods such as vinegar, orange juice, grapefruit juice, pickles, red currants, yoghurt, etc. These foods will upset the Liver and increase pain. For those suffering from the pattern of Blood deficiency, it is important not to overwork and to take adequate rest. A short period of rest lying down after lunch is very beneficial: it is important to lie down as the Blood flows back to the Liver then and has a regenerating effect.
CHAPTER 21 Oedema During Periods
AETIOLOGY 405 PATHOLOGY 405 IDENTIFICATION OF PATTERNS AND TREATMENT 405 Spleen- and Kidney-Yang deficiency 405 Stagnation of Qi 408 Ancient acupuncture prescriptions for oedema at period time 409 PROGNOSIS AND PREVENTION 410 Oedema at period time can affect the face, hands, lower legs and abdomen. It usually occurs before the period.
Aetiology
Excessive physical work Excessive physical work weakens the Spleen; if it goes on for many years it may also affect the Kidneys. Deficient Spleen- and Kidney-Yang fails to transform, transport and excrete fluids which accumulate in the space between the skin and muscles and lead to oedema, usually affecting the ankles and occurring before or during the period. This is called ‘real oedema’, i.e. the visible swelling is caused by actual retention of fluids under the skin: if the skin is pressed with the thumb, it leaves a dip. If the oedematous area is needled with fairly thick needles, a clear fluid can be seen trickling out when the needles are withdrawn. Emotional stress Prolonged emotional stress due to anger, worry, guilt, frustration and resentment may lead to stagnation of Liver-Qi; stagnant Liver-Qi does not flow freely and fails to promote the transformation of fluids all over the body. This may lead to accumulation of Qi in the space between the skin and muscles. This is called ‘not real oedema’ because it is caused by stagnation of Qi rather than actual fluids. When the skin is pressed with the thumb, it does not leave a dip. This type of oedema is more likely to affect the face, hands and breast and occurs before the period.
Pathology The main pathological factors causing oedema at period time are: • Spleen- and Kidney-Yang deficiency • stagnation of Qi. The oedema from Spleen- and Kidney-Yang deficiency tends to be permanent and becomes worse during the period, while that from stagnation of Qi may appear only before the period.
Identification of patterns and treatment
Spleen- and Kidney-Yang deficiency
Clinical manifestations Oedema before or during the period, backache, tiredness, loose stools, chilliness, heavy period. Tongue: Pale and Swollen. Pulse: Deep and Weak. Treatment principle Tonify the Kidneys, strengthen the Spleen, warm Yang, transform fluids. Acupuncture BL-20 Pishu, BL-23 Shenshu, Ren-12 Zhongwan, ST-36 Zusanli, KI-7 Fuliu, Ren-9 Shuifen, ST-28 Shuidao, SP-9 Yinlingquan, BL-22 Sanjiaoshu, Ren-5 Shimen, LU-7 Lieque, L.I.-6 Pianli The first five points with reinforcing method, the others with reducing or even method. Moxa is applicable. Explanation
– BL-20, BL-23, Ren-12, ST-36 and KI-7 tonify the Spleen and Kidneys. Moxa can be used to warm the Yang. KI-7, in particular, also resolves oedema. – Ren-9, ST-28, SP-9, BL-22 and Ren-5 promote the transformation, transportation and excretion of fluids to resolve oedema. Ren-5 is the FrontCollecting (Mu) point of the Triple Burner and specifically of the Lower Burner. In order to understand the function of this point, one must recall the
role of the Triple Burner in relation to Original Qi (Yuan Qi). The Original Qi arises from between the Kidneys and spreads to the five Yin and six Yang organs via the intermediary of the Triple Burner. This point is the FrontCollecting point of the Triple Burner and rouses the Original Qi to circulate to all the organs and channels. In particular, this point stimulates the Triple Burner (and specifically the Lower Burner) to transform and excrete fluids, and ensures that the Water passages of the Lower Burner are open. Its use is therefore indicated for oedema of any part of the body. – LU-7 and L.I.-6 can be used if the oedema is concentrated in the hands. Herbal treatment
a Prescription
– LING GUI ZHU GAN TANG Variation – Poria-Ramulus Cinnamomi-Atractylodes-Glycyrrhiza Decoction Variation Explanation A very old prescription from the Discussion of Cold-induced Diseases by Zhang Zhong Jing is composed of the first four herbs listed above. It tonifies the Spleen and promotes the transformation of fluids. – Bu Gu Zhi and Ba Ji Tian are added to tonify Kidney-Yang. – Chuan Xiong is added because of the interrelationship between fluids and Blood. Invigorating Blood helps to move fluids.
b Prescription
– QUAN SHENG BAI ZHU SAN Variation – Whole Generating Atractylodes Powder Variation Explanation The first five herbs constitute the formula Quan Sheng Bai Zhu San which tonifies Spleen-Qi and promotes the transformation of fluids. – Gui Zhi is added to warm Yang and transform fluids. Compared with the previous formula, this prescription tonifies only the Spleen and not the Kidneys. c Prescription
– JI SHENG SHEN QI WAN – Kidney-Qi Pill from Formulae to Aid the Living Explanation The first eight herbs constitute the well-known Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill which warms and tonifies Kidney-Yang. – Niu Xi performs two functions. First of all, it invigorates Blood and, by doing that, it helps to transform fluids because of the interrelationship between fluids and Blood. Second, it directs the herbs to the lower part of the body and therefore helps to relieve oedema of the ankles.
– Che Qian Zi drains Dampness and helps to resolve oedema. Please note that the dosages given in Appendix 1 are those of the original prescription and, generally speaking, they should be reduced substantially. Compared with the previous two formulae, this prescription mostly tonifies Kidney-Yang (rather than Spleen-Yang) and it is more warming than the others. Three Treasures remedies
– STRENGTHEN THE ROOT This remedy tonifies and warms Kidney-Yang and is therefore suitable to treat the root of this condition. The tongue presentation appropriate to this remedy is a Pale and Swollen body. – SEPARATE CLEAR AND TURBID This formula promotes the transformation of fluids in the Lower Burner and can relieve oedema. The tongue presentation appropriate to this remedy is a Pale body. It can be combined with the previous remedy Strengthen the Root: in such a case, the patient should take Strengthen the Root in the morning (2–3 tablets) and Separate Clear and Turbid after lunch (2–3 tablets). Summary Spleen- and Kidney-Yang Deficiency
Clinical manifestations
Oedema before or during the period, backache, tiredness, loose stools, chilliness, heavy period. Tongue: Pale and Swollen. Pulse: Deep and Weak.
Treatment principle
Tonify the Kidneys, strengthen the Spleen, warm Yang, transform fluids. Acupuncture
BL-20 Pishu, BL-23 Shenshu, Ren-12 Zhongwan, ST-36 Zusanli, KI-7 Fuliu, Ren-9 Shuifen, ST-28 Shuidao, SP-9 Yinlingquan, BL-22 Sanjiaoshu, Ren-5 Shimen, LU-7 Lieque, L.I.-6 Pianli The first five points with reinforcing method, the others with reducing or even method. Moxa is applicable. Herbal treatment
Pre scriptions
• LING GUI ZHU GAN TANG Variation Poria-Ramulus CinnamomiAtractylodes-Glycyrrhiza Decoction Variation • QUAN SHENG BAI ZHU SAN Variation Whole Generating Atractylodes Powder Variation • JI SHENG SHEN QI WAN Kidney-Qi Pill from Formulae to Aid the Living Three Treasures remedies
• STRENGTHEN THE ROOT • SEPARATE CLEAR AND TURBID
Case history
A 47-year-old woman had been suffering from oedema for about 5 years: this was permanent but got worse during the period. It was concentrated around the ankles. She had put on a lot of weight in the previous few years. Her periods were regular and quite scanty, lasting only 2–3 days. She also suffered from lower backache, chilliness, tiredness, slight shortness of breath, dizziness and night sweating. Interestingly, the oedema started soon after cryotherapy for cervical dysplasia. Cryotherapy consists in the application of intense cold to the cervix. One could speculate that this treatment may have induced a sudden Cold in the Uterus and therefore weakened Kidney-Yang, but obviously this may have been more a precipitating rather than causative factor. Her pulse was very Deep and Weak especially on both Rear positions and her tongue was Pale, Swollen and slightly peeled on the root. Diagnosis The main pattern is clearly one of Kidney-Yang deficiency as evidenced by the backache, dizziness, oedema of the ankles, scanty period, obesity, chilliness, Pale and Swollen tongue and a Deep and Weak pulse on both Rear positions. There are, however, some contradictions. The night sweating and peeling of the coating on the root indicate Yin deficiency. As explained in Chapter 3 on pathology, it is not at all unusual for women to suffer from a deficiency of both Kidney-Yin and Kidney-Yang although one of them will necessarily predominate, in this case Kidney-Yang deficiency. Treatment principle The principle of treatment adopted was to treat both the Root (Kidney-Yang deficiency) and the Manifestation (Water overflowing causing oedema) and to regulate the periods. I treated her with both acupuncture and herbal decoctions. Acupuncture
The main points used over the course of treatment were selected from the following: • Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu and SP-6 Sanyinjiao to tonify the Spleen. • BL-23 Shenshu and KI-7 to tonify and warm Kidney-Yang. Moxa was applied to KI-7. • LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to regulate the Directing Vessel and the Uterus. • Ren-9 Shuifen and BL-22 Sanjiaoshu to promote the transformation and excretion of fluids.
Herbal treatment The herbal formula used was a variation of Ling Gui Zhu Gan Tang PoriaRamulus Cinnamomi-Atractylodes-Glycyrrhiza Decoction. • Fu Ling Poria 12 g • Gui Zhi Ramulus Cinnamomi 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Bu Gu Zhi Fructus Psoraleae 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Ba Ji Tian Radix Morindae officinalis 6 g • Fu Zi Radix Aconiti lateralis preparata 1.5 g • Zhu Ling Polyporus 6 g • Ze Xie Rhizoma Alismatis 6 g
Explanation The first four herbs constitute the original formula which tonifies the Spleen and resolves oedema. • Bu Gu Zhi and Ba Ji Tian tonify Kidney-Yang. • Chuan Xiong moves Blood which helps to move fluids. • Fu Zi strongly warms Kidney-Yang and resolves oedema. • Zhu Ling and Ze Xie drain Dampness and resolve oedema.
This patient was treated for 9 months after which time the oedema was reduced by about 80%. Her general condition had improved in many ways. She reported longer periods, more energy and a total weight loss of 1 stone. However, it should be added that after about 2 months of treatment, I began suspecting that she might suffer from a thyroxine deficiency as she had many of the symptoms (chilliness, scanty period, shortness of breath, tiredness and oedema). Surprisingly, no doctor had ever suggested this to her and I therefore asked her to insist on having a thyroid function test. This proved that the thyroid function was extremely deficient and she was therefore put on 150 micrograms daily of thyroxine. Case history This case history is not one of oedema at period time but it is nevertheless somewhat related to it and I report it here without the treatment (which the patient did not pursue). It is about a 55-year-old woman who had been suffering from oedema of the ankles and hands ever since she had had a hysterectomy 8 years previously. The connection between this operation and the onset of oedema is interesting from the point of view of Chinese pathology. A hysterectomy usually induces a deficiency of Blood and of the Kidneys. In her case, it obviously induced a deficiency of the Kidneys and therefore oedema.
Stagnation of Qi
Clinical manifestations Swelling and apparent oedema of abdomen, breasts, hands or ankles before the period, abdominal distension, irritability, pre-menstrual tension. Tongue: could be normal or slightly Red on the sides. Pulse: Wiry or Wiry and Fine. Treatment principle Move fluids, move Qi, pacify the Liver. Acupuncture LIV-3 Taichong, G.B.-34 Yanglingquan, LIV-14 Qimen, BL-18 Ganshu, T.B.-6 Zhigou, Ren-5 Shimen, Ren-6 Qihai, Ren-9 Shuifen, P-6 Neiguan. All with reducing or even method. Explanation
– LIV-3, G.B.-34, LIV-14, and BL-18 move Qi and pacify the Liver. – T.B.-6 moves Qi and, being a point of the Triple Burner, it promotes the transformation of fluids. – Ren-5, Front-Collecting point of the Triple Burner, promotes the transformation of fluids in the abdomen. It also moves Qi in the Lower Burner. – Ren-6 moves Qi in the lower abdomen.
– Ren-9 promotes the transformation of fluids and relieves oedema. – P-6 moves Qi and pacifies the Liver (due to its connection with the Liver channel within the Terminal Yin), calms the Mind and settles the Ethereal Soul. Herbal treatment
a Prescription
– BA WU TANG Variation – Eight Substances Decoction Variation Explanation The first four herbs constitute the Si Wu Tang Four Substances Decoction to nourish and harmonize Blood. – Yan Hu Suo, Chuan Lian Zi, Mu Xiang, Bing Lang and Xiang Fu (this last herb added to the original formula) move Qi and pacify the Liver. – Fu Ling Pi resolves oedema. b Prescription
– DAO ZHI TONG JING TANG and SI WU TANG Variation – Conducting Stagnation and Penetrating the Menses Decoction and
Four Substances Decoction Variation Explanation
– Mu Xiang moves Qi and pacifies the Liver. – Bai Zhu, Chen Pi and Fu Ling tonify the Spleen and dry Dampness. – Sang Bai Pi is in the formula to promote the descending of Lung-Qi: this helps to move Qi and also to resolve oedema. – Dang Gui, Chi Shao and Chuan Xiong are a variation of Si Wu Tang (without Shu Di Huang and with Chi Shao substituted for Bai Shao) and they nourish and harmonize Blood. Compared with the previous formula, this prescription concentrates more on transforming fluids, the former more on moving Qi. Modifications The following modifications apply to both formulae. • If there is pronounced abdominal distension, add Da Fu Pi Pericarpium Arecae and Qing Pi Pericarpium Citri reticulatae viride. • If there is shortness of breath, add Sha Ren Fructus Amomi. • If the period stops and starts (indicating stasis of Blood), add Yi Mu Cao Herba Leonuri. Women’s Treasure remedy
– FREEING THE MOON This remedy is a variation of Xiao Yao San Free and Easy Wanderer Powder which moves Qi, pacifies the Liver, tonifies Spleen-Qi and nourishes Blood. Compared with the original formula, Freeing the Moon has more herbs to move Qi and to nourish Blood. The tongue presentation appropriate to this remedy is a body that could be either Pale or normal coloured, depending on how much Blood deficiency there is. The pulse corresponding to this remedy is Wiry but Fine. Summary Stagnation of Qi
Clinical manifestations
Swelling and apparent oedema of abdomen, breasts, hands or ankles before the period, abdominal distension, irritability, pre-menstrual tension. Tongue: could be normal or slightly Red on the sides. Pulse: Wiry or Wiry and Fine. Treatment principle
Move fluids, move Qi, pacify the Liver. Acupuncture
LIV-3 Taichong, G.B.-34 Yanglingquan, LIV-14 Qimen, BL-18 Ganshu, T.B.-6 Zhigou, Ren-5 Shimen, Ren-6 Qihai, Ren-9 Shuifen, P-6 Neiguan. All with reducing or even method. Herbal treatment
Pre scriptions
• BA WU TANG Variation Eight Substances Decoction Variation • DAO ZHI TONG JING TANG and SI WU TANG Variation Conducting Stagnation and Penetrating the Menses Decoction and Four Substances Decoction Variation Women’s Treasure remedy
• FREEING THE MOON
Ancient acupuncture prescriptions for oedema at period time 1
1. ST-36 Zusanli; or also Du-23 Shangxing, BL-45 Yixi, T.B.-16 Tianyou and G.B.-20 Fengchi (ABC of Acupuncture, Zhen Jiu Jia Yi Jing, AD 259). 2. ST-43 Xiangu and Ren-9 Shuifen with moxa cones (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601).
Prognosis and prevention Oedema is not easy to treat and will usually take a long time. ‘True’ oedema from actual retention of fluids is more difficult to treat than the one from stagnation of Qi. For the ‘true’ type, herbs are usually more effective than acupuncture. A woman suffering from oedema should avoid consuming excessive amounts of cold, raw foods and iced drinks. End note 1. Chen You Bang 1990 Chinese Acupuncture Therapy (Zhong Guo Zhen Jiu Zhi Liao Xue
), China Scientific Publishing House, Beijing, p. 870..
CHAPTER 22 Diarrhoea at Period Time
AETIOLOGY 411 PATHOLOGY 411 IDENTIFICATION OF PATTERNS AND TREATMENT 411 Spleen-Qi deficiency 411 Liver-Qi stagnant and invading the Spleen 412 Kidney-Yang deficiency 413 PROGNOSIS AND PREVENTION 414 This includes diarrhoea or loose stools occurring before, during or after each period.
Aetiology
Excessive physical work, irregular diet Excessive physical work may injure the Spleen and lead to Spleen-Qi deficiency. The Spleen can also be weakened by a diet lacking in nourishment or by the excessive consumption of raw, cold foods. When the period arrives, Blood percolates down to the Uterus; Spleen-Qi is already depleted and since it holds blood in the vessels the extra exertion weakens it further; it cannot transform and transport the food essences and diarrhoea results. This is more likely to occur during or after the period. Emotional stress Emotional stress such as anger, resentment or frustration may lead to LiverQi stagnation. Stagnant Liver-Qi often invades the Spleen and induces Spleen-Qi deficiency. In the time before the period, Liver-Qi should flow and flourish in order that Qi may move Blood. If Liver-Qi has grown stagnant, it stagnates even more before the period; this weakens the Spleen, which fails to transform and transport food essences; and diarrhoea results. This is more likely to occur before or during the period. Overwork Overwork in the sense of working long hours under stress may weaken the Kidneys. This organ controls the two orifices and the Uterus; thus, when the period comes, and especially after the period, the Kidneys are relatively weakened, they fail to restrain the two orifices and diarrhoea results. In this case, diarrhoea is more likely to occur after the period.
Pathology The main pathological conditions that may cause diarrhoea at period time are: • Spleen-Qi deficiency • Liver-Qi stagnant and invading the Spleen • Kidney-Yang deficiency.
Identification of patterns and treatment
Spleen-Qi deficiency
Clinical manifestations Diarrhoea during or after the period, slight abdominal pain, tiredness, poor digestion. Tongue: Pale. Pulse: Weak. Treatment principle Strengthen the Spleen, resolve Dampness, regulate menstruation. Acupuncture Ren-12 Zhongwan, Du-20 Baihui, Ren-6 Qihai, ST-37 Shangjuxu, ST-25 Tianshu, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu. All with reinforcing method, moxa is applicable. Explanation
– Ren-12 and SP-6 tonify the Spleen. – Du-20 raises Qi: this will help to stop diarrhoea because in part it is caused by Spleen-Qi sinking. – Ren-6 tonifies Qi in general and, used with moxa cones, is excellent to stop diarrhoea. It is particularly effective if the moxa cones are on a thin slice of fresh ginger (after piercing the centre of it). – ST-37, lower Sea point of the Large Intestine, is specific to stop diarrhoea.
– ST-25 stops diarrhoea. – BL-20 and BL-21 tonify the Stomach and Spleen. Herbal treatment
Prescription
– SHEN LING BAI ZHU SAN – Ginseng-Poria-Atractylodes Powder Explanation This formula is specific to treat diarrhoea from Spleen deficiency. It tonifies Spleen- and Stomach-Qi, it slightly nourishes Stomach- and Spleen-Yin, and resolves Dampness. – Ren Shen, Bai Zhu and Shan Yao tonify the Stomach and Spleen. – Fu Ling, Bian Dou, Sha Ren and Yi Yi Ren resolve Dampness. Bian Dou also tonifies Spleen-Yin. – Zhi Gan Cao harmonizes the ingredients and tonifies Qi. – Lian Zi is astringent and stops diarrhoea. – Jie Geng directs the formula to the Upper Burner and, by so doing, it helps to raise Spleen-Qi. Three Treasures remedy
– CENTRAL MANSION This remedy is a variation of the formula Shen Ling Bai Zhu San Ginseng-Poria-Atractylodes Powder, which tonifies Stomach- and SpleenQi and Stomach- and Spleen-Yin, and which stops diarrhoea. The tongue presentation appropriate to this remedy is a Pale body with a sticky but rootless coating; the tongue may also have a central Stomach crack or scattered small Stomach cracks, and it may be peeled in patches. Summary Spleen-Qi deficiency
Clinical manifestations
Diarrhoea during or after the period, slight abdominal pain, tiredness, poor digestion. Tongue: Pale. Pulse: Weak. Treatment principle
Strengthen the Spleen, resolve Dampness, regulate menstruation. Acupuncture
Ren-12 Zhongwan, Du-20 Baihui, Ren-6 Qihai, ST-37 Shangjuxu, ST-25 Tianshu, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu. All with reinforcing method, moxa is applicable. Herbal treatment
Pre scription
• SHEN LING BAI ZHU SAN Ginseng-Poria-Atractylodes Powder Three Treasures remedy
• CENTRAL MANSION
Liver-Qi stagnant and invading the Spleen
Clinical manifestations Diarrhoea before the period, pre-menstrual tension, irritability, irregular periods, tiredness, depression, abdominal distension. Tongue: Red sides. Pulse: Wiry. Treatment principle Pacify the Liver, strengthen the Spleen, resolve Dampness, regulate menstruation. Acupuncture LIV-3 Taichong, G.B.-34 Yanglingquan, LIV-13 Zhangmen, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, ST-37 Shangjuxu, BL-18 Ganshu, BL-20 Pishu. LIV-3, G.B.-34 and LIV-3 with reducing or even method, the others with reinforcing method. Explanation
– LIV-3 and G.B.-34 pacify the Liver and eliminate stagnation of Qi. – LIV-13 pacifies the Liver and harmonizes the Liver and Spleen. – Ren-12, ST-36, SP-6 and ST-37 tonify Spleen-Qi. ST-37 is specific to treat diarrhoea. – BL-18 and BL-20 pacify the Liver and strengthen the Spleen.
Herbal treatment
Prescription
– TONG XIE YAO FANG – Painful Diarrhoea Formula Explanation
– Bai Zhu tonifies the Spleen and dries Dampness. – Bai Shao pacifies the Liver. It is also astringent and will therefore tend to stop diarrhoea. – Chen Pi moves Qi and dries Dampness. – Fang Feng pacifies the Liver and soothes the Spleen. Three Treasures remedy
– SOOTHE THE CENTRE This remedy tonifies Spleen-Qi, pacifies the Liver and moves Qi. Summary Liver-Qi stagnant and invading the Spleen
Clinical manifestations
Diarrhoea before the period, pre-menstrual tension, irritability, irregular periods, tiredness, depression, abdominal distension. Tongue: Red sides. Pulse: Wiry. Treatment principle
Pacify the Liver, strengthen the Spleen, resolve Dampness, regulate menstruation. Acupuncture
LIV-3 Taichong, G.B.-34 Yanglingquan, LIV-13 Zhangmen, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, ST-37 Shangjuxu, BL-18 Ganshu, BL-20 Pishu. LIV-3, G.B.-34 and LIV-3 with reducing or even method, the others with reinforcing method. Herbal treatment
Pre scription
• TONG XIE YAO FANG Painful Diarrhoea Formula Three Treasures remedy
• SOOTHE THE CENTRE
Kidney-Yang deficiency
Clinical manifestations Watery diarrhoea after the period, feeling cold, backache, frequent urination. Tongue: Pale, Swollen and wet. Pulse: Deep, Weak. Treatment principle Tonify and warm the Kidneys, strengthen the Fire of the Gate of Life. Acupuncture BL-23 Shenshu, BL-20 Pishu, Ren-4 Guanyuan (with moxa), ST-25 Tianshu, ST-37 Shangjuxu. All with reinforcing method, moxa is applicable. Explanation
– BL-23 tonifies Kidney-Yang. – BL-20 tonifies the Spleen: this is necessary because in cases of KidneyYang deficiency, the Spleen-Yang is nearly always also deficient. – Ren-4 (with direct moxa cones) tonifies Kidney-Yang. – ST-25 and ST-37 stop diarrhoea. Herbal treatment
Prescription
– JIAN GU TANG – Strengthening and Consolidating Decoction Explanation
– Ren Shen, Fu Ling and Bai Zhu tonify Spleen-Qi. – Ba Ji Tian tonifies Kidney-Yang. – Yi Yi Ren drains Dampness. Three Treasures remedy
– STRENGTHEN THE ROOT This remedy is a variation of You Gui Wan Restoring the Right [Kidney] Pill which tonifies Kidney-Yang. For women, I prefer this to the remedy Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill, as the former also nourishes Blood and strengthens the Directing and Penetrating Vessels.
Prognosis and prevention Diarrhoea at period time is usually easily resolved with acupuncture or Chinese herbs, singly or in combination. The least easy pattern to treat is that of Kidney-Yang deficiency. A woman suffering from diarrhoea because of Kidney-Yang or SpleenQi deficiency should avoid eating too many cold, raw foods such as fruit, salads and cold drinks as these will readily aggravate the diarrhoea. If her diarrhoea is caused by Liver-Qi stagnation, she should avoid eating in a hurry or under conditions of stress while at work. Summary
Kidney-Yang deficiency
Clinical manifestations Watery diarrhoea after the period, feeling cold, backache, frequent urination. Tongue: Pale, Swollen and wet. Pulse: Deep, Weak. Treatment principle Tonify and warm the Kidneys, strengthen the Fire of the Gate of Life. Acupuncture BL-23 Shenshu, BL-20 Pishu, Ren-4 Guanyuan (with moxa), ST-25 Tianshu, ST-37 Shangjuxu. All with reinforcing method, moxa is applicable. Herbal treatment
Prescription
• JIAN GU TANG Strengthening and Consolidating Decoction
Three Treasures remedy
• STRENGTHEN THE ROOT
CHAPTER 23 Body Aches at Period Time
AETIOLOGY 415 PATHOLOGY 416 IDENTIFICATION OF PATTERNS AND TREATMENT 416 Blood deficiency (alone or with Yang rising) 416 Blood stasis 418 PROGNOSIS AND PREVENTION 419 Many women suffer from aches and pains in connection with the periods and these may occur before, during or after the period. There is an interesting relationship between Blood and body aches in women. Blood, and therefore menstrual blood, nourishes the sinews and muscles and keeps the tendons and joints supple. It also flows in the channels and, by nourishing and filling them, prevents invasions of external Wind in them. If Blood is deficient, the channels are empty and therefore prone to external Wind invasions. It is for this reason that one usually needs to nourish Blood when expelling Wind, and this principle applies both to external and internal Wind. The relationship between Blood and aches and pains in women accounts for many cases of rheumatic joint pains that resemble Painful Obstruction Syndrome (Bi) while, in reality, they are simply due to deficient Blood failing to nourish joints, sinews and muscles: these are examples of what Dr J H F Shen calls ‘not true Bi syndrome’. Such cases are extremely common in women, more so than in men, because of the close relationship
between menstrual blood and body nourishment. The Standards of Diagnosis and Treatment (1602) by Wang Ken Tang says: Menstrual Blood moves Qi and Blood, penetrates Yin and Yang, nourishes the body [so that] Qi and Blood flourish, Yin and Yang are harmonized hence the body functions well. If externally the nourishment by the Defensive Qi is lost and internally the irrigation by the Nutritive Qi and Blood is lacking, Qi and Blood become deficient and body aches develop during the periods.1 Thus, particularly if aches and pains occur in connection with the menstrual cycle, they are often related to a Blood pathology rather than to actual Painful Obstruction Syndrome with invasion of external Wind, Dampness or Cold. Of course, the two conditions may be, and often are, combined so that there is a deficiency of Blood in the channel which facilitates the invasion of external pathogenic factors. The treatment in such cases must definitely stress nourishing the Blood as, if this is not done, external pathogenic factors will not be expelled.
Aetiology
Excessive physical work, inadequate diet, chronic illness Excessive physical work (including sports) injures the Spleen and therefore the muscles; by injuring the Spleen, it also leads to Qi and Blood deficiency (because the Spleen is the main source of Qi and Blood). A diet lacking in nourishment and Blood-forming foods may lead to Qi and Blood deficiency. This happens when women follow too strict slimming diets or when young girls become vegetarian without a proper understanding of how to combine foods to obtain enough protein. A long, protracted illness (such as a bronchitis that might drag on for months) may also lead to Qi and Blood deficiency. Whatever the cause of Qi and Blood deficiency, deficient Blood fails to nourish the sinews, muscles, channels and joints, and aches develop. Since blood is lost during menstruation, the aches occur at period time and, in this case, they tend to occur more during and after the period. Emotional stress, irregular diet Emotional problems may lead to stagnation of Qi; after a prolonged time this may generate stasis of Blood. Blood may stagnate in the channels, cause an obstruction and therefore lead to aches and pains. During the period, Blood should flow easily, and if it stagnates, the aches and pains become worse. This would usually happen before or during the period. An excessive consumption of dairy foods, sugar, sweets, raw, cold foods or greasy foods may lead to the formation of Dampness. This may settle in the channels and joints and lead to pain and swelling. If the Blood is also deficient or stagnant, the aches and pains occur during the period time.
Pathology Thus, the pathology of aches and pains at period time is closely linked with a Blood pathology which essentially includes either Blood deficiency or Blood stasis. Blood deficiency may be complicated with Yang rising. In fact, if Liver-Blood is deficient, Liver-Yang may rise causing typically aches and stiffness of the upper back and neck. I have noticed in practice that this situation often arises after a hysterectomy because removing the uterus seems to induce a deficiency of Blood and consequently Liver-Yang rising affecting the upper back and neck. Thus, the main pathologies and patterns are: • Blood deficiency • Blood deficiency with Yang rising • Blood stasis.
Identification of patterns and treatment
Blood deficiency (alone or with Yang rising)
Clinical manifestations Aches and pains during or after the period, aches mostly in the limbs, numbness, tingling of the limbs, tiredness, dizziness, muscular weakness, insomnia. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle Nourish Blood, nourish and relax the sinews. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, BL-17 Geshu (with direct moxa), BL-11 Dashu, L.I.-10 Shousanli, T.B.-5 Waiguan, G.B.-34 Yanglingquan, BL-18 Ganshu, BL-20 Pishu, BL-23 Shenshu, BL-60 Kunlun, G.B.-21 Jianjing. All with reinforcing method, moxa can be used. Explanation
– LU-7 and KI-6 open and regulate the Directing Vessel which nourishes the Uterus and Blood. – Ren-4 nourishes Blood and the Uterus. – ST-36, SP-6 and LIV-8 nourish Blood. – BL-17, with direct moxa cones, nourishes Blood.
– BL-11, point of the Sea of Blood, also with direct moxa cones, nourishes Blood. – L.I.-10 nourishes the channels of the upper limbs; it has a tonic action somewhat equivalent to ST-36 Zusanli. – T.B.-5 is used as a local point for aches in the arms and hands as it expels Wind from the channels. – G.B.-34, Gathering point for the sinews, nourishes the sinews and joints. – BL-18, in conjunction with BL-17, nourishes Liver-Blood. – BL-20 and BL-23, in combination and with direct moxa cones, tonify Qi and Blood. – BL-60 is selected if the aches and stiffness are concentrated in the upper back and neck (as is the case if there is Liver-Yang rising). – G.B.-21 is selected in the same situation: it also subdues Liver-Yang. Herbal treatment
a Prescription
– BA ZHEN TANG Variation – Eight Precious Decoction Variation Explanation
The first eight herbs constitute the formula Ba Zhen Tang which nourishes Blood and tonifies Qi. – Ji Xue Teng nourishes and invigorates Blood and benefits the sinews. – Wu Jia Pi benefits the sinews and especially the lower back and knees. – Sang Ji Sheng nourishes Liver-Blood, benefits the sinews and expels Wind. b Prescription
– QIN JIAO SI WU TANG – Gentiana macrophylla Four Substances Decoction Explanation This formula differs from the previous one insofar as, besides nourishing Blood, it has a more complex action. It also cools Blood slightly and is therefore suitable when the patient has some Blood-Heat together with Blood deficiency. Secondly, it drains Dampness and expels Wind-Dampness from the joints. It is therefore suitable if the joints are swollen. The first four herbs are the formula Si Wu Tang (with Sheng Di Huang substituted for Shu Di Huang). – Qin Jiao expels Wind-Dampness from the joints and also clears EmptyHeat. – Yi Yi Ren drains Dampness and resolves swelling from the joints. – Can Sha expels Wind-Dampness from the joints and is particularly suitable for chronic conditions.
– Gan Cao harmonizes. Modifications
• If the Blood deficiency has given rise to Liver-Yang rising causing aches and stiffness of the upper back and neck and dizziness, add: • Ge Gen Radix Puerariae to relax the sinews • Tian Ma Rhizoma Gastrodiae to subdue Liver-Yang • Qiang Huo Rhizoma seu Radix Notopterygii to expel Wind and relax the sinews of the upper back • Ju Hua Flos Chrysanthemi to subdue Liver-Yang. • If there is insomnia and irritability, add Long Yan Rou Arillus Longan and Bai Zi Ren Semen Platycladi. c Prescription
– QIANG GUI SI WU TANG – Notopterygium-Ramulus Cinnamomi Four Substances Decoction Explanation This formula, from the Golden Mirror of Medicine (1742), is specific for period-time joint aches from Blood deficiency. It expels Wind, Dampness and Cold from the channels, especially from the upper limbs. The first four herbs constitute the formula Si Wu Tang which nourishes and invigorates Blood. – Qiang Huo and Gui Zhi expel Wind-Dampness and Cold from the channels.
Three Treasures remedy
– BROCADE SINEWS This remedy was formulated specifically for conditions of Blood deficiency in women with aches and pains due to some Wind-ColdDampness in the joints. The tongue presentation appropriate to this remedy is a Pale and Thin tongue body. Women’s Treasure remedy
– PRECIOUS SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. It has been modified with the addition of Kidney tonics. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Blood deficiency (alone or with Yang rising)
Clinical manifestations
Aches and pain during or after the period, aches mostly in the limbs, numbness, tingling of the limbs, tiredness, dizziness, muscular weakness, insomnia. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle
Nourish Blood, nourish and relax the sinews. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, BL-17 Geshu (with direct moxa), BL-11 Dashu, L.I.-10 Shousanli, T.B.-5 Waiguan, G.B.-34 Yanglingquan, BL-18 Ganshu, BL-20 Pishu, BL-23 Shenshu, BL-60 Kunlun, G.B.-21 Jianjing. All with reinforcing method, moxa can be used. Herbal treatment
Pre scriptions
• BA ZHEN TANG Variation Eight Precious Decoction Variation • QIN JIAO SI WU TANG Gentiana macrophylla Four Substances Decoction • QIANG GUI SI WU TANG Notopterygium-Ramulus Cinnamomi Four Substances Decoction Three Treasures remedy
• BROCADE SINEWS Women’s Treasure remedy
• PRECIOUS SEA
Blood stasis
Clinical manifestations Severe aches and pains during or before the period with pain more in the joints (rather than in the muscles), painful periods with dark and clotted blood. Tongue: Purple. Pulse: Choppy. Treatment principle Invigorate Blood, eliminate stasis, benefit the sinews. Acupuncture SP-4 Gongsun with P-6 Neiguan, BL-17 Geshu, SP-10 Xuehai, BL-11 Dashu, T.B.-5 Waiguan, P-6 Neiguan, SP-6 Sanyinjiao, Baxie extra points, Bafeng extra points, ST-34 Liangqiu, ST-41 Jiexi, ST-43 Xiangu, SP-5 Shangqiu, LIV-8 Ququan, LIV-3 Taichong. All with reducing or even method. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel. – BL-17 and SP-10 invigorate Blood and eliminate stasis. – BL-11, point of the Sea of Blood, invigorates Blood and treats especially aches in the upper shoulders and neck. – T.B.-5 expels Wind-Dampness from the channels, especially in the arms.
– P-6 and SP-6 invigorate Blood. – Baxie and Bafeng are local points to expel Wind-Dampness from the fingers and toes respectively. – ST-34, Accumulation point, moves Qi and invigorates Blood in the legs. – ST-41, ST-43 and SP-5 are local points to expel Wind-Dampness from the feet. – LIV-8 nourishes Blood. – LIV-3 invigorates Liver-Blood. Herbal treatment
a Prescription
– TAO HONG YIN – Persica-Carthamus Decoction Explanation
– Tao Ren, Hong Hua, Chuan Xiong and Dang Gui (Wei) all invigorate Blood and eliminate stasis. – Wei Ling Xian expels Wind-Dampness from the channels. b Prescription
– TAO HONG SI WU TANG – Persica-Carthamus Four Substances Decoction Explanation This formula is similar to the previous one, but it differs from it insofar as, besides invigorating Blood, it also nourishes Blood. The first four herbs constitute the Si Wu Tang which nourishes Blood. – Tao Ren and Hong Hua invigorate Blood and eliminate stasis. c Prescription
– CHEN TONG SAN Variation – Stopping Pain Powder Variation Explanation The first nine herbs constitute the formula Chen Tong San. – Dang Gui, Bai Zhu, Huang Qi and Zhi Gan Cao tonify Qi and Blood. – Rou Gui warms the Fire of the Gate of Life and expels Cold. – Du Huo and Chuan Niu Xi expel Wind-Dampness from the channel, benefit the lower back and invigorate Blood. – Xie Bai and Sheng Jiang warm the channels and expel Cold.
– Ji Xue Teng and Sang Ji Sheng invigorate Blood, nourish Blood and benefit the sinews. This formula is suitable in cases of stasis of Blood deriving from Cold and with deficiency of Blood. Modifications
• If the symptoms of Cold are pronounced, add Rou Gui Cortex Cinnamomi. • If there is abdominal pain, add Yan Hu Suo Rhizoma Corydalis and Yi Mu Cao Herba Leonuri. Three Treasures remedy
– STIR FIELD OF ELIXIR This remedy, a variation of Ge Xia Zhu Yu Tang Eliminating Stasis of Blood below the Diaphragm Decoc-tion, invigorates Blood and stops pain. Summary Blood stasis
Clinical manifestations
Severe aches and pains during or before the period with pain more in the joints (rather than in the muscles), painful periods with dark and clotted blood. Tongue: Purple. Pulse: Choppy. Treatment principle
Invigorate Blood, eliminate stasis, benefit the sinews. Acupuncture
SP-4 Gongsun with P-6 Neiguan, BL-17 Geshu, SP-10 Xuehai, BL-11 Dashu, T.B.-5 Waiguan, P-6 Neiguan, SP-6 Sanyinjiao, Baxie extra points, Bafeng extra points, ST-34 Liangqiu, ST-41 Jiexi, ST-43 Xiangu, SP-5 Shangqiu, LIV-8 Ququan, LIV-3 Taichong. All with reducing or even method. Herbal treatment
Pre scriptions
• TAO HONG YIN Persica-Carthamus Decoction • TAO HONG SI WU TANG Persica-Carthamus Four Substances Decoction • CHEN TONG SAN Variation Stopping Pain Powder Variation Three Treasures remedy
• STIR FIELD OF ELIXIR
Prognosis and prevention The condition of body aches occurring at period time is quite common. It reacts well to treatment by acupuncture or herbs. The pattern of Blood stasis is more difficult to treat. A woman suffering from this problem should avoid eating too many cold, raw foods as these will tend to create Cold and slow down the circulation of Blood: this will aggravate both the Blood deficiency and the Blood stasis. It is also advisable not to consume excessive amounts of sour foods such as yoghurt, grapefruit, vinegar, pickles, etc., as these, in excess, may injure the muscles and affect Liver-Blood. End note 1. Wang Ken Tang 1602 Standards of Diagnosis and Treatment (Zheng Zhi Zhun Sheng) cited in Cong Chun Yu 1989 Chinese Medicine Gynaecology (Zhong Yi Fu Ke Xue
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 98..
CHAPTER 24 Fever at Period Time
AETIOLOGY 421 PATHOLOGY 422 IDENTIFICATION OF PATTERNS AND TREATMENT 422 Blood-Heat 422 Kidney- and Liver-Yin deficiency with Empty-Heat 423 Qi and Blood deficiency with disharmony of Nutritive and Defensive Qi 424 Blood stasis with Heat 426 Ancient acupuncture prescriptions for fever during periods 427 PROGNOSIS AND PREVENTION 427 ‘Fever’ here includes both an actual fever and a pronounced feeling of heat, which is more frequent before or during the period but may also occur after it. It should be stressed that if there is only a feeling of heat, this should be both subjective and objective, i.e. the patient has a feeling of heat and her skin (particularly of the dorsum of the hands) also feels hot to the touch.
Aetiology
Emotional stress, irregular diet Emotional stress such as actual or repressed anger, resentment or frustration may lead to Liver-Qi stagnation which frequently turns into Fire; Fire can invade the Blood portion (especially Liver-Fire because this organ stores Blood) and give rise to Blood-Heat. Since Blood accumulates before the periods, Blood-Heat causes a feeling of heat or fever before or during the periods. The pathology of this condition is also influenced by a disharmony of the Penetrating Vessel. This vessel is the Sea of Blood and its chief pathology is Qi rebelling upwards. The Penetrating Vessel has a deep influence on the menstrual function and the vessel is full of Blood before the period. If Blood has Heat, and if Qi rebels upwards, this may carry Blood with it and cause an intense feeling of heat in the face. In fact, as we have seen in Chapter 7, even rebellious Qi of the Penetrating Vessel by itself (without Blood-Heat) may cause a feeling of heat in the face. Overwork Overwork (in the sense explained before) and having too many children too close together may lead to Yin deficiency and Empty-Heat: the latter heats the Blood and also causes Blood-Heat. Since Blood is in a state of relative depletion after each period, the Empty-Heat becomes more pronounced at this time and causes a feeling of heat or fever after the period. This type of Heat is different from Full- or Empty-Heat insofar as it derives from Qi and Blood deficiency: it is treated by using not bitter, cold herbs but sweet, warm ones that gently tonify Qi and the Original Qi. The idea behind this method derives from Li Dong Yuan who said that
when the Fire of the Original Qi declines, a pathological Minister Fire takes over, giving rise to a feeling of heat. Since this derives from a decline of the Original Qi, it is treated by tonifying this with sweet, warm herbs. Chronic illness, excessive physical work A long, chronic illness may cause Qi and Blood deficiency, while excessive physical work (including sports) may injure the Spleen and also lead to Qi and Blood deficiency. This causes a disharmony between Nutritive and Defensive Qi so that there is a feeling of heat or fever during or after the period. Emotional stress, surgery Emotional stress as mentioned above may also lead to Blood stasis; when Blood stagnates for a long time it may give rise to Heat. Blood-Heat causes a feeling of heat or fever before or during the period. The stasis of Blood may also derive from abdominal surgery following a hysterectomy, ovarectomy or an operation for endometriosis.
Pathology The main pathological factors leading to a feeling of heat or fever at period times are: • Blood-Heat • Kidney- and Liver-Yin deficiency with Empty-Heat • Qi and Blood deficiency with disharmony of Nutritive and Defensive Qi • Blood stasis with Heat. The second pattern is more common in older women.
Identification of patterns and treatment
Blood-Heat
Clinical manifestations An intense feeling of heat or fever before or during the period, heavy period, mental restlessness, agitation, headache, blood-shot eyes, thirst, hot nose, red lips. Tongue: Red. Pulse: Rapid, Overflowing. Treatment principle Clear Heat, cool Blood, regulate the periods. Acupuncture L.I.-11 Quchi, SP-10 Xuehai, Du-14 Dazhui, LIV-2 Xingjian, KI-2 Rangu, SP-1 Yinbai, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), L.I.-4 Hegu, HE-6 Yinxi, P-7 Daling. All with reducing or even method, no moxa. Explanation
– L.I.-11 and SP-10 clear Heat and cool Blood. – Du-14 clears Heat. – LIV-2 and KI-2 cool Blood. LIV-2 also clears Liver-Fire which is often the root cause of this type of Blood-Heat. – SP-1 cools Blood and reduces excessive uterine bleeding.
– SP-4 and P-6 open the Penetrating Vessel. This vessel is the Sea of Blood and one of its main pathologies is Qi rebelling upwards which, by itself, can also cause a feeling of heat. The rebellious Qi carries Blood with it, and when the latter is hot this would contribute to the feeling of heat. For this reason, SP-4 and P-6 are used to harmonize the Penetrating Vessel and subdue rebellious Qi. – L.I.-4 is used to regulate the ascending and descending of Qi and thus reduce the feeling of heat which usually occurs on the face. – HE-6 and P-7 calm the Mind and also clear Heat. These points are used also because the pattern of Blood-Heat is often caused by emotional stress and, in turn, it causes irritability (as Heat usually does). Herbal treatment
a Prescription
– QIN LIAN SI WU TANG – Scutellaria-Coptis Four Substances Decoction Explanation The last four herbs are the formula Si Wu Tang Four Substances Decoction (with Sheng Di Huang substituted for Shu Di Huang). These are used to enter the Blood portion. Sheng Di Huang is used to cool Blood. – Huang Qin and Huang Lian are used to clear Heat: in combination with the Si Wu Tang, the herbs enter the Blood portion and cool Blood.
– Mai Men Dong nourishes Yin. b Prescription
– QING JING SAN – Clearing the Menses Powder Explanation Compared with the previous formula, this prescription is used when BloodHeat is more intense and there is also a tendency to Empty-Heat. – Mu Dan Pi cools Blood and clears Liver-Heat. – Bai Shao pacifies the Liver. – Shu Di Huang enters the Blood portion. – Di Gui Pi and Qing Hao clear Empty-Heat. – Fu Ling resolves Dampness. – Huang Bo clears Kidney Empty-Heat. c Prescription
– DAN ZHI XIAO YAO SAN Variation – Moutan-Gardenia Free and Easy Wanderer Powder Variation Explanation
This formula is chosen if there is a pronounced stagnation of Liver-Qi and this has given rise to Liver-Fire. The first eight herbs constitute a variation of the formula Dan Zhi Xiao Yao San (also called Jia Wei Xiao Yao San Augmented Free and Easy Wanderer Powder) which is specific for Liver-Fire deriving from stagnation of Liver-Qi. – Xiang Fu is added to move Liver-Qi. – Huang Qin clears Heat. – Gou Teng subdues Liver-Yang and clears Liver-Fire. It is especially suitable if the patient suffers also from headaches. Modifications
• If there is also some stasis of Liver-Blood, the formula Shi Xiao San Breaking into a Smile Powder can be added. Three Treasures remedy
– DRAIN FIRE This remedy is a variation of the formula Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction which drains Liver-Fire. The tongue presentation appropriate to this remedy is a Red body, with redder sides and with a yellow, dry coating. Summary Blood-Heat
Clinical manife stations
An intense feeling of heat or fever before or during the period, heavy period, mental restlessness, agitation, headache, blood-shot eyes, thirst, hot nose, red lips. Tongue: Red. Pulse: Rapid, Overflowing. Tre atme nt principle
Clear Heat, cool Blood, regulate the periods. Acupuncture
L.I.-11 Quchi, SP-10 Xuehai, Du-14 Dazhui, LIV-2 Xingjian, KI-2 Rangu, SP-1 Yinbai, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), L.I.-4 Hegu, HE-6 Yinxi, P-7 Daling. All with reducing or even method, no moxa. He rbal tre atme nt
Prescriptions
• QIN LIAN SI WU TANGScutellaria-Coptis Four Substances Decoction • QING JING SANClearing the Menses Powder • DAN ZHI XIAO YAO SAN Variation Moutan-Gardenia Free and Easy Wanderer Powder Variation Thre e Tre asure s remedy
• DRAIN FIRE
Kidney- and Liver-Yin deficiency with Empty-Heat
Clinical manifestations A fever or feeling of heat during or after the period, less intense than the previous case, worse in the evening, five-palm heat, mental restlessness, night sweating. Tongue: Red without coating. Pulse: Floating-Empty or FineRapid. Treatment principle Strengthen Kidneys and Liver, nourish Yin, clear Empty-Heat. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-3 Taixi, HE-6 Yinxi, KI-2 Rangu. LU-7 and KI-6 with even method, Ren-4, SP-6 and KI-3 reinforced, and HE-6 and KI-2 with reducing or even method, no moxa. Explanation
– LU-7 and KI-6 open the Directing Vessel and nourish Yin. The Directing Vessel also regulates the Uterus and the periods. – Ren-4 nourishes Kidneys and Liver and subdues Empty-Heat. It has a calming effect by drawing Qi downwards to the lower dan tian. – SP-6 and KI-3 strengthen the Liver and Kidneys and nourish Yin.
– HE-6 and KI-2 clear Empty-Heat. Herbal treatment
a Prescription
– DI GU PI YIN (from the Golden Mirror of Medicine) – Cortex Lycii Decoction Explanation The first four herbs are the formula Si Wu Tang Four Substances Decoction (with Sheng Di Huang substituted for Shu Di Huang, to cool Blood). These four herbs enter the Blood portion to which they therefore direct the other two. By doing so, they will regulate the period and treat symptoms arising at period time. – Mu Dan Pi clears Heat, cools Blood and clears Liver Empty-Heat. – Di Gu Pi clears Empty-Heat. b Prescription
– LIANG DI TANG – Two ‘Di’ Decoction Explanation
Compared with the previous formula, this prescription is used when Yin deficiency and Empty-Heat are more pronounced. – Sheng Di Huang, Mai Men Dong, Bai Shao and E Jiao nourish Blood and Yin and strengthen Liver and Kidneys. – Di Gu Pi and Xuan Shen clear Empty-Heat. Women’s Treasure remedy
– EASE THE JOURNEY-YIN This remedy is a variation of Zuo Gui Wan Restoring the Left [Kidney] Pill and it nourishes both Kidney-Yin and Kidney-Yang (but primarily Kidney-Yin) and clears Empty-Heat. The tongue presentation appropriate to this remedy is a Red body without coating.
Qi and Blood deficiency with disharmony of Nutritive and Defensive Qi
Clinical manifestations A fever or feeling of heat during or after the period, scanty periods, pale complexion, dizziness, tiredness. Tongue: Pale and Thin. Pulse: Choppy or Fine. Summary Kidney- and Liver-Yin deficiency with Empty-Heat
Clinical manifestations A fever or feeling of heat during or after the period, less intense than the previous case, worse in the evening, five-palm heat, mental restlessness, night sweating. Tongue: Red without coating. Pulse: Floating-Empty or FineRapid. Treatment principle Strengthen Kidneys and Liver, nourish Yin, clear Empty-Heat. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-3 Taixi, HE-6 Yinxi, KI-2 Rangu. LU-7 and KI-6 with
even method, Ren-4, SP-6 and KI-3 reinforced, and HE-6 and KI-2 with reducing or even method, no moxa. Herbal treatment
Prescriptions
• DI GU PI YIN (from the Golden Mirror of Medicine) Cortex Lycii Decoction • LIANG DI TANGTwo ‘Di’ Decoction
Women’s Treasure remedy
• EASE THE JOURNEY-YIN
Treatment principle Tonify Qi, nourish Blood, clear Heat with sweet, warm herbs. Acupuncture ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, Ren-4 Guanyuan, BL20 Pishu, BL-21 Weishu, T.B.-5 Waiguan. All with reinforcing method, except for T.B.-5 which should be needled with even method. Explanation
– ST-36, SP-6 and Ren-12 tonify Qi and Blood.
– Ren-4 nourishes Blood and regulates the Uterus. – BL-20 and BL-21 strengthen the Spleen and tonify Qi and Blood. – T.B.-5 harmonizes the Lesser Yang channels and clears Heat. Herbal treatment
Prescription
– BU ZHONG YI QI TANG – Tonifying the Centre and Benefiting Qi Decoction Explanation This formula (from Li Dong Yuan) is specific to clear Heat deriving from Qi and Blood deficiency and a decline of the Original Qi. As explained above, when this declines, a pathological Minister Fire takes its place giving rise to a feeling of heat. Thus, this type of Heat is treated by tonifying the Original Qi with sweet, warm herbs, which is what this formula does. The Discussion on Stomach and Spleen (1249) in fact says: Dietary irregularity and immoderate eating of cold and warm foods damage the Spleen and Stomach. Joy, anger, worry and fright consume and bring detriment to the Original Qi. If Spleen and Stomach Qi become decrepit and the Original Qi becomes insufficient, Heart-Fire becomes effulgent on its own. This Heart-Fire is a Yin Fire. It starts from the Lower Burner and its ligation links to the Heart. The Heart does not reign personally, Ministerial Fire is its deputy. Ministerial Fire is the Fire of the Pericardium developing
from the Lower Burner. It is a foe to the Original Qi. This Yin Fire and the Original Qi are irreconcilable to each other. When one is victorious, the other must be the loser.1 The book Treatment of Different Kinds of Diseases (Lei Zheng Zhi Cai) written in 1839 by Lin Pei Qin says: If there is a feeling of heat after the period, with tiredness and a feeling as if the eyes were covered by a silk sheet, it means that the pure essences of the Spleen and Kidneys cannot brighten the eyes; in such a case, use Bu Zhong Yi Qi Tang in the morning and Liu Wei Di Huang Wan with the addition of Gou Qi Zi in the evening.2 – Huang Qi, Ren Shen and Bai Zhu tonify and raise Qi and strengthen the Original Qi. – Dang Gui nourishes Blood. – Chen Pi resolves Dampness. – Sheng Ma and Chai Hu, in combination with Huang Qi, raise Qi. The original reason for the inclusion of these herbs, however, was to clear the pathological Minister Fire in the upper part of the body (as these herbs have an ascending movement). This remedy is the same as the homonymous formula and it therefore has the same actions and indications. The tongue presentation appropriate to this remedy is a pale body. Three Treasures remedy
– TONIFY QI AND EASE THE MUSCLES This remedy is a variation of the formula Bu Zhong Yi Qi Tang with the same actions and indications. The main difference is that this remedy has
some herbs to resolve Dampness. The tongue presentation appropriate to this remedy is a Pale body with thin, sticky, white coating. Summary Qi and Blood deficiency with disharmony of Nutritive and Defensive Qi
Clinical manife stations
A fever or feeling of heat during or after the period, scanty periods, pale complexion, dizziness, tiredness. Tongue: Pale and Thin. Pulse: Choppy or Fine. Tre atme nt principle
Tonify Qi, nourish Blood, clear Heat with sweet, warm herbs. Acupuncture
ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, Ren-4 Guanyuan, BL20 Pishu, BL-21 Weishu, T.B.-5 Waiguan. All with reinforcing method, except for T.B.-5 which should be needled with even method. He rbal tre atme nt
Prescriptions
• BU ZHONG YI QI TANGTonifying the Centre and Benefiting Qi Decoction Thre e Tre asure s remedy
• TONIFY QI AND EASE THE MUSCLES
Blood stasis with Heat
Clinical manifestations A fever or feeling of heat before or during the periods, dark menstrual blood with clots, abdominal pain. Tongue: Purple. Pulse: Wiry or Choppy. Treatment principle
– Invigorate Blood, eliminate stasis, clear Heat. Acupuncture
– L.I.-11 Quchi, SP-10 Xuehai, BL-17 Geshu, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-6 Sanyinjiao, Ren-6 Qihai. All with reducing or even method. Explanation
– L.I.-11 clears Heat. – SP-10 and BL-17 invigorate Blood and eliminate stasis. – SP-4 and P-6 open and regulate the Penetrating Vessel which is the Sea of Blood: these points therefore invigorate Blood and subdue rebellious Qi. – SP-6 invigorates Blood.
– Ren-6 invigorates Blood by moving Qi. Herbal treatment
a Prescription
– TAO HONG SI WU TANG Variation – Persica-Carthamus Four Substances Decoction Variation Explanation The formula Tao Hong Si Wu Tang invigorates Blood and eliminates stasis. – Dan Shen and Bie Jia invigorate Blood and eliminate stasis. b Prescription
– XUE FU ZHU YU TANG Variation – Blood Mansion Eliminating Stasis Decoction Variation Explanation Compared with the previous formula, this prescription is used when stasis of Blood is more pronounced. The first 11 herbs constitute the formula Xue Fu Zhu Yu Tang which invigorates Blood and eliminates stasis.
– Mu Dan Pi is added because it both invigorates and cools Blood. c Prescription
– XUE FU ZHU YU TANG and YUE JU WAN – Blood-Mansion Eliminating Stasis Decoction and GardeniaChuanxiong Pill Explanation This formula is indicated if the stasis of Blood derives from stagnation of Qi occurring against a background of intense emotional strain. The formula Yue Ju Wan, in fact, is excellent to relieve mental depression deriving from Qi stagnation. The first 11 herbs constitute the formula Xue Fu Zhu Yu Tang which invigorates Blood and eliminates stasis. The next four herbs constitute the formula Yue Ju Wan (minus Chuan Xiong which is already in the former formula) which eliminates stagnation of Qi. Three Treasures remedy
– RED STIRRING This remedy is a variation of Xue Fu Zhu Yu Tang Blood Mansion Eliminating Stasis Decoction. It invigorates Blood and eliminates stasis but it does not clear Heat. Therefore, attention should be paid to clearing Heat with acupuncture. The tongue presentation appropriate to this remedy is a Purple body. Summary
Blood stasis with Heat
Clinical manifestations
A fever or feeling of heat before or during the periods, dark menstrual blood with clots, abdominal pain. Tongue: Purple. Pulse: Wiry or Choppy. Treatment principle
Invigorate Blood, eliminate stasis, clear Heat. Acupuncture
L.I.-11 Quchi, SP-10 Xuehai, BL-17 Geshu, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-6 Sanyinjiao, Ren-6 Qihai. All with reducing or even method. Herbal treatment
Pre scriptions
• TAO HONG SI WU TANG Variation Persica-Carthamus Four Substances Decoction Variation • XUE FU ZHU YU TANG Variation Blood Mansion Eliminating Stasis Decoction Variation • XUE FU ZHU YU TANG and YUE JU WANBlood-Mansion Eliminating Stasis Decoction and Gardenia-Chuanxiong Pill Three Treasures remedy
• RED STIRRING
Ancient acupuncture prescriptions for fever during periods 3
1. ST-30 Qichong (ABC of Acupuncture, Zhen Jiu Jia Yi Jing, AD 259). 2. Bailao (extra point situated on the Governing Vessel 2 cun above Du14 Dazhui), BL-23 Shenshu, BL-12 Fengmen, Ren-3 Zhongji, Ren-6 Qihai, SP-6 Sanyinjiao for feelings of heat and cold and loss of weight; or also L.I.-4 Hegu, Bailao, Zhongquan (an extra point situated on the dorsum of the hand half way between L.I.-5 Yangxi and T.B.-4 Yangchi), BL-15 Xinshu, P-8 Laogong and KI-1 Yongquan for mental restlessness and fever during the period (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601).
Prognosis and prevention Both acupuncture and herbs can be effective in treating this condition, but herbs probably more so. The two most difficult patterns to treat are those from Blood-Heat and Stasis of Blood with Heat. As for prevention, it is important that women suffering from this complaint do not consume excessive amounts of hot foods, i.e. meat (especially lamb, beef or game), spices and alcohol. They should also avoid overwork as this may lead to Liver- and Kidney-Yin deficiency. End notes 1. Yang Jian Bing 2002 A Vernacular Explanation of the Discussion of Stomach and Spleen (Pi Wei Lun Bai Hua Jie ), San Qin Publishing House, Xian, p. 110. The Discussion on Stomach and Spleen was written by Li Dong Yuan and first published in 1249..
2. Cited in Nanjing College of Traditional Chinese Medicine 1979 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Nanjing College of Traditional Chinese Medicine, Nanjing, p. 63..
3. Chen You Bang 1990 Chinese Acupuncture Therapy (Zhong Guo Zhen Jiu Zhi Liao Xue
), China Scientific Publishing House, Beijing, p. 866..
CHAPTER 25 Epistaxis or Haemoptysis at Period Time AETIOLOGY 429 PATHOLOGY 429 IDENTIFICATION OF PATTERNS AND TREATMENT 430 Stagnant Liver-Qi turning into Fire 430 Lung- and Kidney-Yin deficiency 431 PROGNOSIS AND PREVENTION 432 Epistaxis or haemoptysis may occur before, during or after the period. From a Western perspective, these symptoms may indicate endometriosis, but they may also occur in the absence of such a disease. From a Chinese perspective, they are usually associated with a situation of Qi rebelling upwards and are therefore strongly related to a Penetrating Vessel pathology: for these reasons, this condition was sometimes called ni jing (
), i.e. ‘rebellious period’, or
dao jing ( period’.
), i.e. ‘reverse
Aetiology
Emotional stress Longstanding emotional problems such as anger, frustration, worry, guilt, hatred or resentment cause Liver-Qi to stagnate: after some time, stagnant Liver-Qi easily turns into Liver-Fire. If Qi rebels upwards due to a Penetrating Vessel (Chong Mai) pathology, it carries Fire with it; Fire agitates Blood and Liver-Fire, especially because the Liver stores Blood; rebellious Qi in the Penetrating Vessel becomes particularly evident during periods because of this vessel’s activity at this time, hence this causes bleeding upwards, i.e. epistaxis or haemoptysis. This type of bleeding usually occurs before or during the period. Overwork, emotional stress Overwork may weaken both Lung- and Kidney-Yin, Yin deficiency gives rise to Empty-Heat, this rises to damage the Lung’s Blood-Connecting channels and causes either epistaxis or haemoptysis (both of which are related to the Lung channel). This situation is aggravated if the patient suffers also from emotional problems which weaken the Lungs such as sadness, grief and worry.
Pathology The pathology of epistaxis and/or haemoptysis at period time is mostly related to the Liver channel and the Penetrating Vessel. The Liver stores Blood, this is abundant at the time when the period is due, and it percolates down to the Sea of Blood of the Penetrating Vessel, giving rise to the period. When women are affected by emotional stress such as anger, frustration or resentment, Liver-Qi, and therefore Blood also, stagnates. Since the Liver’s pathology in women is closely related to the Penetrating Vessel, when the Qi of this vessel rebels upwards, Liver-Qi also rebels upwards. When LiverFire is formed from stagnant Liver-Qi, Fire follows rebellious Qi upwards; it damages the Blood-Connecting channels and causes bleeding from the nose or lungs. Thus, the essential pathological conditions in this problem are Fire (or Empty-Heat) and rebellious Qi: the treatment principles to be adopted are therefore to drain Fire (or clear Empty-Heat), subdue rebellious Qi and attract blood downwards. Such principles of treatment apply to both excess or deficiency patterns causing this condition: thus, in Lung- and Kidney-Yin deficiency one must also pacify the Liver and subdue rebellious Qi. Thus, the main pathological factors in this condition are: • stagnant Liver-Qi turning into Fire • Lung- and Kidney-Yin deficiency.
Identification of patterns and treatment The formulae discussed below are all aimed at stopping bleeding: however, they do so by treating also the underlying pattern causing the bleeding. They can therefore be administered throughout the menstrual cycle and especially during the period itself. However, it may not be necessary for the patient to take the prescription throughout the month as she could time the therapy according to the four phases of the menstrual cycles discussed in Chapter 2. Thus, in this case, the patient could take the prescription only during the fourth and first phases, i.e. in the pre-menstrual phase and during the period itself.
Stagnant Liver-Qi turning into Fire
Clinical manifestations Epistaxis or haemoptysis before or during the period, heavy period, red face, irritability, pre-menstrual tension, feeling of heat, red eyes, thirst. Tongue: red sides. Pulse: Wiry and Rapid. Treatment principle Clear the Liver, drain Fire, subdue rebellious Qi, stop bleeding. Acupuncture LIV-2 Xingjian, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), L.I.-11 Quchi, SP-10 Xuehai, LU-6 Kongzui, L.I.-4 Hegu, LU-5 Chize, LU-10. All with reducing or even method. Explanation
– LIV-2 clears Liver-Fire and also subdues rebellious Qi. – SP-4 and P-6 open and regulate the Penetrating Vessel and help to subdue rebellious Qi. – L.I.-11 and SP-10 in combination clear Heat and cool Blood to stop bleeding. – LU-6, Accumulation point of the Lung channel, stops bleeding (this is a general property of Accumulation points, especially those on Yin channels).
– L.I.-4 treats the nose in case of epistaxis. – LU-5 and LU-10 clear Lung-Heat or Lung Empty-Heat in a case of haemoptysis. Herbal treatment
a. Prescription
– QING GAN YIN JING TANG – Clearing the Liver and Guiding the Period Decoction Explanation
– Dang Gui, Bai Shao and Sheng Di Huang nourish and harmonize Blood. Bai Shao and Sheng Di Huang, in particular, also ‘calm Blood’, a treatment principle adopted in bleeding syndromes, which means that these herbs make the Blood settle back into the vessels. Dang Gui is also used as a messenger to direct the formula to the Blood portion. – Shan Zhi Zi and Huang Qin clear Heat and drain Fire. – Chuan Lian Zi moves Liver-Qi. – Qian Cao Gen cools Blood and stops bleeding. It also invigorates Blood. – Bai Mao Gen stops bleeding, particularly from the lungs.
– Niu Xi directs Qi downwards and therefore subdues rebellious Qi. – Mu Dan Pi cools Blood and stops bleeding. – Gan Cao harmonizes. b. Prescription
– SHU GAN JIANG NI TANG – Pacifying the Liver and Subduing Rebellious Qi Decoction Explanation
– Sang Ye and Dai Zhe Shi subdue rebellious Liver-Qi. – Bai Shao and Sheng Di Huang ‘calm Blood’ to stop bleeding. – Mu Dan Pi cools and invigorates Blood. – Xiang Fu moves Liver-Qi. – Bai Mao Gen stops bleeding. – Niu Xi attracts Qi downwards and therefore helps to subdue rebellious Qi. This formula is used when Fire is not so intense and there is the beginning of Yin deficiency. Three Treasures remedy
– DRAIN FIRE This remedy is a variation of the formula Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction which drains Liver-Fire. The tongue presentation appropriate to this remedy is a Red body with redder sides and a yellow, dry coating. Summary Stagnant Liver-Qi turning into Fire
Clinical manifestations
Epistaxis or haemoptysis before or during the period, heavy period, red face, irritability, pre-menstrual tension, feeling of heat, red eyes, thirst. Tongue: Red sides. Pulse: Wiry and Rapid. Treatment principle
Clear the Liver, drain Fire, subdue rebellious Qi, stop bleeding. Acupuncture
LIV-2 Xingjian, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), L.I.-11 Quchi, SP-10 Xuehai, LU-6 Kongzui, L.I.-4 Hegu, LU-5 Chize, LU-10. All with reducing or even method. Herbal treatment
Pre scriptions
• QING GAN YIN JING TANG Clearing the Liver and Guiding the Period
Decoction • SHU GAN JIANG NI TANG Pacifying the Liver and Subduing Rebellious Qi Decoction Three Treasures remedy
• DRAIN FIRE
Lung- and Kidney-Yin deficiency
Clinical manifestations Epistaxis or haemoptysis during or after the period, scanty period, dry throat, dry cough, night sweating, dizziness, tinnitus, irregular periods. In case of Empty-Heat: five-palm heat, feeling of heat in the evening. Tongue: without coating; Red in case of Empty-Heat. Pulse: Fine-Rapid or Floating-Empty. Treatment principle Nourish Yin, nourish the Lungs, cool Blood, clear Empty-Heat, stop bleeding. Acupuncture LU-9 Taiyuan, BL-13 Feishu, LU-6 Kongzui, L.I.-4 Hegu, Ren-12 Zhongwan, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, KI-2 Rangu, L.I.-11 Quchi and SP-10 Xuehai. All with reinforcing method, except for the last two points which should be needled with reducing or even method. No moxa. Explanation
– LU-9 and BL-13 nourish the Lungs. – LU-6, Accumulation point, stops bleeding from the Lung channel. – L.I.-4 is used in case of epistaxis.
– Ren-12 and SP-6 nourish Lung-Yin (based on the principle of tonifying the Earth to support Metal). – KI-3 and Ren-4 nourish Kidney-Yin. – KI-2 clears Empty-Heat. – L.I.-11 and SP-10 cool Blood to stop bleeding. Herbal treatment
a. Prescription
– SHUN JING FANG Variation – Ordering the Periods Formula Variation Explanation All the herbs but the last one form the formula Shun Jing Tang. – Dang Gui, Shu Di Huang and Bai Shao nourish Blood. Sheng Di Huang and Bai Shao also ‘calm’ Blood to stop bleeding. Dang Gui directs the herbs to the Blood portion. – Bei Sha Shen nourishes the Lungs. – Jing Jie stops bleeding (especially if charred). – Fu Ling is added to balance the Yin-nourishing herbs by resolving Dampness.
– Mu Dan Pi cools Blood and stops bleeding. – Niu Xi directs the herbs downwards and subdues rebellious Qi. Three Treasures remedy
– JADE SPRING This remedy nourishes Lung- and Stomach-Yin and clears Empty-Heat. It is therefore suitable if there is Lung-Yin deficiency and Empty-Heat, although it does not specifically stop bleeding. Summary Lung- and Kidney-Yin deficiency
Clinical manifestations
Epistaxis or haemoptysis during or after the period, scanty period, dry throat, dry cough, night sweating, dizziness, tinnitus, irregular periods. In case of Empty-Heat: five-palm heat, feeling of heat in the evening. Tongue: without coating; Red in case of Empty-Heat. Pulse: Fine-Rapid or Floating-Empty. Treatment principle
Nourish Yin, nourish the Lungs, cool Blood, clear Empty-Heat, stop bleeding. Acupuncture
LU-9 Taiyuan, BL-13 Feishu, LU-6 Kongzui, L.I.-4 Hegu, Ren-12
Zhongwan, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, KI-2 Rangu, L.I.-11 Quchi and SP-10 Xuehai. All with reinforcing method, except for the last two points which should be needled with reducing or even method. No moxa. Herbal treatment
Pre scription
• SHUN JING FANG Variation Ordering the Periods Formula Variation Three Treasures remedy
• JADE SPRING
Prognosis and prevention The complaint of epistaxis and/or haemoptysis is not frequently encountered in practice; perhaps epistaxis is the more frequent of the two. The prognosis in this case depends to a large extent on the Western diagnosis: if the epistaxis or haemoptysis are due to endometriosis, they will be more difficult to treat than if they are not. Endometriosis can be treated with acupuncture and Chinese herbs but it does take quite a long time to achieve permanent results. Of the two patterns, the one due to Lung- and Kidney-Yin deficiency with Empty-Heat is the more difficult to treat. Herbs are somewhat more effective than acupuncture in bleeding conditions. As for prevention and advice to patients, it is important that a woman suffering from this condition refrains from consuming excessive amounts of hot and spicy foods: these include lamb, game, spices, curry and also alcohol. These foods tend to create Blood-Heat and would therefore aggravate the bleeding. Another important recommendation is to avoid, as much as possible, emotional strain because this will tend to cause Qi to rebel upwards especially when it affects the Liver. Of course, this is difficult to do and, in serious and longstanding cases, the help of a psychotherapist might be necessary.
CHAPTER 26 Mouth Ulcers at Period Time
AETIOLOGY 433 PATHOLOGY 433 IDENTIFICATION OF PATTERNS AND TREATMENT 433 Heart-Fire 433 Heart- and Kidney-Yin deficiency with Empty-Heat 434 Stomach-Fire or Stomach Damp-Heat 435 Stomach Damp-Heat with Spleen deficiency 436 PROGNOSIS AND PREVENTION 437 This condition consists in the appearance of mouth and/or tongue ulcers at period time. It was called kou chuang, kou mi or kou gan all meaning ‘mouth ulcers’.
Aetiology
Overwork Overwork often leads to Kidney-Yin deficiency. At period time, Blood and Yin percolate down to the Uterus so that a pre-existing Yin deficiency will be aggravated: this will result in Empty-Heat which rises to the mouth and tongue producing ulcers. The tongue may be particularly affected because this organ is connected to the Uterus by means of the Uterus Vessel (Bao Mai). The ulcers are more likely to appear during or after the period.
Irregular diet The excessive consumption of hot, spicy and greasy foods may cause the formation of Damp-Heat in the Stomach. During the period, rebellious Qi of the Penetrating Vessel may rise and, since this vessel is closely connected to the Stomach channel, Stomach-Fire or Stomach Damp-Heat will ascend with it and cause mouth ulcers. This condition will tend to cause mouth rather than tongue ulcers and is more likely to occur before or during the period. In many cases, the Stomach Damp-Heat may be associated with a Spleen deficiency.
Pathology The pathology of this condition is mostly related to the Heart and Stomach, the former with either Full- or Empty-Heat, and the latter mostly with FullHeat. The tongue pertains to the Heart and the mouth to the Stomach, hence these two organs are mostly involved in mouth or tongue ulcers. A fourth pathology is that of Damp-Heat with Spleen deficiency and, because of the connection between Spleen and lips, in this case there may be cold sores on the lips. Thus, the main pathological factors occurring in this condition are: • Heart-Fire • Heart- and Kidney-Yin deficiency with Empty-Heat • Stomach-Fire or Stomach Damp-Heat • Stomach Damp-Heat with Spleen deficiency.
Identification of patterns and treatment
Heart-Fire
Clinical manifestations Mouth ulcers at period time, tongue ulcers, ulcers with a red, raised rim and very painful, palpitations, anxiety, mental restlessness, agitation, feeling of heat, red cheeks, thirst. Tongue: Red with redder tip, yellow coating. Pulse: Overflowing-Rapid. Treatment principle Clear the Heart, drain Fire, calm the Mind. Acupuncture
– HE-8 Shaofu, P–8 Laogong. Reducing method. Explanation
– HE-8 and P-8 drain Heart-Fire. In particular, P-8 enters the channels of the Heart and Pericardium and treats tongue ulcers. Herbal treatment
Prescription
– DAO CHI SAN Variation – Eliminating Redness Powder Variation Explanation The root formula drains Heart-Fire. Please note that Mu Tong is illegal and should be removed. Huang Lian drains Heart-Fire. Summary Heart-Fire
Clinical manife stations
Mouth ulcers at period time, tongue ulcers, ulcers with a red, raised rim and very painful, palpitations, anxiety, mental restlessness, agitation, feeling of heat, red cheeks, thirst. Tongue: Red with redder tip, yellow coating. Pulse: Overflowing-Rapid. Tre atme nt principle
Clear the Heart, drain Fire, calm the Mind. Acupuncture
HE-8 Shaofu, P–8 Laogong. Reducing method. He rbal tre atme nt
Prescription
• DAO CHI SAN Variation Eliminating Redness Powder Variation
Heart- and Kidney-Yin deficiency with Empty-Heat
Clinical manifestations Tongue ulcers during or after the period, five-palm heat, night sweating, feeling of heat in the evening, dizziness, tinnitus, dry mouth. Tongue: Red without coating. Pulse: Floating-Empty or Fine-Rapid. Treatment principle Nourish Kidney-Yin, clear Empty-Heat. Acupuncture KI-3 Taixi, Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), HE-5 Tongli, HE-6 Yinxi, KI-2 Rangu, HE-8 Shaofu. All with reinforcing method except for the Heart points which should be needled with reducing or even method. No moxa. Explanation
– KI-3 and Ren-4 nourish Kidney-Yin. – LU-7 and KI-6 regulate the Directing Vessel and nourish Yin. In particular, KI-6 will reach the throat, mouth and tongue, nourishing Yin and easing Heat. – HE-5 specifically affects the tongue. – HE-6 clears Empty-Heat from the Heart channel.
– HE-8 clears Heat. – KI-2 clears Empty-Heat, especially in combination with HE-6. Herbal treatment
Prescription
– YU NU JIAN and DAO CHI SAN – Jade Woman Decoction and Eliminating Redness Powder Explanation The first four herbs make up the formula Yu Nu Jian together with Shu Di Huang which is here replaced by Sheng Di Huang, one of the second group of four herbs which make up the formula Dao Chi San. – Shi Gao and Zhi Mu clear Stomach-Heat and will therefore affect the mouth area. – Mai Men Dong nourishes Stomach-Yin. – Niu Xi attracts Heat downwards away from the mouth (due to its descending movement). – Sheng Di Huang nourishes Kidney-Yin. – Mu Tong and Zhu Ye clear Heart-Heat. – Gan Cao clears Heat and resolves Toxin.
Three Treasures remedies
– JADE SPRING and EASE THE JOURNEY YIN The first remedy (Jade Spring) nourishes Stomach-Yin and clears Empty-Heat. It affects the mouth area. The second remedy nourishes Kidney-Yin and clears Empty-Heat. When two remedies are used, the dosage of each should be reduced: thus, in this case, one might use two tablets of each of the remedies a day. Women’s Treasure remedy
– HEAVENLY EMPRESS This remedy is a variation of the formula Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill and it nourishes Heart- and Kidney-Yin and clears Heart Empty-Heat. The tongue presentation appropriate to this remedy is a Red body without coating, a redder tip and a central Heart crack. Summary Heart- and Kidney-Yin deficiency with Empty-Heat
Clinical manifestations
Tongue ulcers during or after the period, five-palm heat, night sweating, feeling of heat in the evening, dizziness, tinnitus, dry mouth. Tongue: Red without coating. Pulse: Floating-Empty or Fine-Rapid. Treatment principle
Nourish Kidney-Yin, clear Empty-Heat. Acupuncture
KI-3 Taixi, Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), HE-5 Tongli, HE-6 Yinxi, KI-2 Rangu, HE-8 Shaofu. All with reinforcing method except for the Heart points which should be needled with reducing or even method. No moxa. Herbal treatment
Pre scription
• YU NU JIAN and DAO CHI SAN Jade Woman Decoction and Eliminating Redness Powder Three Treasures remedies
• JADE SPRING • EASE THE JOURNEY YIN Women’s Treasure remedy
• HEAVENLY EMPRESS
Stomach-Fire or Stomach Damp-Heat
Clinical manifestations Mouth ulcers before or during the period, foul-smelling breath, thirst, dry stools, irritability. Tongue: Red with yellow coating. Pulse: Overflowing. Treatment principle Clear Heat, drain Fire, clear the Stomach. Acupuncture ST-44 Neiting, L.I.-4 Hegu, L.I.-11 Quchi, Ren-13 Shangwan, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), ST-25 Tianshu, SP-15 Daheng. All with reducing or even method. Explanation
– ST-44 clears Stomach-Heat. – L.I.-4 clears Heat and specifically affects the mouth. – L.I.-11 clears Heat in the Stomach and Intestines. – Ren-13 regulates the Upper Burner and therefore the upper part of the digestive system. – SP-4 and P-6 regulate the Penetrating Vessel and subdue its rebellious Qi.
– ST-25 clears Stomach-Heat. – SP-15 is used if there is constipation. Herbal treatment
Prescription
– LIANG GE SAN – Cooling the Diaphragm Powder Explanation This formula clears Heat in the Upper Burner and drains Fire through the Lower Burner: thus, it is ideally suited to treat mouth ulcers (in the Upper Burner) deriving from Stomach-Fire (the Middle Burner). The dosages indicated above are obviously to make a batch of powder. If a decoction is used, the dosages of each herb can be kept in the same proportion so that, for example, 600 g corresponds to 6 g, 300 g to 3 g and 1200 g to 12 g. – Da Huang, Mang Xiao and Gan Cao constitute the formula Tiao Wei Cheng Qi Tang Regulating the Stomach and Conducting Qi Decoction which drains Fire from the Stomach and Intestines by moving downwards. – Huang Qin, Shan Zhi Zi and Lian Qiao clear Heat in the Upper and Middle Burner. – Bo He directs the herbs to the Upper Burner and head. – Zhu Ye clears Heart-Heat and also directs the herbs to the Upper
Burner. Summary Stomach-Fire or Stomach Damp-Heat
Clinical manife stations
Mouth ulcers before or during the period, foul-smelling breath, thirst, dry stools, irritability. Tongue: Red with yellow coating. Pulse: Overflowing. Tre atme nt principle
Clear Heat, drain Fire, clear the Stomach. Acupuncture
ST-44 Neiting, L.I.-4 Hegu, L.I.-11 Quchi, Ren-13 Shangwan, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), ST-25 Tianshu, SP-15 Daheng. All with reducing or even method. He rbal tre atme nt
Prescription
• LIANG GE SAN Cooling the Diaphragm Powder
Stomach Damp-Heat with Spleen deficiency
Clinical manifestations Mouth ulcers, cold sores around the lips, abdominal distension, loose stools, tiredness, thirst, a sticky taste. Tongue: Red with sticky coating, teethmarks. Pulse: Slippery and Weak. Treatment principle Resolve Dampness, clear Heat, clear the Stomach, tonify Spleen-Qi. Acupuncture SP-9 Yinlingquan, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, ST-44 Neiting, ST25 Tianshu, L.I.-11 Quchi, ST-37 Shangjuxu, BL-20 Pishu, Ren-12 Zhongwan. All with reducing or even method except for BL-20 and Ren-12 which should be reinforced. Explanation
– SP-9, SP-6 and BL-22 resolve Dampness. – ST-44 and ST-25 clear Stomach-Heat; ST-25 also treats diarrhoea. – L.I.-11 resolves Damp-Heat. – ST-37 treats loose stools. – BL-20 and Ren-12 tonify the Spleen.
Herbal treatment
Prescription
– GAN LU XIAO DU YIN – Sweet Dew Eliminating Toxin Decoction Explanation
– Lian Qiao, Huang Qin, Mu Tong, Yin Chen Hao and Hua Shi resolve Damp-Heat. – Bo He clears Wind-Heat and Heat from the top part of the body. – She Gan and Chuan Bei Mu clear Lung-Heat and benefit the throat. – Huo Xiang and Bai Dou Kou fragrantly resolve Dampness. – Shi Chang Pu opens the orifices and helps the transformation of Water. Three Treasures remedies
– EASE THE MUSCLES and SOOTHE THE CENTRE The remedy Ease the Muscles drains Damp-Heat and Soothe the Centre resolves Dampness and tonifies the Spleen. When two remedies are taken in combination, their respective dosages should be reduced: for example, the patient could take two tablets of Soothe the Centre after lunch
and two of Ease the Muscles in the evening. Summary Stomach Damp-Heat with Spleen deficiency
Clinical manifestations
Mouth ulcers, cold sores around the lips, abdominal distension, loose stools, tiredness, thirst, a sticky taste. Tongue: Red with sticky coating, teethmarks. Pulse: Slippery and Weak. Treatment principle
Resolve Dampness, clear Heat, clear the Stomach, tonify Spleen-Qi. Acupuncture
SP-9 Yinlingquan, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, ST-44 Neiting, ST25 Tianshu, L.I.-11 Quchi, ST-37 Shangjuxu, BL-20 Pishu, Ren-12 Zhongwan. All with reducing or even method except for BL-20 and Ren-12 which should be reinforced. Herbal treatment
Pre scription
• GAN LU XIAO DU YIN Sweet Dew Eliminating Toxin Decoction Three Treasures remedies
• EASE THE MUSCLES • SOOTHE THE CENTRE
Prognosis and prevention This condition is frequently seen in practice. In fact, the pathology of mouth and/or tongue ulcers in women is nearly always intimately connected with the state of the Directing and Penetrating Vessels even when the ulcers do not necessarily occur in coincidence with the periods. As a rule of thumb, tongue ulcers are usually caused by Empty-Heat and Yin deficiency and are related to the Directing Vessel, while mouth ulcers are usually due to Stomach-Fire and are related to the Penetrating Vessel. The ones from Yin deficiency and Empty-Heat are more difficult to treat, but both types respond well to acupuncture and/or herbs. It is important that a woman suffering from this problem does not consume an excessive amount of hot, spicy foods and alcohol as these will make both Empty-Heat and Fire worse.
CHAPTER 27 Skin Eruptions at Period Time
AETIOLOGY 439 PATHOLOGY 439 ACUPUNCTURE 440 IDENTIFICATION OF PATTERNS AND TREATMENT 440 Wind-Heat with Blood deficiency 440 Blood-Heat 442 Damp-Heat 443 PROGNOSIS AND PREVENTION 444 Papular, itchy skin eruptions may appear suddenly before the period and subside after the period. Generalized skin eruptions such as these are not common but those that are localized around the chin and face are very common indeed.
Aetiology
Overwork, chronic illness, haemorrhage after childbirth All these can cause Blood deficiency; during and after the period the Blood is in a state of relative deficiency. When Blood is deficient, the relative emptiness within the blood vessels and channels allows Wind to develop and this causes skin eruptions. Irregular diet, Yang constitution An excessive consumption of hot and spicy foods (including alcohol), especially by a person with a Yang constitution, may cause internal WindHeat to develop. This is especially likely to happen if the patient consumes Wind-producing foods such as shellfish, spinach or mushrooms. The excessive consumption or hot foods as defined above may also affect the Liver and cause Liver-Heat which, in turn, will cause Blood-Heat.
Pathology The pathology of this condition is often related to Wind and Dryness invading the Blood portion: this may happen either because the Blood is deficient so that Wind-Heat develops by itself, or because diet-induced Wind-Heat invades the Blood portion. The eruptions develop at period time because at this time the Blood is a state of relative deficiency and therefore prone to develop (or be invaded by) Wind-Heat. For this reason, it is a well-known axiom in Chinese medicine that ‘one must treat Blood to extinguish Wind’. The herbal treatment therefore consists in harmonizing Blood and pacifying Wind but not with pungent, warm or drying, aromatic herbs which may tend to injure Blood or Yin. Another pathology of skin eruptions at period time is also Blood-Heat: as we have seen, Yang is rising rapidly in phase 4 and any aetiological factor that heats the Blood will manifest more in phase 4, especially just before the period. Furthermore, Blood-Heat may easily combine with Dampness and therefore Damp-Heat, especially when the patient consumes an excessive amount of Damp-producing foods (a very common dietary irregularity in Western societies). Thus, the main pathological factors are: • Blood deficiency • Wind-Heat invading Blood • Blood-Heat with or without Damp-Heat. In addition to the above pathological conditions, although unlikely to be the only pathology, Blood stasis may accompany any of the above; in this case, the formulae indicated below need to be modified with addition of Blood-invigorating herbs and my choice would be Hong Hua Flos Carthami and Dan Shen Radix Salviae miltiorrhizae. In older women, the pattern of Wind-Heat invading the Blood portion
may also occur against a background of Kidney-Yin deficiency.
Acupuncture From the point of view of acupuncture, whatever the pattern causing the skin eruptions, the Penetrating and Directing Vessels (Chong and Ren Mai) are involved. Both the Penetrating and the Directing Vessels flow over the chin, around the mouth and up to the eyes. I personally always treat the Penetrating and Directing Vessel to regulate the periods and harmonize Blood; in particular, if the skin eruptions are on the chin and around the mouth (which is often the case), it is even more important to treat the Penetrating and Directing Vessels. I usually do not treat both these vessels together. I treat the Directing Vessel if there is Blood or Yin deficiency and the Penetrating Vessel if there is Heat. Another reason for choosing the Penetrating Vessel is if the skin eruptions occur only before the period. Another point about the choice of points in skin eruptions: if they are located on the chin and around the mouth or, indeed, anywhere on the face, the point L.I.-4 should be selected in every case. Clinical Note It is nearly always necessary to regulate the Penetrating and Directing Vessels to treat skin eruptions occurring at period time, especially if they are located on the chin and around the mouth. Summary
Acupuncture
• The Penetrating and Directing Vessels (Chong and Ren Mai) are involved. • I personally always treat the Penetrating and Directing Vessels to regulate the periods and harmonize Blood. • I treat the Directing Vessel if there is Blood or Yin deficiency and the Penetrating Vessel if there is Heat. • If the skin eruptions are located on the chin and around the mouth or, indeed, anywhere on the face, the point L.I.-4 should be selected in every case.
Identification of patterns and treatment The treatment with herbs should be carefully adapted according to the appearance of the skin eruptions: • Red papules indicate Wind-Heat. • Pale papules also indicate Wind-Heat but one occurring against a background of Blood deficiency. • White vesicles filled with clear fluid indicate Dampness. • Pustules filled with a yellow, sticky fluid indicate Damp-Heat. • Purple eruptions indicate Blood stasis. The formulae described below should therefore be modified according to the prevailing pathogenic factor as indicated by the appearance of the skin eruptions, by the addition of herbs as follows: • Wind-Heat: Ju Hua Flos Chrysanthemi and Sheng Ma Rhizoma Cimicifugae. • Wind-Heat with Blood deficiency: Ju Hua Flos Chrysanthemi with Shou Wu Radix Polygoni multiflori preparata. • Dampness: Cang Zhu Rhizoma Atractylodis and Yi Yi Ren Semen Coicis. • Damp-Heat: Huang Qin Radix Scutellariae, Huang Bo Cortex Phellodendri, Bai Xian Pi Cortex Dictami. • Blood stasis: Dan Shen Radix Salviae miltiorrhizae and Hong Hua Flos Carthami.
Wind-Heat with Blood deficiency
Clinical manifestations Itchy, papular skin eruption before, during or after the period on the body and limbs, worse at night, insomnia, dizziness, scanty periods. Tongue: Pale and Thin; the sides in the front third of the tongue may be Red. Pulse: Choppy or Fine. Treatment principle Nourish Blood, expel Wind, regulate the periods, harmonize the Penetrating and Directing Vessels. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, SP-6 Sanyinjiao, ST-36 Zusanli, LIV-8 Ququan, L.I.-11 Quchi, T.B.-6 Zhigou, G.B.-31 Fengshi, Du-14 Dazhui. L.I.-11, T.B.-6, G.B.-31 and Du14 should be needled with reducing or even method, the others should be reinforced. No moxa. Explanation
– LU-7 and KI-6 regulate the Directing Vessel, nourish Blood and Yin, and regulate the periods. – Ren-4, SP-6, ST-36 and LIV-8 nourish Blood.
– L.I.-11 clears Heat and stops itching. – T.B.-6, G.B.-31 and Du-14 expel Wind and stop itching. Herbal treatment
a Prescription
– DANG GUI YIN ZI Variation – Angelica Decoction Variation Explanation The original formula has been modified by removing Chuan Xiong. – Sheng Di Huang, Dang Gui, Bai Shao and Shou Wu nourish Blood. – Fang Feng, Jing Jie and Bai Ji Li expel Wind and stop itching. – Gan Cao harmonizes. b Prescription
– YANG XUE DING FENG TANG – Nourishing Blood and Subduing Wind Decoction Explanation
This prescription is specific to nourish Blood and expel Wind-Heat in skin diseases. – Sheng Di Huang, Dang Gui, Chuan Xiong and Chi Shao are a modified version of Si Wu Tang Four Substances Decoction to nourish Blood. – Tian Men Dong and Mai Men Dong help to nourish Blood by nourishing Yin. They also moisten the skin. – Jiang Can expels Wind and stops itching. – Shou Wu nourishes Blood and the skin. – Shan Zhi Zi and Mu Dan Pi clear Heat and cool Blood to stop itching. Modifications
• If the Exterior is weak, Defensive Qi deficient and the patient prone to invasions of external Wind, first consolidate the Exterior with Yu Ping Feng San Jade Wind Screen Decoction plus Hei Da Dou Semen Glycinis max and Niu Bang Zi Fructus Arctii to stop itching. • If the Wind-Heat occurs against a background of Kidney-Yin deficiency, add Sheng Di Huang Radix Rehmanniae and Gou Qi Zi Fructus Lycii. c Prescription
– QIN JIAO NIU BANG TANG Variation – Gentiana macrophylla Arctium Decoction Variation
Explanation This formula expels Wind-Heat occurring against a background of KidneyYin deficiency. – Ma Huang, Fang Feng, Sheng Ma and Niu Bang Zi expel Wind-Heat from the skin and stop itching. – Xuan Shen and Sheng Di Huang nourish Kidney-Yin and cool Blood. Sheng Di Huang has been added to the original formula. – Mu Dan Pi and Shui Niu Jiao cool Blood. Mu Dan Pi has been added to the original formula. – Qin Jiao clears Empty-Heat. – Huang Qin clears Heat. – Gan Cao harmonizes. Three Treasures remedies
– GLORIOUS SEA This remedy nourishes Liver-Blood and the skin, and resolves DampHeat from the skin. It does not specifically expel Wind, so this should be achieved with acupuncture. – NOURISH THE ROOT AND CLEAR WIND Although this remedy was devised to nourish Yin and expel WindDampness from the joints, it may be used also for skin eruptions from WindHeat and Yin deficiency because some of the herbs that expel WindDampness from the joints have the same effect on the skin. The tongue
presentation appropriate to this remedy is a Red body without coating in severe cases, or a slightly Red body with rootless coating in mild ones. Women’s Treasure remedy
– PRECIOUS SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Wind-Heat with Blood deficiency
Clinical manifestations
Itchy, papular skin eruption before, during or after the period on the body and limbs, worse at night, insomnia, dizziness, scanty periods. Tongue: Pale and Thin; the sides in the front third of the tongue may be Red. Pulse: Choppy or Fine. Treatment principle
Nourish Blood, expel Wind, regulate the periods, harmonize the Penetrating and Directing Vessels. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, SP-6 Sanyinjiao, ST-36 Zusanli, LIV-8 Ququan, L.I.-11 Quchi, T.B.-6
Zhigou, G.B.-31 Fengshi, Du-14 Dazhui. L.I.-11, T.B.-6, G.B.-31 and Du14 should be needled with reducing or even method, the others should be reinforced. No moxa. Herbal treatment
Pre scriptions
• DANG GUI YIN ZI Variation Angelica Decoction Variation • YANG XUE DING FENG TANG Nourishing Blood and Subduing Wind Decoction • QIN JIAO NIU BANG TANG Variation Gentiana macrophylla Arctium Decoction Variation Three Treasures remedies
• GLORIOUS SEA • NOURISH THE ROOT AND CLEAR WIND Women’s Treasure remedy
• PRECIOUS SEA
Blood-Heat
Clinical manifestations Red, papular skin eruptions before and during the period, itching, irritability, red face, thirst, blood-shot eyes, headaches. Tongue: Red with redder sides and yellow coating. Pulse: Wiry-Rapid. Treatment principle Clear Heat, cool Blood, clear the Liver, calm the Mind, settle the Ethereal Soul (Hun). Acupuncture L.I.-11 Quchi, SP-10 Xuehai, P-3 Quze, LIV-3 Taichong, KI-2 Rangu, SP4 Gongsun with P-6 Neiguan. All with reducing method except the last two points which should be needled with even method. Explanation
– L.I.-11 and SP-10 clear Heat, cool Blood and stop itching. – P-3 cools Blood and calms the Mind. – LIV-3 and KI-2 cool Blood and settle the Ethereal Soul. – SP-4 and P-6 regulate the Penetrating Vessel which is the Sea of Blood. Herbal treatment
Prescription
– XIAO FENG SAN Variation – Expelling Wind Powder Variation Explanation
– Jing Jie, Fang Feng and Chan Tui expel Wind and stop itching. These are used if Wind-Heat accompanies Blood-Heat (which is often the case in skin diseases). – Sheng Di Huang, Mu Dan Pi and Zi Cao clear Heat and cool Blood. – Shi Gao clears Heat. – Zhi Mu clears Heat and nourishes Yin. – Dang Gui enters the Blood portion and directs the Blood-invigorating herbs to the Penetrating and Directing Vessels. – Hong Zao enters the Blood portion and, being a flower, it floats towards the Exterior and therefore to the skin. It also invigorates Blood. – Gan Cao harmonizes. Summary Blood-Heat
Clinical manife stations
Red, papular skin eruptions before and during the period, itching, irritability, red face, thirst, blood-shot eyes, headaches. Tongue: Red with redder sides and yellow coating. Pulse: Wiry-Rapid. Tre atme nt principle
Clear Heat, cool Blood, clear the Liver, calm the Mind, settle the Ethereal Soul (Hun). Acupuncture
L.I.-11 Quchi, SP-10 Xuehai, P-3 Quze, LIV-3 Taichong, KI-2 Rangu, SP4 Gongsun with P-6 Neiguan. All with reducing method except the last two points which should be needled with even method. He rbal tre atme nt
Prescription
• XIAO FENG SAN Variation Expelling Wind Powder Variation
Damp-Heat
Clinical manifestations Red, papular or vesicular eruptions before or during the period, vesicles filled with clear fluid if there is no Heat, feeling of heaviness, greasy skin, tendency to obesity, epigastric and abdominal fullness, sticky taste, excessive vaginal discharge. Tongue: sticky, yellow coating. Pulse: Slippery or Soggy; Rapid if the Heat is pronounced. Treatment principle Resolve Dampness, tonify the Spleen, regulate the Penetrating and Directing Vessels. Acupuncture L.I.-11 Quchi, L.I.-4, SP-9 Yinlingquan, Ren-9 Shuifen, ST-28 Shuidao, BL-22 Sanjiaoshu, BL-20 Pishu, Ren-12 Zhongwan. All with reducing or even method except the last two points that should be needled with reinforcing method. Explanation
– L.I.-11 and L.I-4 resolve Dampness and clear Heat. L.I.-4 is particularly indicated if the skin eruptions are on the face. – SP-9, Ren-9, ST-28 and BL-22 resolve Dampness.
– BL-20 and Ren-12 tonify the Spleen to resolve Dampness. Herbal treatment
Prescription
– LIANG XUE CHU SHI TANG – Cooling Blood and Expelling Dampness Decoction Explanation
– Sheng Di Huang, Mu Dan Pi and Chi Shao cool Blood. – Fu Ling, Chi Xiao Dou and Yi Yi Ren resolve Dampness. – Bai Xian Pi resolves Dampness and clears Heat; it is a very important herb for skin problems from Damp-Heat. – Xi Xian Xao expels Wind and Dampness. From the category of expelling Wind-Dampness (usually used in Painful Obstruction Syndrome, Bi Syndrome), these herbs are frequently used for skin diseases. – Di Fu Zi and Ku Shen resolve Dampness and they are both used for chronic skin problems from Dampness. The also treat itching from Dampness. Summary Damp-Heat
Clinical manife stations
Red, papular or vesicular eruptions before or during the period, vesicles filled with clear fluid if there is no Heat, feeling of heaviness, greasy skin, tendency to obesity, epigastric and abdominal fullness, sticky taste, excessive vaginal discharge. Tongue: sticky, yellow coating. Pulse: Slippery or Soggy; Rapid if the Heat is pronounced. Tre atme nt principle
Resolve Dampness, tonify the Spleen, regulate the Penetrating and Directing Vessels. Acupuncture
L.I.-11 Quchi, L.I.-4, SP-9 Yinlingquan, Ren-9 Shuifen, ST-28 Shuidao, BL-22 Sanjiaoshu, BL-20 Pishu, Ren-12 Zhongwan. All with reducing or even method except the last two points that should be needled with reinforcing method. He rbal tre atme nt
Prescription
• LIANG XUE CHU SHI TANG Cooling Blood and Expelling Dampness Decoction
Prognosis and prevention The condition of skin eruptions occurring at period time usually responds well to treatment with acupuncture and/or herbs. However, if a woman has been suffering from this problem for several years, she must be patient as it may take several months to achieve results. The pattern of Wind-Heat occurring against a background of KidneyYin deficiency is more difficult to treat. Generally speaking, the darker the eruption the more Heat there is, and the more purple they are, the more stasis there is. Also, the denser the distribution, the more intense the pathogenic factor. These factors are important for prognosis: the denser the distribution, the darker the colour, the more difficult they are to treat. It is very important for a woman suffering from skin eruption to avoid eating shellfish entirely; these include mussels, cockles, shrimps, prawns, crab and lobster. These foods increase Wind, aggravate any skin disease and worsen itching. Other foods with a similar effect to be avoided are spinach and mushrooms. If there is Dampness or Damp-Heat, the patient should also cut down on dairy foods and greasy, fried foods.
CHAPTER 28 Dizziness at Period Time
AETIOLOGY 445 PATHOLOGY 445 IDENTIFICATION OF PATTERNS AND TREATMENT 445 Blood deficiency 445 Kidney- and Liver-Yin deficiency with Liver-Yang rising 446 Phlegm with Spleen-Qi deficiency 447 PROGNOSIS AND PREVENTION 448 ‘Dizziness at period time’ may occur before, during or after the period. The term ‘dizziness’ in Chinese medicine encompasses also blurred vision. In fact, dizziness in Chinese medicine is called Xuan Yun. Xuan means ‘blurred vision’, while Yun means ‘dizziness’. This symptom may range from a very slight dizziness, sometimes only on changing posture, to very severe vertigo with loss of balance when everything around the patient seems to be spinning. The term ‘dizziness’ also includes the very common sensation of ‘muzziness’ or ‘fuzziness’ – a heavy feeling as if the head was full of cotton wool and, linked to this, an inability to think properly and to concentrate. In English, I shall call the symptom Xuan Yun ‘dizziness’; I shall use ‘vertigo’ to indicate a stronger sensation of dizziness to the point of losing balance.
Aetiology
Chronic illness, irregular diet, haemorrhage A long, chronic illness, a diet lacking in nourishment or a severe haemorrhage may all cause Blood deficiency. Blood nourishes the Brain and a severe deficiency may cause dizziness: this occurs at period time because the Blood deficiency becomes more evident when blood is lost through menstruation. This type of dizziness tends to occur during or after the period. Emotional stress, overwork Overwork leads to Yin deficiency and when it is combined with stress about work over a long period of time, it may easily induce Liver-Yang rising. This causes dizziness before the period as at that time Yang has a tendency to rise. Excessive exercise, irregular diet Too much exercise weakens the Spleen and a deficiency of this organ may lead to Dampness. Excessive consumption of dairy foods and greasy, fried foods also leads to the formation of Dampness and Phlegm. Phlegm obstructs the clear orifices of the head, the clear Yang cannot rise and dizziness results. This is more likely to occur before or during the period.
Pathology The main pathological factors are: • Blood deficiency • Kidney- and Liver-Yin deficiency with Liver-Yang rising • Phlegm with Spleen-Qi deficiency. The second pattern is more common in older women.
Identification of patterns and treatment
Blood deficiency
Clinical manifestations Dizziness during or after the period, blurred vision, tingling of limbs, poor memory, insomnia, scanty period, dull complexion. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle Tonify the Kidneys, Spleen and Liver, nourish Blood. Acupuncture LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, BL-23 Shenshu, Ren-4 Guanyuan, Du-20 Baihui. All with reinforcing method, moxa can be used. Explanation
– LIV-8, ST-36, SP-6 and Ren-12 tonify Qi and Blood, strengthen the Spleen and Liver and nourish Blood. – BL-20 and BL-23 tonify the Spleen and Kidneys to nourish Blood. – Ren-4 nourishes Blood. For this action, it is particularly effective with direct moxa cones. – Du-20 raises the clear Qi to the head and opens the head’s orifices to relieve dizziness.
Herbal treatment
Prescription
– BA ZHEN TANG Variation – Eight Precious Decoction Variation Explanation The first eight herbs constitute the formula Ba Zhen Tang which nourishes Blood. – Shou Wu and Gou Qi Zi nourish Blood and the Essence. Strengthening the Essence, these herbs can nourish the Brain. Three Treasures remedy
– BRIGHTEN THE EYES This remedy nourishes Blood, strengthens the Essence and tonifies the Brain. Although it was devised for eye problems from Blood deficiency, it is suitable to treat dizziness. The tongue presentation appropriate to this remedy is a Pale and Thin body. Women’s Treasure remedy
– Precious sea
This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. It has been modified with the addition of Kidney tonics. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Blood deficiency
Clinical manifestations
Dizziness during or after the period, blurred vision, tingling of limbs, poor memory, insomnia, scanty period, dull complexion. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle
Tonify the Kidneys, Spleen and Liver, nourish Blood. Acupuncture
LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-20 Pishu, BL-23 Shenshu, Ren-4 Guanyuan, Du-20 Baihui. All with reinforcing method, moxa can be used. Herbal treatment
Pre scription
• BA ZHEN TANG Variation Eight Precious Decoction Variation
Three Treasures remedy
• BRIGHTEN THE EYES Women’s Treasure remedy
• PRECIOUS SEA
Kidney- and Liver-Yin deficiency with Liver-Yang rising
Clinical manifestations Severe dizziness during or before the period, tinnitus, scanty period, insomnia, mental restlessness, feeling of heat, malar flush. Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty or, if there is Empty-Heat, Fine and Rapid. Treatment principle Nourish Yin, strengthen the Kidneys and Liver, subdue Liver-Yang. Acupuncture Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, SP-6 Sanyinjiao, LIV-8 Ququan, G.B.-20 Fengchi, L.I.-4 Hegu, LIV-3 Taichong, G.B.-13 Benshen, Du-19 Houding. G.B.-20, L.I.-4 and LIV-3 with reducing or even method to subdue Liver-Yang. Ren-4, KI-3, SP-6 and LIV-8 with reinforcing method to nourish Blood. LU-7, KI-6, G.B.-13 and Du-19 with even method. No moxa. Explanation
– Ren-4 nourishes Blood and tonifies the Uterus and the Kidneys. – LU-7 and KI-6 regulate the Directing Vessel, nourish Yin and strengthen the Uterus.
– KI-3, SP-6 and LIV-8 nourish Liver and Kidneys. – G.B.-20 subdues Liver-Yang and relieves dizziness. – L.I.-4 and LIV-3 subdue Liver-Yang, calm the Mind and settle the Ethereal Soul (Hun). – G.B.-13 and Du-19 subdue Liver-Yang, calm the Mind and settle the Ethereal Soul. Herbal treatment
Prescription
– QI JU DI HUANG WAN Variation – Lycium-Chrysanthemum-Rehmannia Pill Variation Explanation The first eight herbs constitute Qi Ju Di Huang Wan, itself a variation of Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill, which nourishes Kidney- and Liver-Yin deficiency and mildly subdues Liver-Yang (with Ju Hua). – Gou Teng and Bai Ji Li are added to subdue Liver-Yang and relieve dizziness. Women’s Treasure remedy
– FEMALE TREASURE This remedy nourishes Liver- and Kidney-Yin and subdues Liver-Yang. Summary Kidney- and Liver-Yin deficiency with Liver-Yang rising
Clinical manifestations
Severe dizziness during or before the period, tinnitus, scanty period, insomnia, mental restlessness, feeling of heat, malar flush. Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty or, if there is Empty-Heat, Fine and Rapid. Treatment principle
Nourish Yin, strengthen the Kidneys and Liver, subdue Liver-Yang Acupuncture
Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, SP-6 Sanyinjiao, LIV-8 Ququan, G.B.-20 Fengchi, L.I.-4 Hegu, LIV-3 Taichong, G.B.-13 Benshen, Du-19 Houding. G.B.-20, L.I.-4 and LIV-3 with reducing or even method to subdue Liver-Yang. Ren-4, KI-3, SP-6 and LIV-8 with reinforcing method to nourish Blood. LU-7, KI-6, G.B.-13 and Du-19 with even method. No moxa. Herbal treatment
Pre scription
• QI JU DI HUANG WAN Variation Lycium-Chrysanthemum-Rehmannia Pill Variation Women’s Treasure remedy
• FEMALE TREASURE
Phlegm with Spleen-Qi deficiency
Clinical manifestations Severe dizziness during or before the period, blurred vision, a feeling of muzziness (fuzziness) and heaviness of the head, excessive vaginal discharge, swelling of breasts before the period, a sticky taste. Tongue: Swollen with a sticky coating. Pulse: Slippery. Treatment principle Warm the Yang, strengthen the Spleen, resolve Phlegm, drain Dampness. Acupuncture Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu, ST-40 Fenglong, SP-9 Yinlingquan, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, Ren-9 Shuifen, ST-8 Touwei. Ren-12, ST-36 and BL-20 with reinforcing method; ST-40, SP-9, SP-6, BL-22 and Ren-9 with reducing or even method. ST-8 with even method. Moxa is applicable to warm the Yang. Explanation
– Ren-12, ST-36 and BL-20 tonify the Spleen. Moxa can be applied to warm the Yang if there is a pronounced Yang deficiency. – ST-40 resolves Phlegm. – SP-9, SP-6, BL-22 and Ren-9 drain Dampness.
– ST-8 is the main local point to resolve Phlegm from the head. Herbal treatment
Prescription
– BAN XIA BAI ZHU TIAN MA TANG – Pinellia-Atractylodes-Gastrodia Decoction Explanation
– This formula is specific to treat dizziness deriving from Phlegm and Wind. – Ban Xia, Fu Ling and Chen Pi resolve Phlegm. – Tian Ma subdues Wind and relieves dizziness. – Bai Zhu tonifies the Spleen and dries Dampness. – Gan Cao, Sheng Jiang and Da Zao harmonize. Three Treasures remedy
– CLEAR YANG This remedy is a variation of the formula Ban Xia Bai Zhu Tian Ma Tang Pinellia-Atractylodes-Gastrodia Decoction: it tonifies the Spleen, resolves Phlegm, extinguishes Wind and relieves dizziness and headaches. The tongue
presentation appropriate to this remedy is a Swollen body with a sticky coating. Summary Phlegm with Spleen-Qi deficiency
Clinical manifestations
Severe dizziness during or before the period, blurred vision, a feeling of muzziness (fuzziness) and heaviness of the head, excessive vaginal discharge, swelling of breasts before the period, a sticky taste. Tongue: Swollen with a sticky coating. Pulse: Slippery. Treatment principle
Warm the Yang, strengthen the Spleen, resolve Phlegm, drain Dampness. Acupuncture
Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu, ST-40 Fenglong, SP-9 Yinlingquan, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, Ren-9 Shuifen, ST-8 Touwei. Ren-12, ST-36 and BL-20 with reinforcing method; ST-40, SP-9, SP-6, BL-22 and Ren-9 with reducing or even method. ST-8 with even method. Moxa is applicable to warm the Yang. Herbal treatment
Pre scription
• BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia
Decoction Three Treasures remedy
• CLEAR YANG
Prognosis and prevention The problem of dizziness during the periods responds well to treatment with acupuncture and/or herbs. The pattern from Yin deficiency will take the longest to treat; that from Phlegm may also be stubborn because it takes time to resolve Phlegm. Herbal treatment is rather better than acupuncture for resolving Phlegm. A woman suffering from the pattern of Phlegm should avoid eating dairy food and greasy foods. If she suffers from the pattern of Blood deficiency or Yin deficiency, it is very important that she takes adequate rest and organizes her working day to allow this. In particular, she should make sure that she has a short period of rest after lunch, preferably lying down.
SECTION 6 Diseases of Pregnancy
Introduction 29. MORNING SICKNESS 457 30. ABDOMINAL PAIN DURING PREGNANCY 469 31. THREATENED MISCARRIAGE 477 32. FETUS NOT GROWING 491 33. OEDEMA DURING PREGNANCY 495 34. ANXIETY DURING PREGNANCY 501 35. DIZZINESS DURING PREGNANCY 509 36. CONVULSIONS DURING PREGNANCY 513 37. FEELING OF SUFFOCATION DURING PREGNANCY 519 38. APHONIA DURING PREGNANCY 523 39. COUGH DURING PREGNANCY 525 40. URINARY SYNDROME DURING PREGNANCY 529 41. RETENTION OF URINE DURING PREGNANCY 533 42. CONSTIPATION DURING PREGNANCY 539 43. HABITUAL MISCARRIAGE 545 44. ACUPUNCTURE AND HERBAL TREATMENT IN MIDWIFERY 555
As we have seen in the chapters on physiology (Ch. 2) and pathology (Ch. 3), a normal pregnancy does not necessarily weaken a woman and, in certain cases, her health may even improve: in proof of this, certain diseases
(especially migraine or asthma) often improve during pregnancy. In general, however, the effect of pregnancy on women’s physiology is ambivalent, because, on the one hand, the mother’s energy of Blood and Kidneys is diverted to nourish the fetus, but, on the other hand, the stoppage of the menses means that there is more Blood available to the mother. The Medical Collection of Four Families from Meng He says: “In non-pregnant women, Blood is the source of menstruation; in pregnancy, Blood gathers to nourish the fetus and is also transformed into breast milk.”1 Thus, under normal circumstances, pregnancy will not cause a healthy woman any problems. However, if a woman has a preexisting tendency to Blood/Yin deficiency or to a Kidney deficiency, then problems may develop during pregnancy because such deficiencies will be accentuated. Three main problems may develop during pregnancy: a Blood and/or Yin deficiency, stagnation of Qi and Phlegm. Blood and/or Yin deficiency usually develops in women who have a preexisting tendency towards them through overwork or a hereditary Kidney weakness. This deficiency is aggravated because much of the mother’s Blood and Yin goes to nourish the fetus. The deficiency of Blood and/or Yin frequently leads to Liver-Yang or Liver-Wind rising. A deficiency of the mother’s Kidneys often leads to a weakness of the fetus’s Original Qi, while a deficiency of the mother’s Kidney-Essence may fail to nourish the fetus. Stagnation of Qi is another pathological condition frequently seen in pregnancy. The ‘obstruction’ created by the fetus, especially in the later months of pregnancy, prevents the proper ascending and descending of Qi in the Middle Burner and therefore leads to stagnation of Qi. Another consequence of the ‘obstruction’ of the Middle Burner by the fetus is a weakness of the Spleen and therefore Phlegm. Apart from the above pathological patterns, many problems occurring during pregnancy, whether pathologies or simply uncomfortable symptoms, are due to a disharmony of the Directing and Penetrating Vessels (Ren and Chong Mai). These two vessels undergo profound changes during pregnancy, which cause a variety of symptoms or simply a sense of
discomfort. During the first 3 months of the pregnancy, they undergo the biggest changes. Their pathology is characterized by a deficiency of Blood and Kidneys because the mother’s Blood and Essence go to nourish the fetus and promote the formation of its major body systems (the fetus’s major body systems are all formed within the first 3 months); this is why most women feel particularly tired in the first 3 months of pregnancy. The Penetrating Vessel, in particular, undergoes profound changes and the relative depletion of its Kidney energy in the lower part of its trajectory, i.e. the abdomen, leads to a rebelling of Qi in its upper part, i.e. the stomach and chest. The Penetrating Vessel is related to the Stomach channel through the point ST-30 Qichong, so rebellious Qi in it causes Stomach-Qi to rise, which explains the morning sickness occurring in the first 3 months of pregnancy and also the general feeling of breathlessness and of energy rising to the chest experienced by pregnant women. A deficiency of the Directing Vessel involves a deficiency of the Kidneys which often leads to Liver-Yang or Liver-Wind rising: this explains the aggravation of migraine during pregnancy in some women, or the more serious condition of eclampsia or pre-eclampsia. In the last 3 months of pregnancy, the growth of the baby tends to create stagnation of Qi in the Penetrating Vessel with consequent symptoms of slight breathlessness, tightness of the chest, a feeling of energy rising and an inability to lie down. Thus, the treatment principles adopted in relation to the Directing and Penetrating Vessels are to tonify the Kidneys and subdue rebellious Qi. The main pathological conditions of pregnancy may be summarized as: • deficiency of Blood/Yin and Kidneys • stagnation of Qi • Spleen deficiency and Phlegm.
Thus, the main principles of treatment during pregnancy are to: • nourish Blood and tonify the Kidneys • move Qi and eliminate stagnation
• tonify the Spleen and resolve Phlegm.
Since Blood and Yin deficiency often lead to Liver-Yang or Liver-Wind rising and Yin deficiency easily leads to Empty-Heat, auxiliary principles of treatment are to subdue Liver-Yang or Liver-Wind and to clear Empty-Heat. Because during pregnancy one is in effect treating two patients simultaneously, it is important to consolidate the Original Qi of the fetus to prevent miscarriage. For this reason, the treatment principle of ‘calming the fetus’ is often adopted in combination with the principles listed above, which are aimed at treating the mother. ‘Calming the fetus’ should not be interpreted literally; indeed, when the mother feels the presence of the fetus moving in the abdomen, it is a good, not a bad, sign. Thus, ‘calming the fetus’ is an expression of the treatment principle consisting in consolidating the fetus’s Original Qi and preventing a miscarriage. It consists essentially in tonifying the mother’s Kidney-Yang which will strengthen the fetus’s Original Qi. However, preventing miscarriage may also involve the use of other herbs as a miscarriage may be caused by something other than a Kidney deficiency: for example, Huang Qin Radix Scutellariae is used to prevent miscarriage when there are signs of Heat. The only times when one deviates from the principle of ‘calming the fetus’ are when the mother has already miscarried or when the fetus is dead but has not yet been miscarried: in such cases, one should obviously not ‘calm the fetus’ but, on the contrary, actively promote the expulsion of the fetus or of the placenta in case of incomplete miscarriage. Herbs that ‘calm the fetus’ span different categories and they include: • Tu Si Zi Semen Cuscutae • Xu Duan Radix Dipsaci • Du Zhong Cortex Eucommiae • Huang Qin Radix Scutellariae • Ai Ye Folium Artemisiae argyi • E Jiao Colla Corii asini
• Zi Su Ye Folium Perillae • Bai Zhu Rhizoma Atractylodis macrocephalae • Sha Ren Fructus Amomi • Lian Fang Receptaculum Nelumbinis nuciferae • Sang Ji Sheng Herba Taxilli • Huang Qi Radix Astragali • Zhu Ma Gen Radix Boehmeriae.
If we analyse the above herbs we can see that some act by raising Qi, thus preventing the descending of the fetus: these are, for example, Huang Qi Radix Astragali and Bai Zhu Rhizoma Atractylodis macrocephalae. Others act by tonifying the mother’s Kidney-Yang and therefore the fetus’s Original Qi: these are Tu Si Zi Semen Cuscutae, Xu Duan Radix Dipsaci and Du Zhong Cortex Eucommiae. Some act by nourishing Blood and stopping uterine bleeding (and therefore miscarriage) as do Sang Ji Sheng Herba Taxilli and E Jiao Colla Corii asini. It is difficult to explain the effect of herbs such as Zi Su Ye Folium Perillae and Sha Ren Fructus Amomi in threatened miscarriage, given their known actions: their use must therefore be empirical. Finally, a glaring discrepancy between Chinese and Western herbalism should be noted: Artemisia (Ai Ye) is indicated for threatened miscarriage in Chinese herbalism while it is contraindicated in pregnancy in Western herbalism, a curious discrepancy even allowing for the fact that different species of Artemisia are used. It should be remembered that certain acupuncture points are forbidden in pregnancy. These are L.I.-4 Hegu, SP-6 Sanyinjiao, BL-60 Kunlun and BL-67 Zhiyin. In addition to these, points below the umbilicus should not be used at any time during pregnancy, while points above the umbilicus may be used during the first 3 months of pregnancy but not after that. I personally also refrain from using the opening points of the Directing Vessel, i.e. LU-7 Lieque and KI-6 Zhaohai, although I do use the opening points of the other Extraordinary Vessels.
The Medical Collection of Four Families from Meng He reports traditional pregnancy tests done in old China with herbal decoctions. The first is a decoction of Chuan Xiong Rhizoma Chuanxiong 8 g and Ai Rong (moxa wool) 30 g: if it causes abdominal pain, the woman is pregnant. The second is a decoction of Lai Fu Zi Semen Raphani 90 g to open the bowels; if there is abdominal pain, the woman is pregnant. Such decoctions will not harm the fetus in case of pregnancy.2 During pregnancy, the pulse becomes strong on both Front and Rear positions, and the pulse of the cubital artery (along the Heart channel) also becomes strong. Chinese gynecologists advise pregnant women to take particular care with their lifestyle. A pregnant woman should avoid overwork in the sense of working long hours without rest, she should rest enough, she should avoid physical overexertion and lifting or jumping, she should avoid high-altitude places and she should have enough sleep. Chinese gynecologists also advise pregnant women to take a rest in the afternoon. A pregnant woman should also avoid too tight clothing. Of course, the mental–emotional state is also very important during pregnancy and the expectant mother should avoid emotional stress, worry or anger as all these emotions may affect the fetus. However, although adequate rest is much stressed in China, a pregnant woman should equally have enough exercise as, while too much exercise causes a deficiency of Qi and Blood, not enough exercise causes stagnation of Qi. As for diet, this is discussed below. As for sexual activity, Chinese books advise against having sexual intercourse in the first 3 and last 3 months of pregnancy. However, Fu Qing Zhu advises against sexual intercourse at any time of pregnancy. Of course, we should see many of the ancient Chinese precautions about pregnancy in their historical context and not all of them apply to us. Many of the precautions counselled by ancient Chinese gynecologists may seem somewhat ‘quaint’ and outdated to us. However, we should also pay attention to some of them: excessive physical exercise and overwork are certainly to be avoided in pregnancy.
Diet during pregnancy A pregnant woman should eat nourishing but easily digestible foods such as meat, fish and eggs. She should avoid spicy, pungent foods and greasy foods. She should consume more fruit than normal as during pregnancy there is a certain tendency to Heat. Towards the end of pregnancy, she should avoid salty foods. Sun Si Miao (581–682) gave detailed instructions about foods to avoid during pregnancy as they affect the developing fetus negatively. He said that eating mule meat during pregnancy may lead to difficult labour; eating rabbit meat, to speech difficulties or hare-lip; eating eggs and carp, to a tendency to develop boils and furuncles; eating mulberries and duck, to malposition of the fetus or heart disease; eating sparrows and soya milk, to the growth of moles and freckles; and eating sparrows and drinking alcohol, to lazy and sexually promiscuous offspring. Dr Chen Zi Ming of the Song dynasty listed the herbs forbidden in pregnancy as being Shui Zhi Hirudo, Wu Tou Radix Aconiti, Fu Zi Radix Aconiti lateralis preparata, Niu Huang Calculus Bovis, She Tui Exuviae Serpentis, Ba Dou Fructus Crotonis, Wu Gong Scolopendra, Niu Xi Radix Achyranthis bidentatae seu Cyathulae, Li Lu Radix et Rhizoma Veratri, Yi Yi Ren Semen Coicis, Xiong Huang Realgar, Mang Xiao Sulfas Natrii, Di Bie Chong Eupolyphaga, She Xiang Moschus, Yan Hu Suo Rhizoma Corydalis, San Leng Rhizoma Sparganii, Qian Niu Zi Semen Pharbitidis, Zao Jiao Fructus Gleditsiae, Tao Ren Semen Persicae, Bai Mao Gen Rhizoma Imperatae, Ting Li Zi Semen Descurainiae seu Lepidii, Qu Mai Herba Dianthi, Ban Xia Rhizoma Pinelliae preparatum, Tian Nan Xing Rhizoma Arisaematis, Tong Cao Medulla Tetrapanacis, Gan Jiang Rhizoma Zingiberis, Da Suan Bulbus Alli sativi, and eggs, mule meat and rabbit meat. Dr Han Bai Ling also adds Ban Mao Mylabris, Meng Chong Tabanus, Ming Fan Alumen, Yuan Hua Flos Daphni, Dai Zhe Shi Haematitum, Chan Tui Periostracum Cicadae, Mu Dan Pi Cortex Moutan, Rou Gui
Cortex Cinnamomi, Huai Hua Flos Sophorae immaturus, Mu Tong Caulis Akebiae, and Huai Zi Semen Sophorae.3
Chinese embryology Dr Chen Jia Yuan of the Qing dynasty gives an account of the changes taking place during pregnancy month by month.4 He says that in the first month, the newly conceived being is like a drop of Essence (Jing) and like a pearl of dew on a leaf; being still outside the Uterus, it may either gather or disperse. The mother experiences morning sickness, dizziness and lack of appetite and her pulse is Floating and Tight. Dr Chen suggests a decoction of Dang Gui Radix Angelicae sinensis, Bai Shao Radix Paeoniae alba, Zhi Ke Fructus Aurantii, Chuan Xiong Rhizoma Chuanxiong, Zi Su Ye Folium Perillae, Sha Ren Fructus Amomi and Gan Cao Radix Glycyrrhizae. In the second month, the fetus is like a peach flower and is situated at the height of Ren-3 Zhongji. The placenta is formed during this time and the mother experiences dizziness, blurred vision, nausea, vomiting and lack of appetite. She can take a decoction of Jie Geng Radix Platycodi, Mu Xiang Radix Aucklandiae, Cang Zhu Rhizoma Atractylodis, Sha Ren Fructus Amomi, Huang Qin Radix Scutellariae, Hou Po Cortex Magnoliae, Zi Su Ye Folium Perillae, Zhi Ke Fructus Aurantii, Chen Pi Pericarpium Citri reticulatae and Gan Cao Radix Glycyrrhizae. In the third month, the fetus is like a cocoon. It begins to look like a silkworm, large at one end and small at the other. The mother experiences nausea and vomiting and she should avoid extremes of heat or cold. From the third month onwards, whatever disease one is treating, one should also adopt the treatment principle of ‘calming the fetus’ (see above). In the fourth month, the foetus and placenta collect at the Field of Elixir (Dan Tian). The mother should not eat rabbit and not be exposed to cold. If she feels tired, hot, breathless and dizzy she can take a decoction of Zi Su Ye Folium Perillae, Gan Cao Radix Glycyrrhizae, Xiao Hui Xiang Fructus Foeniculi, Zhi Ke Fructus Aurantii, Hou Po Cortex Magnoliae officinalis, Xiang Fu Rhizoma Cyperi, Sha Ren Fructus Amomi, Chen Pi Pericarpium Citri reticulatae and Cang Zhu Rhizoma Atractylodis. In the fifth month, the differentiation between male and female gender
occurs and Dr Chen reports a curious test: if one stands behind the pregnant woman and calls her, if she turns to the left the fetus is male, if she turns to the right it is female. Also, if she is carrying a boy she will prefer sour foods, while if she is carrying a girl, bland foods. At this time the fetus is firmly embedded in the Uterus and is steady. In the sixth month, the fetus’s muscles and hair grow: if it is a boy, his movements will be felt more on the left and if it is a girl, more on the right. At this time, the fetus is like a fish in the mother’s abdomen. In the seventh month the fetus grows big, the eyes are bright, the nose has Qi, the ears are open and the mouth can taste. At this time the mother is usually very healthy, but if there is any problem, one should ‘calm the fetus’. In the eighth month, the Qi of the fetus is active and this may cause the mother to become irritable and to experience a feeling of oppression of the chest and poor appetite: the food may all taste sweet and stale to her. If there are any problems at this time, one should regulate the Stomach and again ‘calm the fetus’. In the ninth month, the fetus is very large, reaching up to the hypochondrial regions. The mother may experience a feeling of oppression of the chest and poor appetite. She can take a decoction of Yi Mu Cao Herba Leonuri, Dang Gui Radix Angelicae sinensis, Zhi Ke Fructus Aurantii, Bai Shao Radix Paeoniae alba, Yi Zhi Ren Fructus Alpiniae oxyphyllae, Sha Ren Fructus Amomi, Chen Pi Pericarpium Citri reticulatae and Gan Cao Radix Glycyrrhizae. In the tenth month, the fetus is ready to emerge. The baby’s limbs stretch, and it turns naturally and engages downwards. If the mother experiences backache, one can use the following decoction to expedite the birth: Dang Gui Radix Angelicae sinensis, Chuan Xiong Rhizoma Chuanxiong, Chen Pi Pericarpium Citri reticulatae, Xiang Fu Rhizoma Cyperi, Zi Su Ye Folium Perillae, Da Fu Pi Pericarpium Arecae, Hua Shi Talcum, San Leng Rhizoma Sparganii, E Zhu Rhizoma Curcumae, Sha Ren Fructus Amomi, Gan Jiang Rhizoma Zingiberis, Rou Gui Cortex Cinnamomi, Wu Ling Zhi Faeces Trogopteri and Yan Hu Suo Rhizoma Corydalis.
Fetus education In ancient China, many gynecologists concentrated their attention on what they called ‘fetus education’, i.e. a set of hygiene rules for pregnant women formulated in the belief that the mother’s diet, lifestyle and emotions affect the fetus. Thus, by manipulating her diet and environment and paying attention to her emotional life, the expectant mother could affect the fetus positively. In particular, Dr Xu Zi Cai (AD 493–572) gave detailed instructions on the nourishment of the fetus month by month.
First month In the first month of pregnancy, the woman should eat nourishing and easily digestible cooked food; she is allowed to eat some sour foods if she wants to, for many pregnant women (according to Dr Xu) develop cravings for such foods. Barley, which makes the fetus grow normally, is particularly beneficial at this time. In the first month, the fetus is nourished through the Liver channel and therefore this channel should not be needled. As the chapter on physiology (Ch. 2) described, each month corresponds to a channel, in the following order: Liver, Gall Bladder, Pericardium, Triple Burner, Spleen, Stomach, Lungs, Large Intestine, Kidneys, Bladder. Dr Xu continues by saying that Blood circulation in the first month is impaired and the woman should not overexert herself physically. She should avoid becoming anxious or fearful. The fetus feels pain when the mother is exposed to excess cold and feels fear when the mother is exposed to excess heat. If the mother develops on slight exertion, abdominal distension, frequent urination and a bearing-down sensation, she should eat black-boned chicken soup (black-boned chicken reared in China are particularly valued for their Blood-nourishing property, but any good, free-range hen will do).
Second month During the second month of pregnancy, the woman should not eat pungent, hot and drying foods and she should avoid sexual activity and excessive physical work. At this time, she may develop joint pains all over the body: these are due to the growth of the fetus. During the second month, the fetus is nourished through the Gall Bladder channel which should therefore not be needled. At this time, the Original Qi of the fetus comes into being, so it is very important that the expectant mother takes things very easily. Exposure to excessive cold may bring about a miscarriage and exposure to excessive heat cause the fetus to become weak.
Third month The fetus’s body shape and sex are still changing during this month under the influence of external stimuli (on the mother). If she wants a son, the mother should practise shooting arrows; if a daughter, she should handle jewellery. For a good-looking child, she should feast her eyes on beautiful jade; for a good-hearted child, she should spend as much time as possible sitting quietly. During the third month the fetus is nourished through the Heart channel which should therefore not be needled. If the expectant mother suffers from abdominal fullness, umbilical pain, and a bearing-down sensation, she should eat rooster soup.
Fourth month During the fourth month, the fetus begins to absorb Essence from the mother’s Kidneys to form its blood vessels. At this time, the woman should eat rice, fish or wild goose; this makes the fetus’s Qi and Blood strong, its ears and eyes sensitive and bright, and its channels free from obstructions. In this month, the fetus is nourished through the Triple Burner channel which should therefore not be needled. The Yang organs of the fetus are formed during this month. The mother should keep herself calm and free from any emotional disturbance, and she should be moderate in her eating.
Fifth month In the fifth month of pregnancy, the fetus begins to receive essential Qi of the Heart (from the mother) to establish its temperament. It is therefore advisable for her to sleep long hours, bathe and change her clothes often, stay away from strangers, wear enough clothes and be exposed to sunshine. She should eat wheat, beef and lamb and the herb Shan Zhu Yu Fructus Corni; she should also balance sweet with sour foods and bitter with salty foods. During this month, the fetus is nourished through the Spleen channel which should not be needled. At this time, the fetus’s limbs are formed: the mother should neither go hungry nor eat too much and she should not eat drying foods. She should not receive moxibustion nor have hot compresses applied.
Sixth month During the sixth month, the fetus begins to receive from the mother the Qi of the Lungs which forms its sinews. The woman should take light exercise and not stay indoors all the time. She should go to the countryside to look at horses or dogs running and she should eat meat of wild animals. Doing so will make the fetus’s sinews and muscles strong, its skin luxuriant, its body strong and its back and spine firm. In this month, the fetus is nourished through the Stomach channel which should not be needled. The mouth and eyes of the fetus are formed in this month. The mother should eat sweet foods, but not in excess. In this month, the fetus moves more, which may lead to restlessness. If the woman experiences a bearing-down sensation, limb pain and restlessness, she should take Mai Men Dong Tang Ophiopogon Decoction.
Seventh month During the seventh month, the fetus begins to receive essential Qi of the mother’s Liver to form its bones. She should take enough exercise to encourage the circulation of Qi and Blood by flexing and extending her joints. Her bedroom should be dry. She should avoid cold foods and eat rice which will nourish the fetus’s bones and teeth. In this month, the fetus is nourished through the Lung channel which should not be needled. The fetus’s skin and hair develop at this time. The mother should not speak in a loud voice or shout, she should not wear too thin clothes and she should not bathe too often. If the mother experiences a bearing-down sensation, cold limbs, restlessness, abdominal fullness, shortness of breath and back ache, she should take Cong Bai Tang Allium Decoction.
Eighth month During the eighth month of pregnancy, the fetus begins to receive essential Qi of the mother’s Spleen which promotes the growth of its skin. At this time, the mother should avoid emotional upsets and practise quiet breathing to maintain her Qi which will promote a moist and lustrous skin in the fetus. In this month, the fetus is nourished through the Large Intestine channel which should not be needled. The mother should avoid overeating and getting angry. If she experiences general aching, alternation of chills and fever, restlessness, dizziness and blurred vision, she should take Shao Yao Tang Paeonia Decoction.
Ninth month During the ninth month, the fetus begins to receive the essence of the mother’s Essence which promotes the growth of its skin and hair; by this time, all the organs are formed. The mother should eat sweet foods, wear loose clothes and not live in damp houses. In this month, the fetus is nourished through the Kidney channel which should not be needled. If the mother experiences diarrhoea, a feeling of pressure by the fetus and breathlessness, she should take Ban Xia Tang Pinellia Decoction.
Tenth month During the tenth month, all the Yin organs are formed to completion and the Yang organs are free from obstructions. The mother should concentrate her Qi at the Lower Dan Tian three cun below the umbilicus to promote the growth of the fetus’s joints and its mental faculties. ‘When the melon is ripe and falls off the plant’ the woman goes into labour. In this month, the fetus is nourished through the Bladder channel which should not be needled. End notes 1. Zhang Yuan Kai (editor) 1985 Medical Collection of Four Families from Meng He (Meng He Si Jia Yi Ji
), Jiangsu Science Publishing House, Nanjing, p. 212..
2. Ibid., p. 212..
3. Han Bai Ling 1983 Bai Ling’s Gynaecology (Bai Ling Fu Ke
), Heilongjiang People’s Publishing House, p. 100..
4.
Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong
), Ancient Chinese Medical Books Publishing House, Beijing, p. 16. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang) and published in 1729..
CHAPTER 29 Morning Sickness
PATHOLOGY 457 ACUPUNCTURE 458 IDENTIFICATION OF PATTERNS AND TREATMENT 460 Stomach-Qi deficiency with Empty-Cold 461 Stomach-Yin deficiency 462 Stagnant Liver-Qi invading the Stomach 463 Stomach-Heat 465 Accumulation of Phlegm 465 Heart-Qi deficiency 467 Heart-Fire 467 PROGNOSIS AND PREVENTION 468 Morning sickness is one of the earliest signs of pregnancy although not all pregnant women have it. It may range from a mild nausea to very severe and frequent vomiting. It usually lasts only for about 3 months but in severe cases it may go on for a long time or even for the whole pregnancy. The intensity of morning sickness is obviously related to the pre-existing state of the woman’s digestive system. In spite of its name, ‘morning sickness’ can occur at any time of day although it is usually more pronounced in the morning.
Pathology Morning sickness is closely linked to a relative imbalance between Blood and Qi within the Penetrating Vessel (Chong Mai). During the first 3 months of pregnancy, profound changes take place in the Directing and Penetrating Vessels and the mother’s Blood, Essence and Kidney energy nourish the fetus promoting the formation of all major body systems and organs. This places a certain strain on the Blood, Essence and Kidney energy of the mother’s Penetrating Vessel; Blood and Kidneys become relatively deficient and the vessels’ Qi rebels upwards towards the stomach and chest. ‘Rebel’ is probably not the right word for this process as it is physiological more than pathological: it is related to the normal changes occurring with pregnancy. Since the Penetrating Vessel is closely related to the Stomach through the point ST-30 Qichong, ascending Qi in this vessel affects the Stomach and interferes with the descending of its Qi, thus causing nausea or vomiting. The ascending of the Penetrating Vessel’s Qi is also related to the ascending of Liver-Qi. Sun Si Miao explains morning sickness in a slightly different way which is, however, still related to the ascending of Qi in the Penetrating Vessel. He says: When the periods stop [due to pregnancy] the [menstrual] Water floods the Yin organs, the Qi of these organs becomes obstructed, the Heart becomes restless, and Qi rebels upwards causing vomiting.1 It is interesting that Sun Si Miao refers to the Heart as a pathological condition in nausea and vomiting as Heart-Qi also needs to descend, and when it does not do so, nausea and vomiting may result (see below). Zhu Dan Xi in his Essential Methods of Dan Xi (1347) gives yet another interpretation of morning sickness, slightly different but similar: In the first three months of pregnancy the woman may have hiccup and poor appetite, or the Heart may feel vexed, Qi and Blood gather
to nourish the fetus, Essence and Blood stagnate, turbid Qi rebels upwards towards the Stomach.2 The Foundations of Medicine (1575) says: The uterus is connected to the stomach [via the Penetrating Vessel], when food enters the stomach it attracts the Qi of the Essence upwards, if this causes vomiting the woman must be pregnant.3 Thus, the pathology of morning sickness lies essentially in a disharmony between the Blood and Essence of the Penetrating Vessel (which are diverted to nourish the fetus) and its Qi which ascends as a result of this diversion: because of the connection between the Uterus and the Stomach through the Penetrating Vessel, this interferes with the descending of Stomach-Qi and causes nausea or vomiting in pregnancy. What we have described so far are physiological changes occurring at the beginning of pregnancy that lead to morning sickness. However, if the morning sickness is very severe with frequent vomiting and if it continues beyond the first 3 months, then that means that there are pathological conditions pre-existing in the pregnancy. Liver-Qi stagnation is one such pathology. Prolonged stagnation of Liver-Qi may give rise to Heat which affects the Stomach and this would cause severe vomiting soon after eating. On the other hand, a deficiency of Stomach and Spleen may lead to the formation of Phlegm which would, by itself, aggravate the feeling of nausea. Finally, it should be remembered that, like Stomach- Qi, Heart-Qi also descends and that nausea and vomiting may be caused if it fails to do so: this explains the established use of P-6 Neiguan for nausea and vomiting. The symptoms associated with nausea and vomiting (especially those related to a pathological nausea and vomiting) should be carefully considered to distinguish Heat from Cold and deficiency from excess. The following are the main factors to consider. • Vomiting soon after eating: Heat and Fullness.
• Vomiting of dilute fluids: Cold and deficiency. • Vomiting with retching and belching: Liver-Qi stagnation. • Only slight nausea: Stomach-Qi deficiency. • Vomiting of sour fluids: Liver-Qi stagnation. • Vomiting of bitter fluids: Stomach and Liver-Heat.
Acupuncture I shall discuss first general guidelines for the acupuncture treatment of morning sickness irrespective of the pattern, exploring the meaning of ‘pacify the Penetrating Vessel, subdue rebellious Qi, harmonize the Stomach and stop vomiting’ from an acupuncture perspective. The main points used to achieve the above treatment aim are indicated below (see Fig. 29.1). It should be remembered that the points situated above the umbilicus may be used in the first 3 months of pregnancy but not after that.
Figure 29.1 Main abdominal points used for morning sickness. Usually, in mild cases of morning sickness, I try a very simple combination first, i.e. P-6 Neiguan on the right, Ren-13 Shangwan and ST36 on the left. If the condition of the Stomach is Full, I use the same combination but with ST-40 instead of ST-36. Stomach channel
ST-19 Burong
The name of this point means ‘not containing’ which refers to the stomach being overfull with food and not being able to take in any more; also, this point is level with the upper part of the stomach. It is therefore used for Full patterns of the Stomach especially from retention of Food. In such patterns it is very effective in making Stomach-Qi descend. This point is especially effective for morning sickness when combined with KI-21 Youmen (see below) which is on the same level. ST-20 Chengman
This point, whose name means ‘receiving fullness’, is also used for Full patterns of the Stomach from retention of Food. For morning sickness, it is especially effective combined with Ren-13 Shangwan (see below) which is on the same level. ST-21 Liangmen
The name of this point means ‘beam door’ referring to the ‘door’ through which Stomach-Qi goes in and out. It is suitable to make Stomach-Qi descend when there is nausea and vomiting and it is especially effective combined with ST-44 Neiting for Stomach-Heat or with ST-34 Liangqiu. Kidney (and Penetrating Vessel) channel
KI-21 Youmen
The name of this point means ‘dark door’: it is a ‘door’ because it is the exit
point of the Penetrating Vessel and ‘dark’ refers to its Yin character, being on both the Kidney and Penetrating Vessel channels. All types of Qi go through KI-21 on their way up through the diaphragm and this point pacifies the Five Yin organs and exchanges their clear and turbid Essences. Thus, it is suitable for morning sickness especially when there are clear signs of rebellious Qi within the Penetrating Vessel, such as a feeling of tightness of the chest, a slight anxiety and a feeling of energy rising from the abdomen towards the chest and throat. KI-21 Youmen is effective combined with ST-19 Burong which is on the same level. KI-20 Futonggu
This point, also on the Penetrating Vessel, also stops nausea and vomiting from Qi rebelling upwards in the Penetrating Vessel. It is especially effective combined with ST-20 Chengman which is on the same level. Directing Vessel
Ren-14 Juque
This point is the Front-Collecting point of the Heart and it makes Qi descend. It is therefore particularly suitable for morning sickness when this is also associated with emotional problems. This point is level with ST-19 Burong and KI-21 Youmen with which it can be combined. Ren-13 Shangwan
The three points Ren-13 Shangwan, Ren-12 Zhongwan and Ren-10 Xiawan affect the upper, middle and lower part of the stomach respectively. Ren-13 Shangwan, in particular, subdues rebellious Stomach-Qi and stops nausea
and vomiting. It is level with ST-20 Chengman and KI-20 Tonggu with which it can be combined. Ren-12 Zhongwan
This point is particularly indicated for deficient types of nausea and vomiting from deficiency of the Stomach and Spleen and/or Empty-Cold conditions. It is particularly effective combined with ST-36 Zusanli with warm needle if there are Empty-Cold symptoms. Ren-11 Jianli
This point is better for Full patterns of the Stomach with Qi rebelling upwards. It is therefore suitable for morning sickness from Qi rebelling upwards in the Penetrating Vessel and it is particularly effective when combined with P-6 Neiguan. Ren-10 Xiawan
This point makes Stomach-Qi descend which, it should be noted, is not the same as subduing rebellious Stomach-Qi. Ren-10 Xiawan helps Stomach-Qi to descend, especially in deficient conditions when Stomach-Qi fails to do so because of its deficiency. Thus, this point is suitable for morning sickness occurring against a deficient pattern. According to some old books, this point should not be used with direct moxa in pregnancy. Distal points
P-6 Neiguan
This is one of the main distal points for nausea and vomiting and, suitably combined with other points, it can be used in practically every pattern. Due to its nature, it is also particularly suitable when there are underlying emotional problems and when nausea is caused also by Heart-Qi not descending. SP-4 Gongsun and P-6 Neiguan
These points used in combination (SP-4 on the right and P-6 on the left) open and regulate the Penetrating Vessel. I normally use these opening points with caution in pregnancy and would only use this combination in severe and stubborn cases of morning sickness. These two points in combination help the local Penetrating Vessel’s epigastric points (such as KI-21 Youmen or KI-20 Tonggu) to subdue rebellious Qi in this vessel. ST-34 Liangqiu
This is the Accumulation point of the Stomach channel and is therefore suitable for acute syndromes. I often use this point in combination with P-6 Neiguan and one or two epigastric points in Full patterns such as stagnation of Qi or retention of Food. ST-36 Zusanli
This point is excellent for morning sickness in deficient conditions. In such conditions, I often combine this point with Ren-12 Zhongwan, ST-21 Liangmen and P-6 Neiguan, with warm needle if there is Empty-Cold. ST-40 Fenglong
This is an excellent point for nausea and vomiting, especially from Full conditions. It should be remembered that this point is effective not only to resolve Phlegm but also to regulate and harmonize the Stomach in any of its Full patterns. I often combine it with P-6 Neiguan, Ren-11 Jianli and ST-20 Chengman or ST-21 Liangmen. BL-21 Weishu
This is the Back-Transporting point of the Stomach and it makes StomachQi descend and therefore stops nausea and vomiting. BL-20 Pishu
This is the Back-Transporting point of the Spleen: it is used to tonify the Spleen when morning sickness occurs against a background of deficiency or to resolve Phlegm when this is the cause of the nausea and vomiting.
Identification of patterns and treatment The main principle of treatment in any kind of morning sickness is always to ‘pacify the Penetrating Vessel, subdue rebellious Qi, harmonize the Stomach and stop vomiting’. In addition to this basic approach, one must treat any other pattern that may appear; thus, other treatment principles include pacifying the Liver and eliminating stagnation, tonifying the Stomach and Spleen, clearing Stomach-Heat or resolving Phlegm. The following is a discussion of the various patterns accompanying morning sickness and their treatment with acupuncture and herbal therapy. As explained above, morning sickness is essentially due to the changes taking place in the Penetrating Vessel during pregnancy and the acupuncture points outlined above can be used without reference to a pattern discrimination. However, if the nausea and vomiting are very pronounced or if they persist beyond the 3 months, or both, then it is most likely that there is an underlying pathological condition that aggravates the morning sickness of pregnancy. I should point out that, in my experience, herbal therapy is of little value in morning sickness because it is almost impossible for a pregnant woman suffering from persistent nausea to take unpalatable herbal decoctions or powders; this especially applies if there is some Heat and bitter, cold herbs are used. Of course, concentrated powders can be encapsulated and this would be the best way of prescribing herbs for pregnant women. However, I shall indicate the herbal treatment for each pattern for reference. Before doing so, it is useful to list the herbs which have a specific anti-nausea effect: • Sha Ren Fructus Amomi • Ban Xia Rhizoma Pinelliae preparatum • Sheng Jiang Rhizoma Zingiberis recens • Lu Gen Rhizoma Phragmitis
• Fu Ling Poria • Chen Pi Pericarpium Citri reticulatae • Wu Zhu Yu Fructus Evodiae • Dai Zhe Shi Haematitum • Huang Lian Rhizoma Coptidis • Wa Leng Zi Concha Arcae • Zi Su Ye Folium Perillae • Huo Xiang Herba Pogostemonis • Zhu Ru Caulis Bambusae in Taeniam. On the other hand, one should not use herbs that raise Qi such as Chai Hu Radix Bupleuri, Sheng Ma Rhizoma Cimicifugae, Huang Qi Radix Astragali and Jie Geng Radix Platycodi. Finally, when herbal treatment is used, if the woman has a history of miscarriage or if she has abdominal pain as well as morning sickness, then we should adopt the treatment principle of ‘calming the fetus’, i.e. preventing miscarriage by adding such herbs as Tu Si Zi Semen Cuscutae, Du Zhong Cortex Eucommiae, Sang Ji Sheng Herba Taxilli, etc. (see beginning of this chapter). The patterns discussed are: • Stomach-Qi deficiency with Empty Cold • Stomach-Yin deficiency • Stagnant Liver-Qi invading the Stomach • Stomach-Heat
• Accumulation of Phlegm • Heart-Qi deficiency • Heart-Fire.
Stomach-Qi deficiency with Empty-Cold
Clinical manifestations Slight morning sickness, nausea without vomiting or vomiting of dilute fluids, tiredness, feeling cold, poor appetite, depression. Tongue: Pale and wet. Pulse: Weak. Treatment principle Strengthen the Stomach, tonify the Spleen, harmonize the Stomach, warm the Middle Burner. Acupuncture ST-36 Zusanli, Ren-12 Zhongwan, Ren-13 Shangwan, P-6 Neiguan, BL-20 Pishu, BL-21 Weishu. All with reinforcing method, moxa can be used; the moxa box placed on Ren-12 would be particularly effective. Explanation
– ST-36, Ren-12, BL-20 and BL-21 tonify the Stomach and Spleen. Warming needle can be applied to ST-36. – Ren-13 subdues rebellious Stomach-Qi and stops nausea. – P-6 harmonizes the Stomach and stops nausea. Herbal treatment
a Prescription
– LI ZHONG WAN Variation – Regulating the Centre Pill Variation Explanation
– Ren Shen and Bai Zhu tonify the Stomach and Spleen. – Gan Jiang warms the Middle Burner. – Zhi Gan Cao harmonizes. – Sha Ren alleviates nausea. This formula is used if Cold predominates over the deficiency and the tongue is therefore very Pale and wet. b Prescription
– XIANG SHA LIU JUN ZI TANG – Aucklandia-Amomum Six Gentlemen Decoction Explanation The first six herbs constitute the formula Liu Jun Zi Tang which tonifies Spleen- and Stomach-Qi and resolves Dampness. Ban Xia and Chen Pi also
stop nausea. – Mu Xiang and Sha Ren move Qi and eliminate stagnation in the epigastrium. Sha Ren also stops nausea. This formula is used when the deficiency predominates over the Cold. c Prescription
– EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai4 Explanation
– Bai Zhu and Zhi Gan Cao tonify Stomach and Spleen. – Ban Xia and Chen Pi harmonize the Centre and subdue rebellious Stomach-Qi. – Mu Xiang and Sha Ren move Qi and stop nausea. – Fu Ling resolves Dampness. – Sang Ji Sheng calms the fetus. – Gu Ya harmonizes Stomach and Spleen and stops nausea. – Sheng Jiang warms the Stomach and stops nausea. This formula is suitable when there is a deficiency of the Stomach and Spleen and the symptoms of Stomach-Qi rebelling upwards are relatively pronounced, i.e. the nausea is relatively strong. d Prescription
– BAO SHENG TANG – Preserving Life Decoction Explanation This formula, from the Golden Mirror of Medicine, is for morning sickness from Stomach-Qi deficiency and Fetus-Qi rebelling upwards.5 – Ren Shen, Zhi Gan Cao and Bai Zhu tonify Stomach and Spleen. – Xiang Fu, Wu Yao and Chen Pi move Qi and eliminate stagnation. Three Treasures remedy
– SOOTHE THE CENTRE This remedy tonifies Spleen-Qi, resolves Dampness and moves Qi in the Middle Burner. The tongue presentation appropriate to this remedy is a Pale body with a sticky coating. Summary Stomach-Qi Deficiency with Empty-Cold
Clinical manifestations
Slight morning sickness, nausea without vomiting or vomiting of dilute fluids, tiredness, feeling cold, poor appetite, depression. Tongue: Pale and wet.
Pulse: Weak. Treatment principle
Strengthen the Stomach, tonify the Spleen, harmonize the Stomach, warm the Middle Burner. Acupuncture
ST-36 Zusanli, Ren-12 Zhongwan, Ren-13 Shangwan, P-6 Neiguan, BL-20 Pishu, BL-21 Weishu. All with reinforcing method, moxa can be used; the moxa box placed on Ren-12 would be particularly effective. Herbal treatment
Pre scriptions
• LI ZHONG WAN Variation Regulating the Centre Pill Variation • XIANG SHA LIU JUN ZI TANG Aucklandia-Amomum Six Gentlemen Decoction • EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai • BAO SHENG TANG Preserving Life Decoction Three Treasures remedy
• SOOTHE THE CENTRE
Case history A 41-year-old woman was 10 weeks pregnant and had been suffering
from nausea. She also felt tired, depressed and lethargic. Her tongue was slightly Pale and her pulse was Weak on the right Middle position. Diagnosis In this case, morning sickness is due to a deficiency of Stomach-Qi and to Stomach-Qi not descending. Treatment principle I used only acupuncture and needled: • Ren-12 Zhongwan to tonify the Stomach and Spleen. • P-6 Neiguan (on the right) to restore the descending of Stomach-Qi. • ST-36 Zusanli (on the left) to tonify the Stomach and Spleen.
This simple treatment given only once stopped the nausea completely.
Stomach-Yin deficiency
Clinical manifestations Morning sickness, slight nausea, dry mouth without desire to drink or with desire to drink in small sips, poor appetite. Tongue: without coating, Stomach cracks; Red if there is Empty-Heat. Pulse: Floating-Empty on the right Middle position. Treatment principle Nourish Stomach-Yin, restore the descending of Stomach-Qi, stop vomiting. Acupuncture Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, ST-44 Neiting, ST-21 Liangmen, P-6 Neiguan. All with reinforcing method, except for ST-44 which should be needled with even method. No moxa. Explanation
– Ren-12, ST-36 and SP-6 nourish Stomach-Yin. – ST-21 and P-6 harmonize the Stomach, restore the descending of Stomach-Qi and stop nausea. – ST-44 clears Stomach Empty-Heat. Herbal treatment
Prescription
– MAI MEN DONG TANG – Ophiopogon Decoction Explanation
– Mai Men Dong nourishes Stomach-Yin. – Ban Xia restores the descending of Stomach-Qi and stops nausea. – Ren Shen tonifies Stomach-Qi and nourishes Stomach-Yin. – Zhi Gan Cao and Da Zao harmonize. – Geng Mi harmonizes the Stomach and relieves nausea. Three Treasures remedy
– JADE SPRING This remedy is a variation of the formula Sha Shen Mai Dong Tang Glehnia-Ophiopogon Decoction which nourishes Stomach- and Lung-Yin. The tongue presentation appropriate to this remedy is a peeled and cracked body. Summary
Stomach-Yin deficiency
Clinical manifestations
Morning sickness, slight nausea, dry mouth without desire to drink or with desire to drink in small sips, poor appetite. Tongue: without coating, Stomach cracks; Red if there is Empty-Heat. Pulse: Floating-Empty on the right Middle position. Treatment principle
Nourish Stomach-Yin, restore the descending of Stomach-Qi, stop vomiting. Acupuncture
Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, ST-44 Neiting, ST-21 Liangmen, P-6 Neiguan. All with reinforcing method, except for ST-44 which should be needled with even method. No moxa. Herbal treatment
Pre scription
• MAI MEN DONG TANG Ophiopogon Decoction Three Treasures remedy
• JADE SPRING
Stagnant Liver-Qi invading the Stomach
Clinical manifestations Morning sickness, retching, belching, vomiting of food with sour taste, abdominal and epigastric distension, depression, irritability. Tongue: slightly Red sides. Pulse: Wiry. This pattern, due to stagnation of Liver-Qi, is also influenced by rebellious Qi within the Penetrating Vessel. Treatment principle Pacify the Liver, move Qi, eliminate stagnation, harmonize the Stomach, subdue rebellious Qi, stop vomiting. Acupuncture LIV-14 Qimen, G.B.-34 Yanglingquan, Ren-12 Zhongwan, Ren-13 Shangwan, P-6 Neiguan, T.B.-6 Zhigou, ST-34 Liangqiu, ST-36 Zusanli, KI-21 Youmen. All with even method except for ST-36 which should be needled with reinforcing method. Explanation
– LIV-14 pacifies the Liver. – G.B.-34 and Ren-12 in combination move Qi and eliminate stagnation in the epigastrium.
– Ren-13 subdues rebellious Qi and stops vomiting. – P-6 and T.B.-6 move Qi, pacify the Liver and eliminate stagnation. P-6 also harmonizes the upper and middle part of the Stomach to stop vomiting. – ST-34, Accumulation point, treats acute patterns of the Stomach. – ST-36 tonifies the Stomach. – KI-21, a point of the Penetrating Vessel, moves Qi in the epigastrium and subdues Stomach-Qi. Herbal treatment
a Prescription
– BAN XIA HOU PO TANG and ZUO JIN WAN – Pinellia-Magnolia Decoction and Left Metal Pill Explanation The formula Ban Xia Hou Po Tang harmonizes the Stomach and moves Qi in the Middle Burner. The formula Zuo Jin Wan clears Liver-Heat and moves Qi in the Middle Burner: it treats epigastric distension, belching and vomiting. b Prescription
– SU YE HUANG LIAN TANG Variation
– Perilla-Coptis Decoction Variation Explanation
– Zi Su Ye harmonizes the Centre and stops vomiting. – Huang Lian clears Heat and stops vomiting. – Ban Xia and Chen Pi harmonize the Stomach and stop vomiting. – Zhu Ru stops vomiting. – Bai Shao pacifies the Liver. Three Treasures remedy
– SOOTHE THE CENTRE This remedy tonifies Spleen- and Stomach-Qi, moves Qi in the Middle Burner, resolves Dampness and harmonizes the Stomach. The tongue presentation appropriate to this remedy is a Pale body with a sticky coating: if Qi stagnation is pronounced, it may also be slightly Red on the sides. Summary Stagnant Liver-Qi invading the Stomach
Clinical manifestations
Morning sickness, retching, belching, vomiting of food with sour taste,
abdominal and epigastric distension, depression, irritability. Tongue: slightly Red sides. Pulse: Wiry. Treatment principle
Pacify the Liver, move Qi, eliminate stagnation, harmonize the Stomach, subdue rebellious Qi, stop vomiting. Acupuncture
LIV-14 Qimen, G.B.-34 Yanglingquan, Ren-12 Zhongwan, Ren-13 Shangwan, P-6 Neiguan, T.B.-6 Zhigou, ST-34 Liangqiu, ST-36 Zusanli, KI-21 Youmen. All with even method except for ST-36 which should be needled with reinforcing method. Herbal treatment
Pre scriptions
• BAN XIA HOU PO TANG and ZUO JIN WAN Pinellia-Magnolia Decoction and Left Metal Pill • SU YE HUANG LIAN TANG Variation Perilla-Coptis Decoction Variation Three Treasures remedy
• SOOTHE THE CENTRE
Case history A 31-year-old woman was 6 weeks pregnant and had been suffering from morning sickness. She vomited bitter-tasting fluids about twice a week
and she also experienced thirst, belching, irritability and epigastric and abdominal distension. Her tongue was Reddish-Purple on the sides (Plate 7) and her pulse was slightly Wiry. Diagnosis In this case, the nausea is due to stagnant Liver-Qi invading the Stomach and interfering with the descending of Stomach-Qi. The stagnation of Liver-Qi is evident from the vomiting of bitter fluids, the distension, the belching, the irritability, the Purple tongue and the Wiry pulse. There is also a slight element of Fire caused by the transformation of Liver-Qi stagnation into Liver-Fire. This is evident from the thirst and Red colour of the tongue. Treatment principle I used only acupuncture and needled the following points: • P-6 Neiguan on the right, to harmonize the Stomach and stop vomiting. • ST-36 Zusanli on the left, to tonify the Stomach. • G.B.-34 Yanglingquan to pacify the Liver, move Qi and eliminate stagnation.
Two treatments were sufficient to stop the nausea and vomiting.
Stomach-Heat
Clinical manifestations Morning sickness that may persist beyond the 3 months, vomiting of food soon after eating, thirst, bleeding gums. Tongue: Red with yellow coating in the centre. Pulse: Overflowing on the right Middle position. Treatment principle Clear Stomach-Heat, harmonize the Stomach, stop vomiting. Acupuncture ST-44 Neiting, Ren-11 Jianli, ST-21 Liangmen, ST-34 Liangqiu, P-6 Neiguan, P-3 Quze. All with even method. Explanation
– ST-44, Ren-11 and ST-21 clear Stomach-Heat. – ST-34, Accumulation point, treats acute patterns and can clear Stomach-Heat. – P-6 harmonizes the Stomach and stops vomiting. – P-3 clears Stomach-Heat. Herbal treatment
Prescription
– YU NU JIAN – Jade Woman Decoction Explanation This formula is specific to clear Stomach-Heat principally through the first two herbs Shi Gao and Zhi Mu. Niu Xi stops nausea by attracting Qi downwards. Summary Stomach-Heat
Clinical manife stations
Morning sickness that may persist beyond the 3 months, vomiting of food soon after eating, thirst, bleeding gums. Tongue: Red with yellow coating in the centre. Pulse: Overflowing on the right Middle position. Tre atme nt principle
Clear Stomach-Heat, harmonize the Stomach, stop vomiting. Acupuncture
ST-44 Neiting, Ren-11 Jianli, ST-21 Liangmen, ST-34 Liangqiu, P-6 Neiguan, P-3 Quze. All with even method.
He rbal tre atme nt
Prescription
• YU NU JIAN Jade Woman Decoction
Accumulation of Phlegm
Clinical manifestations Morning sickness, profuse vomiting, occasional vomiting of clear fluids with mucus, a feeling of oppression of the chest, dizziness. Tongue: Swollen with a sticky coating. Pulse: Slippery. Treatment principle Resolve Phlegm, harmonize the Stomach, subdue rebellious Qi, tonify the Spleen. Acupuncture ST-40 Fenglong, SP-9 Yinlingquan, Ren-12 Zhongwan, Ren-13 Shangwan, ST-21 Liangmen, KI-21 Youmen, P-6 Neiguan, ST-22 Guanmen, Ren-11 Jianli, Ren-9 Shuifen, BL-20 Pishu, ST-19 Burong. All with even method except for Ren-12 and BL-20 which should be needled with reinforcing method. Explanation
– ST-40 and SP-9 resolve Phlegm. ST-40 also harmonizes the Stomach and stops vomiting. – Ren-12 and BL-20 tonify the Spleen to resolve Phlegm. – Ren-13 and ST-21 Liangmen subdue rebellious Qi and stop vomiting.
– KI-21, end point of the Penetrating Vessel, is the point where the clear and turbid essences of the Five Yin organs are separated: this point therefore helps to resolve Phlegm while it also subdues rebellious Qi in the Penetrating Vessel. – P-6 harmonizes the Stomach and stops vomiting. – ST-22, Ren-11 and Ren-9, in combination, resolve Phlegm. – ST-19 makes Stomach-Qi descend and resolves Food accumulation. Herbal treatment
a Prescription
– XIAO BAN XIA TANG and LING GUI ZHU GAN TANG – Small Pinellia Decoction and Poria-Ramulus CinnamomiAtractylodes-Glycyrrhiza Decoction Explanation
– Ban Xia and Sheng Jiang harmonize the Stomach and stop vomiting. The last four herbs constitute the formula Ling Gui Zhu Gan Tang which resolves Phlegm from the Middle Burner. b Prescription
– JIA WEI LIU JUN ZI TANG – Augmented Six Gentlemen Decoction Explanation This formula, from the Golden Mirror of Medicine (1742), is for morning sickness from Spleen-Qi deficiency and Phlegm.6 The first six herbs constitute the formula Liu Jun Zi Tang which tonifies Spleen-Qi and resolves Dampness. – Pi Pa Ye and Xuan Fu Hua resolve Phlegm and stimulate the descending of Qi. – Huo Xiang and Sha Ren fragrantly resolve Dampness and stop nausea. – Zhi Ke moves Qi in the Middle Burner and helps to resolve Phlegm. Summary Accumulation of Phlegm
Clinical manife stations
Morning sickness, profuse vomiting, occasional vomiting of clear fluids with mucus, a feeling of oppression of the chest, dizziness. Tongue: Swollen with a sticky coating. Pulse: Slippery. Tre atme nt principle
Resolve Phlegm, harmonize the Stomach, subdue rebellious Qi, tonify the Spleen. Acupuncture
ST-40 Fenglong, SP-9 Yinlingquan, Ren-12 Zhongwan, Ren-13 Shangwan, ST-21 Liangmen, KI-21 Youmen, P-6 Neiguan, ST-22 Guanmen, Ren-11 Jianli, Ren-9 Shuifen, BL-20 Pishu, ST-19 Burong. All with even method except for Ren-12 and BL-20 which should be needled with reinforcing method. He rbal tre atme nt
Prescriptions
• XIAO BAN XIA TANG and LING GUI ZHU GAN TANG Small Pinellia Decoction and Poria-Ramulus Cinnamomi-Atractylodes-Glycyrrhiza Decoction • JIA WEI LIU JUN ZI TANG Augmented Six Gentlemen Decoction
Case history A 34-year-old woman was 8 weeks pregnant and had been experiencing morning sickness. She also complained of a feeling of oppression of the chest. Her tongue was Swollen and had a sticky coating and her pulse was slightly Slippery. Diagnosis
In this case, morning sickness is due to Phlegm obstructing the Middle Burner and interfering with the descending of Stomach-Qi. The Phlegm is evidenced by the feeling of oppression of the chest, the Swollen tongue and the Slippery pulse. Treatment principle
I used only acupuncture and selected the following points:
• P-6 Neiguan on the right, to harmonize the Stomach and stop nausea. • ST-36 Zusanli on the left, to tonify the Stomach and Spleen. • ST-40 Fenglong on the right, to resolve Phlegm and harmonize the Stomach. • KI-7 Fuliu on the left, to tonify the Kidneys and help to resolve Phlegm. • Ren-13 Shangwan to subdue rebellious Stomach-Qi.
Her morning sickness stopped after two treatments.
Heart-Qi deficiency
Clinical manifestations Morning sickness, palpitations, anxiety, depression. Tongue: Pale. Pulse: Empty on the left Front position. Treatment principle Tonify the Heart, calm the Mind, harmonize the Centre, stop vomiting. Acupuncture HE-5 Tongli, BL-15 Xinshu, P-6 Neiguan, Ren-14 Juque, ST-36 Zusanli, Ren-6 Qihai. All with reinforcing method, moxa is applicable. Explanation
– HE-5 and BL-15 tonify the Heart. HE-5 also makes Heart-Qi descend to stop nausea. – P-6 tonifies the Heart, harmonizes the Centre and stops vomiting. – Ren-14 harmonizes the Stomach, tonifies the Heart and calms the Mind. – ST-36 and Ren-6 tonify Qi in general. Herbal treatment
Prescription
– GUI PI TANG – Tonifying the Spleen Decoction Explanation
– This formula, already explained, tonifies Heart-Qi and Heart-Blood and calms the Mind. Three Treasures remedy
– CALM THE SHEN This remedy is a variation of the formula Gui Pi Tang Tonifying the Spleen Decoction which tonifies Heart- and Spleen-Qi and Heart- and Spleen-Blood. The tongue presentation appropriate to this remedy is a Pale body. Summary Heart-Qi Deficiency
Clinical manifestations
Morning sickness, palpitations, anxiety, depression. Tongue: Pale. Pulse: Empty on the left Front position.
Treatment principle
Tonify the Heart, calm the Mind, harmonize the Centre, stop vomiting. Acupuncture
HE-5 Tongli, BL-15 Xinshu, P-6 Neiguan, Ren-14 Juque, ST-36 Zusanli, Ren-6 Qihai. All with reinforcing method, moxa is applicable. Herbal treatment
Pre scription
• GUI PI TANG Tonifying the Spleen Decoction Three Treasures remedy
• CALM THE SHEN
Heart-Fire
Clinical manifestations Morning sickness which may last beyond 3 months, palpitations, mental restlessness, anxiety, thirst, agitation, insomnia. Tongue: Red with redder tip and yellow coating. Pulse: Overflowing on the left Front position. Treatment principle Clear Heart-Fire, calm the Mind, harmonize the Middle, stop vomiting. Acupuncture HE-8 Shaofu, P-6 Neiguan, Ren-14 Juque, BL-15 Xinshu. All with reducing or even method. Explanation
– HE-8 and BL-15 clear Heat-Fire. – P-6 harmonizes the Centre, calms the Mind and stops vomiting. – Ren-14 clears Heart-Heat, calms the Mind and harmonizes the Centre. Herbal treatment
Prescription
– DAO CHI SAN – Eliminating Redness Powder Explanation This formula is specific to clear Heart-Fire. Summary Heart-Fire
Clinical manife stations
Morning sickness which may last beyond 3 months, palpitations, mental restlessness, anxiety, thirst, agitation, insomnia. Tongue: Red with redder tip and yellow coating. Pulse: Overflowing on the left Front position. Tre atme nt principle
Clear Heart-Fire, calm the Mind, harmonize the Middle, stop vomiting. Acupuncture
HE-8 Shaofu, P-6 Neiguan, Ren-14 Juque, BL-15 Xinshu. All with reducing or even method. He rbal tre atme nt
Prescription
• DAO CHI SAN Eliminating Redness Powder
Prognosis and prevention I find acupuncture excellent to stop or alleviate morning sickness, working in almost every case. In mild cases, two treatments a week are sufficient, whereas in severe and protracted cases, it might be necessary to give treatment every day until vomiting stops. As for prevention, I find that although morning sickness is caused by the changes taking place in the Penetrating Vessel in the first 3 months of pregnancy, the severity and duration of the morning sickness depends on the pre-existing state of the woman’s digestive system. Thus, by the time she is pregnant, especially for the first time, there is little she can do about it during pregnancy as she will need to eat more than normal. However, if a woman suffers from morning sickness, she should try to eat little and often and she should avoid greasy and fatty foods. An infusion of fresh mint and fresh ginger is often helpful. End notes 1. Sun Si Miao AD 652 Thousand Golden Ducat Prescriptions (Qian Jin Yao Fang) cited in Luo Yuan Kai 1979 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Nanjing College of Traditional Chinese Medicine, Nanjing, p. 79..
2. Zhu Dan Xi 1347 Essential Methods of Dan Xi (Dan Xi Xin Fa) cited in Gynaecology in Chinese Medicine, p. 79..
3. Foundations of Medicine 1575 (Yi Xue Ru Men) cited in Gynaecology in Chinese Medicine, p. 79..
4. Long Jiajun, Zhang Qi, Shen Kang, Lin Hongyang 1996 Dr Zhang Jian Zhai’s Experience in Treating Gynaecological Diseases (Zhang Jian Zhai Zhi Liao Fu Ke Bing Jing Yan), Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi
), China Academy of Traditional Chinese Medicine, Beijing, No. 1, p. 17..
5. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian
), People’s Health Publishing House, Beijing, Vol. 3, p. 52. First published in 1742..
6. Ibid., p. 52..
CHAPTER 30 Abdominal Pain During Pregnancy
PATHOLOGY 469 IDENTIFICATION OF PATTERNS AND TREATMENT 470 Deficiency of Blood 470 Stagnation of Qi 471 Empty-Cold 472 Blood stasis 473 PROGNOSIS AND PREVENTION 473 WESTERN VIEW 473 Appendix: ectopic pregnancy 474 Blood stasis 474 Collapse of Yang 475 Blood stasis and Qi deficiency 475 Mild abdominal pain is relatively frequent during pregnancy and in most cases it poses no danger to the mother or fetus. However, when faced by a pregnant woman with abdominal pain, we should first exclude the possibility of ectopic pregnancy or threatened miscarriage: these will be discussed at the end of this chapter and in Chapter 31.
Pathology
Blood deficiency During pregnancy, some of the mother’s Blood is diverted to nourishing the fetus and therefore any pre-existing deficiency of Blood will be aggravated. In particular, when Blood is deficient, the Uterus Vessel becomes Empty and obstructed and abdominal pain may result. This pain results from a deficiency and it will therefore be mild. Stagnation of Qi During pregnancy some of the mother’s Blood is diverted to nourishing the fetus and therefore any pre-existing deficiency of Blood will be aggravated. Since the Liver stores Blood, a deficiency of Blood may often induce a secondary stagnation of Liver-Qi, causing abdominal pain. This condition is often caused by emotional stress such as anger, resentment, frustration, guilt or worry. Empty-Cold If the pregnant woman suffers from a pre-existing condition of Kidney-Yang deficiency, the pregnancy will tax the Kidneys and may aggravate such deficiency, giving rise to Empty-Cold. Cold obstructs the circulation of Qi and therefore causes pain. Blood stasis A predisposition to Blood stasis may be aggravated during pregnancy as the
Lower Burner is ‘obstructed’ by the growing fetus. Blood stasis frequently causes severe abdominal pain. We should ascertain the character of the pain clearly in order to differentiate clearly between deficiency, excess, Cold and Heat. If an abdominal pain is improved by pressure, this indicates deficiency; if it is worsened, Fullness. If it is eased by warm liquids this indicates Cold; if worsened, Heat. Abdominal pain with a feeling of distension indicates stagnation of Qi; stabbing, severe pain is due to stasis of Blood. Clinical Note • Pain improved by pressure: Deficiency • Pain worsened by pressure: Fullness • Pain eased by warm liquids: Cold • Pain aggravated by warm liquids: Heat • Pain with distension: Qi stagnation • Severe pain: Blood stasis
Identification of patterns and treatment The treatment principle for abdominal pain during pregnancy is essentially to move Qi and invigorate Blood, adjusted according to the respective predominance of deficiency or excess. In any case, during pregnancy one must avoid using too many pungent, warm, drying herbs or herbs that strongly invigorate Blood. If the deficiency of Blood and/or Kidneys predominates, then one must also adopt the treatment principle of ‘calming the fetus’ by choosing herbs that calm the fetus and also strengthen the Kidneys and nourish Blood such as Du Zhong Cortex Eucommiae, Xu Duan Radix Dipsaci and Sang Ji Sheng Herba Taxilli. The patterns discussed are: • deficiency of Blood • stagnation of Qi • Empty-Cold • Blood stasis.
Deficiency of Blood
Clinical manifestations Mild abdominal pain that comes and goes and that improves with pressure, dull, pale complexion, dizziness, blurred vision, history of scanty periods, insomnia. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle Nourish Blood, calm the fetus, stop pain. Acupuncture LIV-8 Ququan, ST-36 Zusanli, BL-23 Shenshu, BL-20 Pishu, BL-18 Ganshu, BL-17 Geshu (with direct moxa cones). All with reinforcing method, moxa is applicable. Explanation
– LIV-8 and ST-36 nourish Liver-Blood. – BL-23 and BL-20 tonify the Spleen and Kidneys to produce Blood. – BL-18, in combination with BL-23, nourishes Liver-Blood. – BL-17, with moxa cones, tonifies Blood. Herbal treatment
a Prescription
– DANG GUI SHAO YAO SAN – Angelica-Paeonia Powder Explanation This formula is from the Synopsis of Prescriptions from the Golden Cabinet by Zhang Zhong Jing and it is specific for dull abdominal pain in pregnancy.1 – Dang Gui and Chuan Xiong invigorate Blood and eliminate stasis. The low dose of Dang Gui within the prescription is to invigorate Blood gently during pregnancy. – Bai Shao nourishes Blood and stops pain. – Fu Ling, Bai Zhu and Ze Xie tonify the Spleen and resolve Dampness. – Zhi Gan Cao (not in the original prescription) harmonizes. b. Prescription
– JIAO AI TANG Variation – Colla Corii Asini-Artemisia Decoction Variation Explanation
– Sheng Di Huang, Dang Gui, Bai Shao, E Jiao and Gou Qi Zi nourish Blood. – Ai Ye warms the Uterus and prevents miscarriage. – Mu Xiang moves Qi and is added to counterbalance the Blood tonics. – Zhi Gan Cao harmonizes. Modifications These modifications apply to both formulae. • If the deficiency of Blood is severe and there are signs of dryness, remove Ze Xie Rhizoma Alismatis. • If there is backache and weariness, add Shou Wu Radix Polygoni multiflori preparata and Sang Ji Sheng Herba Taxilli. • If there are Cold signs, add Ai Ye Folium Artemisiae argyi. Women’s Treasure remedy
– PRECIOUS SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. It has been modified with the addition of Kidney tonics. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary
Deficiency of Blood
Clinical manifestations
Mild abdominal pain that comes and goes and that improves with pressure, dull, pale complexion, dizziness, blurred vision, history of scanty periods, insomnia. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle
Nourish Blood, calm the fetus, stop pain. Acupuncture
LIV-8 Ququan, ST-36 Zusanli, BL-23 Shenshu, BL-20 Pishu, BL-18 Ganshu, BL-17 Geshu (with direct moxa cones). All with reinforcing method, moxa is applicable. Herbal treatment
Pre scriptions
• DANG GUI SHAO YAO SAN Angelica-Paeonia Powder • JIAO AI TANG Variation Colla Corii Asini-Artemisia Decoction Variation Women’s Treasure remedy
• PRECIOUS SEA
Stagnation of Qi
Clinical manifestations Abdominal pain with a feeling of distension, hypochondriac pain and distension, irritability, belching, poor appetite. Tongue: slightly Red sides or normal. Pulse: Wiry. Treatment principle Pacify the Liver, move Qi, eliminate stagnation, calm the fetus. Acupuncture LIV-3 Taichong, T.B.-6 Zhigou, LIV-14 Qimen, BL-18 Ganshu, P-6 Neiguan, BL-23 Shenshu. All with even method except for BL-23 which should be needled with reinforcing method. Explanation
– LIV-3, BL-18 and LIV-14 pacify the Liver, move Qi and eliminate stagnation. – T.B.-6 moves Qi. – P-6 pacifies the Liver, calms the Mind and moves Qi. – BL-23 tonifies the Kidneys and calms the fetus. Herbal treatment
Prescription
– XIAO YAO SAN – Free and Easy Wanderer Powder Explanation This formula, already explained, pacifies the Liver, moves Qi and eliminates stagnation. Modifications
• If there is also epigastric pain, add Zi Su Ye Folium Perillae and Chen Pi Pericarpium Citri reticulatae. Zi Su Ye also calms the fetus. • If stagnant Liver-Qi is generating some Heat, add Shan Zhi Zi Fructus Gardeniae and Huang Qin Radix Scutellariae. The latter herb also calms the fetus. Women’s Treasure remedy
– FREEING THE MOON This remedy is a variation of the formula Xiao Yao San Free and Easy Wanderer Powder. Summary
Stagnation of Qi
Clinical manifestations
Abdominal pain with a feeling of distension, hypochondriac pain and distension, irritability, belching, poor appetite. Tongue: slightly Red sides or normal. Pulse: Wiry. Treatment principle
Pacify the Liver, move Qi, eliminate stagnation, calm the fetus. Acupuncture
LIV-3 Taichong, T.B.-6 Zhigou, LIV-14 Qimen, BL-18 Ganshu, P-6 Neiguan, BL-23 Shenshu. All with even method except for BL-23 which should be needled with reinforcing method. Herbal treatment
Pre scription
• XIAO YAO SAN Free and Easy Wanderer Powder Women’s Treasure remedy
• FREEING THE MOON
Empty-Cold
Clinical manifestations Dull abdominal pain that improves with the application of heat and by drinking warm liquids, feeling of cold, dull, bright complexion, cold limbs. Tongue: Pale and wet. Pulse: Deep and Weak. Treatment principle Warm the Yang, expel cold, calm the fetus, stop pain. Acupuncture BL-23 Shenshu, ST-36 Zusanli, Ren-12 Zhongwan (only in the first 3 months), KI-5 Shuiquan. All with reinforcing method and moxa. Explanation
– BL-23, with moxa, tonifies Kidney-Yang and expels Cold. – ST-36 and Ren-12, with moxa, tonify Spleen-Yang and expel Cold. – KI-5 tonifies the Kidneys and stops umbilical pain. Herbal treatment
Prescription
– JIAO AI TANG – Colla Corii Asini-Artemisia Decoction Explanation This formula is also from the Synopsis of Prescriptions from the Golden Cabinet by Zhang Zhong Jing and is for abdominal pain from Cold and deficiency of Blood during pregnancy.2 – E Jiao, Sheng Di Huang, Dang Gui and Bai Shao nourish Blood. Bai Shao also stops pain and E Jiao also calms the fetus. – Chuan Xiong invigorates Blood. Together with Sheng Di Huang, Dang Gui and Bao Shao, it forms the formula Si Wu Tang Four Substances Decoction (with Sheng Di Huang substituted for Shu Di Huang) which nourishes Blood. – Ai Ye warms the Uterus and expels Cold. – Gan Cao harmonizes. Modifications
• If there are signs of Kidney-Yang deficiency, add Du Zhong Cortex Eucommiae and Ba Ji Tian Radix Morindae officinalis. Du Zhong also calms the fetus. Summary Empty Cold
Clinical manife stations
Dull abdominal pain that improves with the application of heat and by drinking warm liquids, feeling of cold, dull, bright complexion, cold limbs. Tongue: Pale and wet. Pulse: Deep and Weak. Tre atme nt principle
Warm the Yang, expel cold, calm the fetus, stop pain. Acupuncture
BL-23 Shenshu, ST-36 Zusanli, Ren-12 Zhongwan (only in the first 3 months), KI-5 Shuiquan. All with reinforcing method and moxa. He rbal tre atme nt
Prescription
• JIAO AI TANG Colla Corii Asini-Artemisia Decoction
Blood stasis
Clinical manifestations Severe abdominal pain, uterine bleeding, mental restlessness. Tongue: Purple if the Blood stasis is severe. Pulse: Choppy, Wiry or Firm. Treatment principle Invigorate Blood, regulate the Penetrating Vessel, calm the fetus. Acupuncture SP-4 Gongsun with P-6 Neiguan, BL-17 Geshu, SP-10 Xuehai, LIV-3 Taichong, KI-3 Taixi. Even method except KI-3 which should be needled with reinforcing method. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel. – BL-17, SP-10 and LIV-3 invigorate Blood. – KI-3 Taixi calms the fetus. Herbal treatment I use no herbal treatment for this pattern because the use of Bloodinvigorating herbs is forbidden in pregnancy.
Summary Blood stasis
Clinical manifestations Severe abdominal pain, uterine bleeding, mental restlessness. Tongue: Purple if the Blood stasis is severe. Pulse: Choppy, Wiry or Firm. Treatment principle Invigorate Blood, regulate the Penetrating Vessel, calm the fetus. Acupuncture SP-4 Gongsun with P-6 Neiguan, BL-17 Geshu, SP-10 Xuehai, LIV-3 Taichong, KI-3 Taixi. Even method except KI-3 which should be needled with reinforcing method.
Prognosis and prevention The prognosis depends largely on the Western differentiation. If abdominal pain in pregnancy is not due to an ectopic pregnancy or threatened miscarriage, it responds well to treatment with acupuncture and/or Chinese herbs. The pattern from deficiency of Blood is the easiest to treat while those from Empty-Cold and stagnation of Qi are the most difficult because the pregnant state of the patient imposes several restrictions on the choice of acupuncture points or herbs. For example, the pattern of Empty-Cold would require the application of moxa to points in the lower abdomen which cannot be done during pregnancy. Similarly, the pattern of Qi stagnation would require the needling of points in the lower abdomen.
Western view When seeing a pregnant woman with abdominal pain, we must first of all establish whether there is uterine bleeding or not because this sign may indicate either a threatened miscarriage or an ectopic pregnancy. A ‘simple’ abdominal pain during pregnancy is not uncommon and Western medicine has no explanation for it. For example, a textbook on obstetrics says of abdominal pain during pregnancy: “Very few women manage to experience an entire pregnancy without an episode of abdominal pain. Most of these episodes are transitory … The cause for most episodes is never determined.”3 Uterine contractions cause most cases of abdominal pain during pregnancy. If they occur before the twentieth week, painful uterine contractions usually indicate abortion (threatened, inevitable or complete). After the twentieth week, uterine contractions that become progressively more painful usually indicate imminent labour. If the abdominal pain is severe and is accompanied by uterine bleeding, the woman should be referred to a gynecologist to carry out tests and an examination to exclude the possibility of an ectopic pregnancy or an imminent (or indeed in process) miscarriage. Another possible cause of severe abdominal pain during pregnancy is torsion of a pedunculated ovarian cyst. Ectopic pregnancy The term ‘ectopic pregnancy’ refers to pregnancy occurring anywhere outside the uterus. The most common location of an ectopic pregnancy is one of the fallopian tubes, but it may also occur in the abdominal cavity, in an ovary or in the cervix. In the UK, 1 in 200 pregnancies is ectopic. A history of pelvic inflammatory disease is a predisposing factor to ectopic pregnancy. Ectopic pregnancy can present in an acute or subacute way. In the acute presentation, the woman is in a state of shock with hypotension, tachycardia and signs of peritoneal inflammation (very similar to those of acute
appendicitis with peritonitis): the abdomen is very distended and acutely tender; there is rebound tenderness, i.e. when pressed down on palpation and then released, acute tenderness manifests upon release. The abdominal pain is very severe and usually precedes the uterine bleeding. In the subacute presentation, the woman experiences recurrent attacks of vaginal bleeding and abdominal pain. Thus, ectopic pregnancy should always be suspected in a pregnant woman presenting with severe abdominal pain and vaginal bleeding. The only possible treatment for ectopic pregnancy is termination by salpingectomy, salpingotomy or tubal compression. If pregnancy occurs in the abdominal cavity it is a life-threatening condition for the mother because any attempt to remove the placenta (located in the abdominal cavity rather than the uterus) results in massive haemorrhage. Spontaneous abortion Spontaneous abortion (or miscarriage) occurs in about 10% of pregnancies under 24 weeks. Threatened abortion presents mainly with vaginal bleeding and abdominal pain is either absent or mild. About 50% of women with such symptoms will continue the pregnancy without aborting. The only treatment for threatened abortion in Western medicine is bed rest; sometimes smoothmuscle relaxants are administered. In Chinese medicine, one can prescribe various formulae or prepared remedies to try to prevent abortion, and these will be discussed in Chapter 31 on threatened miscarriage. If the pregnancy does not settle, the woman may proceed to abort and one can distinguish an incomplete from a complete abortion. In both cases, the vaginal bleeding becomes profuse with the passage of large clots and the abdominal pain becomes intense. If some of the products of conception are retained, the abortion is incomplete and requires dilatation and curettage. Again, the role of Chinese medicine in such cases will be discussed in Chapters 43 and 44. If the abortion is complete, the abdominal pain ceases and the vaginal bleeding subsides. Spontaneous completion is more likely in cases of over 16 weeks’ gestation. Abortion, either spontaneous or induced, may give rise to infection: in this case, the vaginal bleeding becomes purulent
and the woman has a high temperature. Abdominal pain and vaginal bleeding also occur in cases when the fetus dies in utero but is not immediately expelled. Ovarian tumour torsion Ovarian tumour torsion occurs especially with dermoid cysts and fibromata when the pedicle is long enough to become twisted. When torsion has occurred, twisting of the pedicle occludes the circulation of blood, obstructing first the veins and then the arteries and leading to ischaemia and necrosis of the tumoral tissue. The main symptoms and signs are a severe abdominal pain, vomiting and vaginal bleeding. On palpation, a firm, tender swelling is felt.
Appendix: ectopic pregnancy Although ectopic pregnancy obviously requires treatment with Western medicine, this can be integrated with treatment with Chinese medicine. As usual in Chinese medicine, a differentiation of patterns is made to decide the treatment. As a general consideration, ectopic pregnancy constitutes a Full condition characterized by Blood stasis and it requires invigorating Blood and eliminating stasis. However, beyond this generalization three patterns can be distinguished and these will be discussed briefly below with their treatment.
Blood stasis
Clinical manifestations Severe, stabbing abdominal pain, Purple tongue and Wiry pulse. Treatment principle Invigorate Blood, eliminate stasis, dissolve masses, terminate pregnancy. Herbal treatment
Prescription
– GONG WAI YUN No. 2 FORMULA – Ectopic Pregnancy Formula No. 2 Explanation This formula is from the First Affiliated Hospital of the Shanxi College of Traditional Chinese Medicine and is reported in Gynaecology in Chinese Medicine.4 – Chi Shao, Dan Shen and Tao Ren invigorate Blood and eliminate stasis. – San Leng and E Zhu break’ Blood, dissolve masses and eliminate stasis.
Summary Blood stasis
Tre atme nt principle
Invigorate Blood, eliminate stasis, dissolve masses, terminate pregnancy. He rbal tre atme nt
Prescription
• GONG WAI YUN No. 2 FORMULA Ectopic Pregnancy Formula No. 2
Collapse of Yang
Clinical manifestations Abdominal pain, bright white complexion, hypertension, sweating, cold hands and feet, nausea, vomiting, Deep-Fine-Scattered pulse. Treatment principle Rescue the Yang, nourish Yin, invigorate Blood, eliminate stasis. Herbal treatment
Prescription
– SHEN FU TANG plus SHENG MAI SAN plus GONG WAI YUN No. 1 FORMULA – Ginseng-Aconitum Decoction plus Generating the Pulse Powder plus Ectopic Pregnancy Formula No. 1. Explanation
– Ren Shen and Fu Zi constitute the formula Shen Fu Tang which is used for collapse of Yang. – Ren Shen, Mai Men Dong and Wu Wei Zi constitute the formula Sheng
Mai San which nourishes Yin and restores the pulse. – Chi Shao, Dan Shen and Tao Ren constitute the formula Gong Wai Yun No. 1 Formula (from the First Affiliated Hospital to the Shanxi College of Traditional Chinese Medicine) which invigorates Blood and eliminates stasis. Summary Collapse of Yang
Tre atme nt principle
Rescue the Yang, nourish Yin, invigorate Blood, eliminate stasis. He rbal tre atme nt
Prescription
• SHEN FU TANG plus SHENG MAI SAN plus GONG WAI YUN No. 1 FORMULA Ginseng-Aconitum Decoction plus Generating the Pulse Powder plus Ectopic Pregnancy Formula No. 1.
Blood stasis and Qi deficiency
Clinical manifestations Abdominal pain that improves with pressure, vaginal bleeding, lassitude, blood pressure normal, Fine pulse. Treatment principle Invigorate Blood, eliminate stasis, tonify Qi. Herbal treatment
Prescription
– GONG WAI YUN NO. 1 FORMULA Variation – Ectopic Pregnancy Formula No. 1 Variation Explanation The first three herbs constitute the formula Gong Wai Yun No. 1 Formula which invigorates Blood and eliminates stasis. – Dang Shen and Huang Qi tonify Qi. Summary
Blood stasis and Qi deficiency
Tre atme nt principle
Invigorate Blood, eliminate stasis, tonify Qi. He rbal tre atme nt
Prescription
• GONG WAI YUN NO. 1 FORMULA Variation Ectopic Pregnancy Formula No. 1 Variation
End notes 1. He Ren 1981 A New Explanation of the Synopsis of Prescriptions from the Golden Cabinet (Jin Gui Yao Lue Xin Jie
), Zhejiang Science Publishing House, p. 173. The Synopsis of Prescriptions from the Golden Cabinet was written by Zhang Zhong Jing c. AD 200..
2. Ibid., p. 172..
3. Malcolm Symonds E 1992 Essential Obstetrics and Gynaecology, Churchill Livingstone, Edinburgh, p. 45..
4. Luo Yuan Kai 1986 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Shanghai Science and Technology Press, Shanghai, p. 130..
CHAPTER 31 Threatened Miscarriage
AETIOLOGY AND PATHOLOGY 478 IDENTIFICATION OF PATTERNS AND TREATMENT 479 Kidney deficiency 480 Qi and Blood deficiency 483 Blood-Heat 484 Falls, traumas 486 Ancient acupuncture prescriptions for threatened miscarriage 487 PROGNOSIS AND PREVENTION 487 WESTERN VIEW 488 ‘Threatened miscarriage’ refers to a collection of symptoms and signs experienced by a pregnant woman usually (but not always) during the first 3 months of pregnancy. ‘Threatened miscarriage’ is a Western medical term. In Chinese medicine, the two disease categories of ‘Vaginal Bleeding during
Pregnancy’, called Tai Lou ( ), and ‘Restless Fetus’,
called
Tai
Dong
Bu
An
(
), correspond to threatened miscarriage. An actual miscarriage that occurs in the first 3 months is called duo tai (
if
it
occurs
after
3
months,
it
), which means ‘falling fetus’; is called xiao chan (
)
or
ban
chan
(
), which mean ‘small labour’ and ‘half labour’ respectively. See also the discussion of habitual miscarriage in Chapter 43. Thus, three conditions may be identified in Chinese medicine: ‘Vaginal Bleeding during Pregnancy’, ‘Restless Fetus’ and ‘Miscarriage’. These three conditions represent different stages of the same process: in the first two
stages, the fetus has not yet been damaged and miscarriage can be prevented, while in the third stage the fetus has been injured or has already left the uterus and miscarriage cannot be prevented. From a Western perspective, ‘Vaginal Bleeding during Pregnancy’ corresponds to ‘threatened abortion’ and ‘Restless Fetus’ may correspond to either ‘threatened abortion’ or to ‘inevitable abortion’ (see the end of this chapter). Thus, interestingly, the ancient Chinese were well aware of the different prognosis of these two clinical conditions, the latter indicating a worse prognosis. I shall refer to the two Chinese disease categories of ‘Vaginal Bleeding during Pregnancy’ and ‘Restless Fetus’ together as ‘threatened miscarriage’. There are, however, differences between these two conditions: in ‘Vaginal Bleeding during Pregnancy’, vaginal bleeding is scanty and is the only symptom, while in ‘Restless Fetus’, besides vaginal bleeding, there is also backache, abdominal pain and a bearing-down feeling. Clinical Note • ‘Vaginal Bleeding during Pregnancy’: scanty vaginal bleeding • ‘Restless Fetus’: vaginal bleeding, backache, abdominal pain, bearing-down feeling
With regard to vaginal bleeding, however, it should be remembered that a slight bleeding a few weeks after becoming pregnant sometimes occurs without consequence and does not necessarily indicate a threatened miscarriage. This was called in old China ‘swimming menses’ (you jing
).
Finally,
habitual
miscarriage
was
called
Hua
Tai
(
), which means ‘slippery fetus’. To summarize, the various Chinese terms referring to miscarriage or threatened miscarriage are as follows (in order of severity): • You Jing, ‘Swimming Menses’: a harmless vaginal bleeding during the first month of pregnancy. • Tai Lou, ‘Vaginal Bleeding during Pregnancy’: threatened miscarriage, with vaginal bleeding. • Tai Dong Bu An, ‘Restless Fetus’: threatened miscarriage, with vaginal bleeding, backache, abdominal pain and a bearing-down feeling. • Duo Tai, ‘Falling Fetus’: miscarriage within the first 3 months. • Xiao Chan or Ban Chan, ‘Small Labour’ or ‘Half Labour’: miscarriage after 3 months. • Hua Tai, ‘Slippery Fetus’: habitual miscarriage (Fig. 31.1).
Figure 31.1 Chinese terms referring to miscarriage or threatened miscarriage. This chapter will deal with the treatment of threatened miscarriage, i.e. the treatment of a pregnant woman who experiences vaginal bleeding and abdominal pain. The treatment of habitual miscarriage, i.e. the treatment of a woman before she becomes pregnant, is outlined in Chapter 43.
Aetiology and pathology The pathology of threatened miscarriage is essentially a weakness of the Directing and Penetrating Vessels (Ren and Chong Mai) which fail to gather Blood and nourish the fetus. Since the Penetrating Vessel is the Sea of Blood and the Directing Vessel influences the fetus, a weakness of these two vessels leads to a deficiency of Blood and of the Kidneys nourishing the fetus: the Original Qi of the fetus becomes weak, the fetus cannot grow properly and threatened miscarriage or miscarriage results. A weakness of the Directing and Penetrating Vessels is associated with a deficiency of the Kidneys: other related pathologies may be deficiency of Blood, deficiency and sinking of Qi, and Blood-Heat. The main aetiological factors are as follows. Overwork, excessive physical work Overwork in the sense of working long hours without adequate rest for many years weakens Kidney-Yin, while excessive physical work including excessive lifting, sports or exercises, injures Kidney-Yang. The deficiency of the Kidneys may lead to weakening of the Directing and Penetrating Vessels and, in a pregnant woman, to threatened miscarriage. Chronic illness, irregular diet A long, chronic illness or a diet lacking in nourishment may lead to Qi and Blood deficiency. A deficiency of Qi affects the fetus’s strength, while deficient Blood fails to nourish the fetus’s Original Qi and threatened miscarriage may result. In particular, when there is Qi deficiency, vaginal bleeding results. Emotional problems, irregular diet, febrile disease
Emotional problems such as worry, anger, frustration and resentment may lead to stagnation of Liver-Qi and, after a long time, this may turn into LiverFire; as the Liver stores Blood, Liver-Fire often causes Blood-Heat. A diet including an excessive amount of hot, pungent foods such as spices, curries and alcohol may also lead to Liver-Fire or Blood-Heat. The Jade Ruler of Gynaecology (1774) says: “If a woman eats too many hot and pungent foods during pregnancy, they injure the Directing and Penetrating vessels.”1 A febrile disease may also lead to Blood-Heat if it is not stopped at the Defensive Qi or Qi levels. Whatever the origin, Blood-Heat affects the Penetrating Vessel (which is the Sea of Blood) and the Uterus and placenta and may cause or threaten a miscarriage. Falls, jumps, traumas A sharp fall or jump or a trauma may all injure the Directing and Penetrating Vessels in a pregnant woman and lead to or threaten miscarriage. The Foundations of Medicine (1575) says: “If a pregnant woman jumps from a high place or lifts heavy objects, it may injure the fetus’s Original Qi.”2 Excessive sexual activity during pregnancy Excessive or too vigorous sex during the first 3 months of pregnancy may be a cause of miscarriage akin to trauma. Although sexual intercourse during the first 3 months is not forbidden according to Chinese medicine (except for Fu Qing Zhu), it should be less frequent and less vigorous than normal. The Jade Ruler of Gynaecology (1774) says: “Many miscarriages are due to the husband having an insatiable desire for indulging in excessive sexual intercourse and to the wife liking sex a lot.”3 Wu Qian, the author of the Golden Mirror of Medicine (1742), gives prognostic guidelines for threatened miscarriage. He says that if the mother’s
face is red and her tongue blue, it indicates imminent miscarriage; if her face is blue and her tongue red, the mother’s life is in danger; if both the face and tongue are blue, both the mother and the fetus are in danger of death.4 Chinese medicine books differentiate between threatened miscarriage and miscarriage, ‘Surging Periods’ and phantom pregnancy. During an actual miscarriage the vaginal bleeding is much more profuse than in threatened miscarriage and it is with clots: in addition, the abdominal pain is much more severe. ‘Surging Periods’ in Chinese medicine indicates the phenomenon whereby some women can continue to have periods for 2–3 months after becoming pregnant without any ill effect and without any other symptom. In some cases of phantom pregnancy, there may be morning sickness, vomiting, vaginal bleeding (sometimes with clots which Chinese books describe as tadpoles) and abdominal pain. Abdominal pain towards the end of term does not usually indicate the possibility of miscarriage. In fact, Wu Qian says that abdominal pain that goes on for a short time and then stops during the eighth or ninth month, is called ‘Testing Fetus’ (shi tai
) and in this case one should nourish Blood and ‘calm the fetus’. If towards the end of term there is an intermittent abdominal pain without backache, this is called ‘Playing Fetus’
(nong tai
).
Summary Aetiology and Pathology
• Overwork, excessive physical work • Chronic illness, irregular diet • Emotional problems, irregular diet, febrile disease • Falls, jumps, traumas • Excessive sexual activity during pregnancy • Actual miscarriage: profuse vaginal bleeding with clots, severe abdominal pain • ‘Surging Periods’: women continuing to have periods for 2–3 months after becoming pregnant without any ill effect and without any other symptom • Phantom pregnancy: morning sickness, vomiting, vaginal bleeding sometimes with clots and abdominal pain • ‘Testing Fetus’: abdominal pain towards the end of term that goes on for a short time and then stops during the eighth or ninth month • ‘Playing Fetus’: intermittent abdominal pain without backache towards the end of term
Identification of patterns and treatment The first thing to establish when treating threatened miscarriage is that the fetus is still alive. It is therefore imperative that the woman is seen by an experienced gynecologist for tests. If the fetus is dead, the patient should obviously be hospitalized for a termination. Whatever the cause and pathology of threatened miscarriage, the main treatment principle is always to ‘calm the fetus’ and strengthen the Directing and Penetrating Vessels. As explained in the introduction to Section 6, ‘calming the fetus’ should not be interpreted literally: in fact, the movement of the fetus is a good sign in threatened miscarriage. Thus, calming the fetus means using treatments that nourish the Original Qi of the fetus and strengthen the Kidneys and consolidate the Penetrating and Directing Vessels of the mother. These are precisely the treatments one wants to use in threatened miscarriage. Indeed, there are many herbs that have a long tradition of empirical application in threatened miscarriage. The Chinese term for threatened miscarriage is ‘fetus moving and restless’ (literally ‘not at peace’), hence the use of the term ‘calming the fetus’. Of course, from a Western point of view, movement of the fetus is normal and in fact a sign that all is well. However, it is also true to say that if a previously quiet fetus suddenly becomes restless, it is not a good sign, and this is perhaps what the Chinese meant by ‘restless fetus’. In addition to these treatment principles, others should be adopted according to the condition: these may include tonifying the Kidneys, nourishing Blood, tonifying and raising Qi and cooling Blood. The main herbs that ‘calm the fetus’, i.e. stop miscarriage, are: • Sang Ji Sheng Herba Taxilli • E Jiao Colla Corii asini • Xu Duan Radix Dipsaci
• Du Zhong Cortex Eucommiae • Huang Qin Radix Scutellariae • Zi Su Ye Folium Perillae • Sha Ren Fructus Amomi • Tu Si Zi Semen Cuscutae • Ai Ye Folium Artemisiae argyi • Lian Fang Receptaculum Nelumbinis • Bai Zhu Rhizoma Atractylodis macrocephalae • Zhu Ma Gen Radix Boehmeriae • Huang Qi Radix Astragali. As can be seen, these herbs are from disparate categories and there is little to link them except the empirical research of past Chinese doctors. Obviously, when choosing herbs that calm the fetus, one would choose those that would also be appropriate to the pattern treated. For example, if threatened miscarriage were due to Kidney-Yang deficiency, one would naturally choose Du Zhong, Xu Duan or Tu Si Zi; were it due to Blood deficiency, one would opt for E Jiao and Sang Ji Sheng; were it due to Heat, Huang Qin; and so on. However, in every case one would have to select at least one herb that tonifies Kidney-Yang in order to strengthen the Governing Vessel and the raising action of Yang because miscarriage is characterized by a Yin, descending movement. Tu Si Zi is a particularly important herb for threatened miscarriage because it is also astringent. Dr Cong Chun Yu, author of Chinese Medicine Gynaecology, advocates always using Tu Si Zi in threatened miscarriage for which he says it is the most important herb: he recommends its use in high doses and he says that he uses up to 150 g
daily!5 When treating a pregnant woman with herbs, when tonifying, one should avoid using hot, pungent herbs and also herbs that make Qi descend; when regulating Qi, one should avoid fragrant, dying herbs; when clearing Heat, one should avoid too bitter, cold herbs; when invigorating Blood, one should avoid herbs that ‘break’ Blood, herbs that promote bowel movement and urination, and toxic herbs. Also, there are three treatment methods that should not be used in pregnant women, especially in threatened miscarriage: one should not cause sweating because this may lead to collapse of Yang; one should not move downwards (promote bowel movement) because it may lead to collapse of Yin; and one should not promote urination (with herbs that drain Dampness via urination such as Yi Yi Ren Semen Coicis) as this may injure Body Fluids. The patterns discussed are as follows: • Kidney deficiency • Qi and Blood deficiency • Blood-Heat • Falls, traumas.
Kidney deficiency
Clinical manifestations Threatened miscarriage early in the pregnancy, lumbar soreness, scanty vaginal bleeding, dizziness, exhaustion, frequent urination. Tongue: Pale if there is Kidney-Yang deficiency; without coating in a case of Kidney-Yin deficiency; without coating and Red if there is Empty-Heat. Pulse: Deep and Weak in a case of Kidney-Yang deficiency; Floating-Empty in a case of Kidney-Yin deficiency. This pattern consists essentially in a weakness of the Directing and Penetrating Vessels and may manifest with Kidney-Yang or Kidney-Yin deficiency. However, even if there is Kidney-Yin deficiency, Kidney-Yang should be tonified as it needs the Yang action and the influence of the Governing Vessel (Du Mai) to prevent the downward movement of the fetus. In other words, in threatened miscarriage or miscarriage there is obviously always some sinking of Qi causing a downward movement of the fetus: to counteract such downward movement, we must tonify Yang and strengthen the Directing, Penetrating and Governing Vessels with Kidney-Yang tonics. Treatment principle Tonify the Kidneys (Yang or Yin), strengthen the Governing, Directing and Penetrating Vessels, calm the fetus. Acupuncture BL-20 Pishu, BL-23 Shenshu, Du-20 Baihui, Ren-12 Zhongwan (if within 3 months), ST-36 Zusanli, KI-3 Taixi, Qimen (extra point, 3 cun lateral to Ren4). All with reinforcing method: moxa is applicable in Kidney-Yang
deficiency. Explanation
– BL-20 tonifies the Spleen and raises Qi. – BL-23 and KI-3 tonify the Kidneys. – Du-20 raises Qi to counteract the downward movement of the fetus. – Ren-12, in conjunction with Du-20, raises Qi. – ST-36 tonifies Qi and Blood in general. – Qimen, only with moxa cones, strengthens the Uterus and prevents miscarriage. This point is situated level with Ren-4 Guanyuan and three cun from the midline. Please note that although this point’s pinyin name sounds the same as that of LIV-14 Qimen, in Chinese it is written with different characters and it means ‘Door of Qi’. Using a point in the lower abdomen runs counter to the advice against using points in this region during pregnancy: however, when a miscarriage is threatened, the use of some of the points in this region, especially with direct moxa, is indicated. Herbal treatment
a. Prescription
– SHOU TAI WAN – Fetus Longevity Pill
Explanation All the herbs in this prescription ‘calm the fetus’, i.e. prevent miscarriage. – Tu Si Zi and Xu Duan tonify Kidney-Yang and strengthen the Governing Vessel. – Sang Ji Sheng and E Jiao nourish Blood. b. Prescription
– TAI SHAN PAN SHI SAN – Huge Rock from Mount Taishan Powder Explanation This formula is essentially a variation of Ba Zhen Tang Eight Precious Decoction with the addition of Xu Duan to tonify Kidney-Yang and the replacing of Dang Shen with Huang Qi. The emphasis of this prescription is therefore to combine tonification of the Kidneys with tonification of Qi and Blood. – Huang Qi, Bai Zhu and Zhi Gan Cao tonify and raise Qi. Bai Zhu also calms the fetus. – Shu Di Huang, Bai Shao and Dang Gui nourish Blood. – Chuan Xiong invigorates Blood: this herb could be removed to avoid any danger of invigorating Blood too much. – Sha Ren and Fu Ling resolve Dampness to counterbalance the Qi tonics.
– Xu Duan tonifies Kidney-Yang and calms the fetus. c. Prescription
– AN TAI YIN – Calming the Fetus Decoction Explanation
– Huang Qi, Tai Zi Shen and Bai Zhu tonify and raise Qi. Bai Zhu also calms the fetus. – Dang Gui, Sheng Di Huang, Bai Shao and Sang Ji Sheng nourish Blood. – Du Zhong and Tu Si Zi tonify Kidney-Yang and calm the fetus. – Huang Qin and Zhu Ma Gen clear Heat, stop bleeding and calm the fetus. This formula tonifies Qi and Blood, tonifies Kidney-Yang, clears Heat and calms the fetus. Modifications
• If vaginal bleeding is profuse, add Xian He Cao Herba Agrimonae, Han Lian Cao Herba Ecliptae and Huang Qi Radix Astragali. • If the abdominal pain is relatively severe and the danger of miscarriage seems greater, add Sheng Ma Rhizoma Cimicifugae and Huang Qi Radix Astragali.
• If urination is very frequent, add Yi Zhi Ren Fructus Alpiniae oxyphyllae, Sang Piao Xiao Ootheca Mantidis and Shan Zhu Yu Fructus Corni. • If the deficiency of Kidney-Yang is pronounced, add Ba Ji Tian Radix Morindae officinalis, Yin Yang Huo Herba Epimedii, Xian Mao Rhizoma Curculiginis and Shou Wu Radix Polygoni multiflori preparata. • If there are signs of Kidney-Yin deficiency, add Gou Qi Zi Fructus Lycii and Sheng Di Huang Radix Rehmanniae. d. Prescription
– SHENG YU TANG Variation – Sage-like Healing Decoction Variation Explanation This formula is recommended by the Golden Mirror of Medicine for threatened miscarriage from Liver and Kidney deficiency and weakness of the Directing and Penetrating Vessels.6 The first six herbs constitute the formula Sheng Yu Tang which tonifies Qi and nourishes Blood. – Du Zhong and Xu Duan tonify Kidney-Yang, strengthen the Governing, Directing and Penetrating Vessels, and prevent miscarriage. – Sha Ren prevents miscarriage. e. Prescription
– AN DIAN ER TIAN TANG – Calming and Settling the Two Heavens Decoction Explanation This formula is from Fu Qing Zhu’s Gynaecology which recommends tonifying both the Kidneys and Spleen in case of threatened miscarriage. – Ren Shen, Bai Zhu and Shan Yao tonify the Spleen. – Shu Di Huang, Shan Zhu Yu, Du Zhong and Gou Qi Zi tonify the Kidneys and consolidate the Directing and Penetrating Vessels. – Bian Dou resolves Dampness and tonifies the Spleen. – Zhi Gan Cao harmonizes. f. Prescription
– YU YIN TANG Variation – Generating Yin Decoction Variation Explanation This formula is used if there is a deficiency of both Kidney-Yin and KidneyYang. – Shu Di Huang and Shan Zhu Yu nourish Liver and Kidneys.
– Xu Duan and Du Zhong tonify Kidney-Yang and calm the fetus. – Sang Ji Sheng and E Jiao nourish Blood and calm the fetus. – Mu Li, Long Gu and Bai Shao nourish Blood and Yin and absorb fluids, which helps to prevent miscarriage. – Zhi Mu and Di Gu Pi nourish Yin and clear Empty-Heat. – Gui Ban nourishes Kidney-Yin and consolidates the Directing and Penetrating Vessels. Women’s Treasure remedy
– PLANTING SEEDS This remedy tonifies and raises Qi, nourishes Blood, tonifies KidneyYang and calms the fetus. It can be used for threatened miscarriage in the presence of the above patterns. The tongue presentation appropriate to this remedy is a Pale body. Summary Kidney deficiency
Clinical manifestations
Threatened miscarriage early in the pregnancy, lumbar soreness, scanty vaginal bleeding, dizziness, exhaustion, frequent urination. Tongue: Pale if there is Kidney-Yang deficiency; without coating in a case of Kidney-Yin deficiency; without coating and Red if there is Empty-Heat. Pulse: Deep and Weak in a case of Kidney-Yang deficiency; Floating-Empty in a case of
Kidney-Yin deficiency. Treatment principle
Tonify the Kidneys (Yang or Yin), strengthen the Governing, Directing and Penetrating Vessels, calm the fetus. Acupuncture
BL-20 Pishu, BL-23 Shenshu, Du-20 Baihui, Ren-12 Zhongwan (if within 3 months), ST-36 Zusanli, KI-3 Taixi, Qimen (extra point). All with reinforcing method: moxa is applicable in Kidney-Yang deficiency. Herbal treatment
Pre scriptions
• SHOU TAI WAN Fetus Longevity Pill • TAI SHAN PAN SHI SAN Huge Rock from Mount Taishan Powder • AN TAI YIN Calming the Fetus Decoction • SHENG YU TANG Variation Sage-like Healing Decoction Variation • AN DIAN ER TIAN TANG Calming and Settling the Two Heavens Decoction • YU YIN TANG Variation Generating Yin Decoction Variation Women’s Treasure remedy
• PLANTING SEEDS
Qi and Blood deficiency
Clinical manifestations Threatened miscarriage towards the end of 3 months, scanty vaginal bleeding with blood that is pale and dilute, tiredness, weariness, palpitations, pale complexion. Tongue: Pale. Pulse: Fine, Weak or Empty. Treatment principle Tonify and raise Qi, nourish Blood, consolidate the Directing and Penetrating Vessels, calm the fetus. Acupuncture ST-36 Zusanli, Ren-12 Zhongwan (if within 3 months), BL-20 Pishu, BL-17 Geshu, BL-18 Ganshu, BL-23 Shenshu, LIV-8 Ququan. All with reinforcing method; moxa is applicable. Explanation
– ST-36 and Ren-12 tonify Qi. – BL-20 and BL-23 tonify Qi and Blood. – BL-17 (with moxa cones) tonifies Blood. – BL-18, with BL-17, nourishes Liver-Blood. – LIV-8 nourishes Liver-Blood.
Herbal treatment
a. Prescription
– JU YUAN JIAN – Raising the Original [Qi] Decoction Explanation
– Ren Shen, Huang Qi, Bai Zhu and Zhi Gan Cao tonify Qi. – Sheng Ma, in combination with Huang Qi, raises Qi and therefore prevents the downward movement of the fetus. b. Prescription
– TAI YUAN YIN Variation – Fetus Original Qi Decoction Variation Explanation
– Ren Shen, Bai Zhu and Huang Qi tonify and raise Qi to prevent downward movement of the fetus. Bai Zhu also calms the fetus. – Shu Di Huang, Bai Shao and E Jiao nourish Blood. E Jiao also calms the
fetus. – Chen Pi resolves Dampness to balance the Qi tonics. – Du Zhong tonifies the Kidneys and calms the fetus. – Zhi Gan Cao harmonizes. – Dang Gui has been removed from this particular formula because of its Blood-invigorating effect which is undesirable in pregnancy, although it is often present in other prescriptions. c. Prescription
– BAO TAI AN – Protecting the Fetus’s Peace Explanation This formula tonifies Qi and Blood and calms the fetus. – Dang Shen, Huang Qi, Bai Zhu and Zhi Gan Cao tonify and raise Qi. Bai Zhu also calms the fetus. – Shu Di Huang, Dang Gui and Bai Shao nourish Blood. – Chuan Xiong invigorates Blood. – Ai Ye warms the Uterus, stops bleeding and calms the fetus. d. Prescription
– YI QI YANG XUE TANG – Benefiting Qi and Nourishing Blood Decoction Explanation
– Ren Shen, Huang Qi, Shan Yao and Bai Zhu tonify and raise Qi. – Sheng Ma, in combination with Huang Qi, raises Qi. – Du Zhong and Xu Duan tonify Kidney-Yang, consolidate the Directing and Governing Vessels and calm the fetus. – Sang Ji Sheng, Shu Di Huang and Dang Gui nourish Blood and calm the fetus. – Ai Ye calms the fetus. – Gan Cao harmonizes. Modifications One would need to add some Blood tonics to the above prescriptions, such as Shou Wu Radix Polygoni multiflori preparata and E Jiao Colla Corii asini (if not already in the formula). The latter is particularly applicable as it also stops miscarriage. • If the vaginal bleeding is profuse, add Ai Ye Folium Artemisiae argyi and Xian He Cao Herba Agrimoniae. • If the abdominal pain is pronounced, add Bai Shao Radix Paeoniae alba and Gan Cao Radix Glycyrrhizae.
• If the woman is very worried and this is affecting the Liver and Spleen, add Chai Hu Radix Bupleuri and Chen Pi Pericarpium Citri reticulatae. • If there is morning sickness and vomiting, add Sheng Jiang Rhizoma Zingiberis recens and Zhu Ru Caulis Bambusae in Taeniam. • If there is poor appetite and loose stools and the tongue has a sticky coating, add Sha Ren Fructus Amomi, Shan Yao Rhizoma Dioscoreae and Fu Ling Poria. e. Prescription
– EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai7 Explanation
– Jing Jie and Qiang Huo raise the fetus. – Chuan Bei Mu facilitates natural labour. – Dang Gui, Chuan Xiong and Bai Shao nourish and harmonize Blood. – Zhi Ke and Hou Po regulate Qi and open the chest. The freeing of Qi in the chest facilitates the raising of Qi. – Ai Ye warms the Uterus. – Huang Qi and Gan Cao tonify and raise Qi. – Sheng Jiang warms the Centre and restores the normal direction of flow of Qi.
– Tu Si Zi tonifies the Kidneys and consolidates the fetus. Summary Qi and Blood deficiency
Clinical manife stations
Threatened miscarriage towards the end of 3 months, scanty vaginal bleeding with blood that is pale and dilute, tiredness, weariness, palpitations, pale complexion. Tongue: Pale. Pulse: Fine, Weak or Empty. Tre atme nt principle
Tonify and raise Qi, nourish Blood, consolidate the Directing and Penetrating Vessels, calm the fetus. Acupuncture
ST-36 Zusanli, Ren-12 Zhongwan (if within three months), BL-20 Pishu, BL-17 Geshu, BL-18 Ganshu, BL-23 Shenshu, LIV-8 Ququan. All with reinforcing method; moxa is applicable. He rbal tre atme nt
Prescriptions
• JU YUAN JIAN Raising the Original [Qi] Decoction • TAI YUAN YIN Variation Fetus Original Qi Decoction Variation • BAO TAI AN Protecting the Fetus’s Peace • YI QI YANG XUE TANG Benefiting Qi and Nourishing Blood Decoction • EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai
Blood-Heat
Clinical manifestations Threatened miscarriage early in the term, scanty vaginal bleeding that is bright red, feeling of heat, thirst, mental restlessness, insomnia, dark urine. Tongue: Red with yellow coating. Pulse: Rapid, Overflowing. Treatment principle Clear Heat, cool Blood, calm the fetus. Acupuncture LIV-2 Xingjian, L.I.-11 Quchi, SP-10 Xuehai, BL-17 Geshu, SP-1 Yinbai, KI-2 Rangu, LIV-3 Taichong. All with reducing or even method; no moxa. Explanation
– LIV-2 clears Liver-Fire which is often the cause of Blood-Heat. – L.I.-11 and SP-10 cool Blood. – BL-17 cools Blood. – SP-1 cools Blood and stops uterine bleeding. – KI-2 and LIV-3, in combination, cool Blood. Herbal treatment
a. Prescription
– BAO YIN JIAN – Protecting Yin Decoction Explanation This formula, already explained, cools Blood, nourishes Yin and strengthens the Kidneys. It is well suited to treat threatened miscarriage as it contains Xu Duan and Huang Qin which calm the fetus. Modifications
• To increase the fetus-calming effect, one usually needs to add Sang Ji Sheng Herba Taxilli and Du Zhong Cortex Eucommiae. • If there is soreness of the back, add Sang Ji Sheng Herba Taxilli and Tu Si Zi Semen Cuscutae. • If there is constipation, add Xuan Shen Radix Scrophulariae. • If the vaginal bleeding is profuse, add Bai Mao Gen Rhizoma Imperatae, Han Lian Cao Herba Ecliptae and Qian Cao Gen Radix Rubiae. b. Prescription
– LI QI XIE HUO TANG – Freeing Qi and Clearing Fire Decoction Explanation This formula is from Fu Qing Zhu’s Gynaecology. He recommends it for threatened miscarriage caused by Liver-Fire deriving from anger. He says: The Liver stores Blood, anger prevents it from storing [Blood]. Although the Liver pertains to Wood, within Wood there is a dragonthunder Fire which is the Minister Fire. The Minister Fire should be quiet and not agitated: if it is quiet, there is tranquillity, if it is agitated, it burns. Because Wood has such Fire within it, it is easily agitated and seldom quiet. In people’s lives not a day goes by that this Fire is not stirred. Violent anger stirs this Fire even more … This Fire cannot generate Qi and nourish the fetus, on the contrary it eats Qi and injures the Essence; when the Essence is injured the fetus cannot grow and this may cause miscarriage.8 – Ren Shen and Bai Zhu tonify Qi and prevent miscarriage. – Gan Cao harmonizes. – Shu Di Huang, Dang Gui and Bai Shao nourish Blood and pacify the Liver. – Qian Shi is astringent and prevents miscarriage. – Huang Qin clears Heat and prevents miscarriage. c. Prescription
– EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan9 Explanation
– Huang Qin and Di Yu clear Heat, cool Blood, stop bleeding and calm the fetus. – Tian Hua Fen nourishes Yin. – Xu Duan consolidates the Uterus and prevents miscarriage. – Chen Pi, Zhi Ke, Qing Pi and Xiang Fu move Qi and eliminate stagnation. – Bai Shao, Dang Gui, Shu Di Huang and Chuan Xiong form the Si Wu Tang Four Substances Decoction which nourishes and invigorates Blood. – Cang Zhu and Cao Guo resolve Dampness. – Ai Ye warms the Uterus and prevents miscarriage. – Mu Li is absorbent and helps to prevent miscarriage. – Gan Cao harmonizes. Although this formula is primarily for threatened miscarriage from Blood-Heat, it has a complex action as it also consolidates the Uterus, resolves Dampness, moves Qi and nourishes Blood. d. Prescription
– QING RE YANG YIN TANG
– Clearing Heat and Nourishing Yin Decoction Explanation This formula is used if there is Kidney-Yin deficiency. – Sheng Di Huang, Huang Qin, Di Gu Pi, Zhi Mu, Mai Men Dong and Bai Shao nourish Yin and clear Empty-Heat. – Du Zhong and Xu Duan strengthen the Uterus, consolidate the Directing and Penetrating Vessels and calm the fetus. – E Jiao and Sang Ji Sheng nourish Blood and calm the fetus. Summary Blood-Heat
Clinical manife stations
Threatened miscarriage early in the term, scanty vaginal bleeding that is bright red, feeling of heat, thirst, mental restlessness, insomnia, dark urine. Tongue: Red with yellow coating. Pulse: Rapid, Overflowing. Tre atme nt principle
Clear Heat, cool Blood, calm the fetus. Acupuncture
LIV-2 Xingjian, L.I.-11 Quchi, SP-10 Xuehai, BL-17 Geshu, SP-1 Yinbai, KI-2 Rangu, LIV-3 Taichong. All with reducing or even method; no moxa. He rbal tre atme nt
Prescriptions
• BAO YIN JIAN Protecting Yin Decoction • LI QI XIE HUO TANG Freeing Qi and Clearing Fire Decoction • EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan • QING RE YANG YIN TANG Clearing Heat and Nourishing Yin Decoction
Falls, traumas
Clinical manifestations Threatened miscarriage following a fall or a trauma, abdominal pain, scanty vaginal bleeding. Tongue: normal. Pulse: normal. Treatment principle Tonify Qi, harmonize Blood, consolidate the Directing and Penetrating Vessels, calm the fetus. Acupuncture Du-20 Baihui, Ren-12 Zhongwan, P-6 Neiguan, SP-10 Xuehai, KI-6 Zhaohai on the right and LU-7 Lieque on the left, Du-3 Yaoyangguan. Du-20 and Ren-12 should be needled with reinforcing method and the others with even method. With acupuncture, the treatment is essentially on the one hand to tonify and raise Qi (with Du-20 and Ren-12) as a fall may cause sinking of Qi in a pregnant woman, and on the other hand to invigorate Blood as traumas often cause Blood stasis. Explanation
– Du-20 and Ren-12 tonify and raise Qi to prevent the downward movement of the fetus. – P-6 and SP-10 invigorate Blood (as Blood stasis often results from
traumas). – KI-6 (on the right) and LU-7 (on the left) regulate the Yin Stepping Vessel which eliminates stagnation in the abdomen and harmonizes left and right. Harmonization of the left and right sides of the body eliminates the stagnation deriving from a trauma as an accident to one side of the body creates an imbalance between left and right. – Du-3 tonifies the Governing Vessel: this is used if the trauma has affected the spine (such as in a fall). Herbal treatment
a. Prescription
– SHENG YU TANG – Sage-like Healing Decoction Explanation
– Ren Shen and Huang Qi tonify and raise Qi to prevent the downward movement of the fetus. – Dang Gui and Chuan Xiong (reduced dosages when compared with the original prescription) nourish and invigorate Blood. – Shu Di Huang tonifies the Kidneys. – Bai Shao nourishes Blood.
Modifications
• If the abdominal pain is not severe, remove Chuan Xiong and add Zhi Gan Cao Radix Glycyrrhizae preparata. • If bleeding is profuse, remove Dang Gui and Chuan Xiong and add Ai Ye Folium Artemisiae argyi, Bai Mao Gen Rhizoma Imperatae and Xiao Ji Herba Cephalanoplos segeti. • If there is severe lower abdominal pain and the tongue is Purple, add Pu Huang Pollen Typhae, Wu Ling Zhi Faeces Trogopteri and San Qi Radix Notoginseng. b. Prescription
– LI QI SAN YU TANG – Regulating Qi and Eliminating Stasis Decoction Explanation
– Ren Shen and Huang Qi tonify and raise Qi to prevent miscarriage. – Dang Gui nourishes and invigorates Blood. – Fu Ling resolves Dampness. – Hong Hua and Mu Dan Pi invigorate Blood and eliminate stasis. – Jiang Tan (charred ginger) stops bleeding.
If there is severe abdominal pain and profuse vaginal bleeding with passage of clots and tissue, it indicates that miscarriage is already taking place and the woman should be referred to hospital for curettage and termination. In the time before the woman is admitted to hospital, the expulsion of the fetus can be facilitated by using a variation of the formula Sheng Hua Tang. c. Prescription
– SHENG HUA TANG Variation – Generating and Transforming Decoction Variation Explanation The original formula Sheng Hua Tang is specific to promote the expulsion of retained lochiae after childbirth. It is therefore suitable to promote the discharge of any remaining products of conception during a spontaneous abortion. – Dang Gui nourishes and invigorates Blood. – Chuan Xiong, Tao Ren and Hong Hua invigorate Blood and eliminate stasis. – Gan Jiang warms the channels and aids the Blood-invigorating herbs to eliminate stasis. – Zhi Gan Cao harmonizes. – Chuan Niu Xi invigorates Blood and directs the herbs to the Lower Burner.
– Che Qian Zi clears obstructions of the Lower Burner by urination. Modifications
• In a case of miscarriage when there is always the danger of profuse bleeding, it is wise to add herbs which invigorate Blood and stop bleeding simultaneously such as Qian Cao Gen Radix Rubiae and San Qi Radix Notoginseng. If necessary, and if bleeding is profuse, one can also give the powder Yun Nan Bai Yao. • Acupuncture can also be used to stimulate the expulsion of the products of conception with the following points: • L.I.-4 Hegu, LIV-3 Taichong, SP-6 Sanyinjiao, BL-67 Zhiyin and BL-54 Zhibian, all with reducing method and possibly electrical stimulation. Summary Falls, traumas
Clinical manife stations
Threatened miscarriage following a fall or a trauma, abdominal pain, scanty vaginal bleeding. Tongue: normal. Pulse: normal. Tre atme nt principle
Tonify Qi, harmonize Blood, consolidate the Directing and Penetrating Vessels, calm the fetus. Acupuncture
Du-20 Baihui, Ren-12 Zhongwan, P-6 Neiguan, SP-10 Xuehai, KI-6
Zhaohai (on the right) and LU-7 Lieque (on the left), Du-3 Yaoyangguan. Du-20 and Ren-12 should be needled with reinforcing method and the others with even method. He rbal tre atme nt
Prescriptions
• SHENG YU TANG Sage-like Healing Decoction • LI QI SAN YU TANG Regulating Qi and Eliminating Stasis Decoction • SHENG HUA TANG Variation Generating and Transforming Decoction Variation
Ancient acupuncture prescriptions for threatened miscarriage 10
1. KI-10 Yingu for threatened miscarriage with vaginal bleeding, abdominal distension and fullness, inability to lie down and dark urine (ABC of Acupuncture, Zhen Jiu Jia Yi Jing, AD 259). 2. The point 1 cun below the patella with moxa cones; or ST-28 Shuidao and Ren-4 Guanyuan with moxa cones (Thousand Golden Ducat Prescriptions, Qian Jin Yao Fang, AD 652). Please note that according to modern views, all points below the umbilicus are forbidden in pregnancy. 3. Ren-5 Shimen for threatened miscarriage with rebellious Qi (Prescriptions for Universal Relief, Pu Ji Fang, 15th century).
Prognosis and prevention The prognosis in threatened miscarriage depends entirely on the stage the process has reached (see below). If the miscarriage is just threatened, the os of the cervix is not dilated, there is no abdominal pain, the fetus is detected on the ultrasound scan and its heart can be detected with the Doppler test, then the prognosis is good. Half of the miscarriages are due to a chromosomal or structural deformity of the fetus and, in such cases, no treatment will be able to arrest a miscarriage. As we would not know this in the beginning stages, the sensible approach is to treat a woman in these situations irrespective of the cause: if the miscarriage is threatened because of an abnormality of the fetus, it will necessarily occur; if not, there is at least a chance of stopping it. On the other hand, the woman need not fear that acupuncture or Chinese herbs may help to carry the pregnancy to term even if there is an abnormality of the fetus, as this is not the case. From a Chinese perspective, the back soreness and abdominal pain are reliable prognostic indicators. Ever since early times the severity of the back soreness has been related to prognosis of threatened miscarriage. The Complete Works of Jing Yue (1624) says: In women the Kidneys are in relation with the Uterus and the Kidneys also control the back. If there is severe backache in pregnancy it indicates imminent miscarriage which cannot be prevented.11 In fact, there is a strong relationship between the severity of sacral pain and abdominal pain and the prognosis in threatened miscarriage: the stronger the sacral and/or abdominal pain, the worse the prognosis. Thus, when treating a woman for threatened miscarriage with abdominal and/or sacral soreness, a decrease in these two pains indicates that a miscarriage can be averted.
Western view The possible causes of spontaneous abortions are discussed in Chapter 43 on habitual miscarriage. Abortion can be classified as threatened, inevitable, incomplete, complete or missed. Threatened abortion In threatened abortion, the cervix is closed and there is only a small amount of vaginal bleeding. The uterine size is that expected for the gestational age and, if the pregnancy is at least 10 weeks old, the fetal heart may be detected with a Doppler monitor. An ultrasound scan will reveal an amniotic sac and fetus and the fetal heart can be seen pulsating if the pregnancy is at least 7 weeks old. Repeated scanning can monitor the growth of the fetus from about 8 mm at the sixth week to about 90 mm in the fourteenth week. The treatment consists only of rest and sometimes the administration of smoothmuscle relaxants. The clinical distinction between threatened abortion and inevitable abortion is based on the undilated os of the cervix, the absence of abdominal pain and the slight degree of bleeding. If the bleeding increases progressively, the prognosis is bad. Inevitable abortion If abortion has become inevitable, the cervix is open, the vaginal bleeding is more profuse and there is abdominal pain caused by rhythmical uterine contractions. At this stage, the pregnancy cannot continue and the abortion will be either incomplete or complete. Incomplete abortion
In an incomplete abortion, the fetus and amniotic fluids are discharged but parts of the placental and chorionic tissue are retained. At this stage, there will also be severe abdominal pain and very profuse bleeding with passing of large clots or tissue. The os of the cervix is open, the fetal heart cannot be detected with a Doppler monitor and an ultrasound scan will reveal no fetus. The treatment consists in suction curettage under anaesthesia to evacuate the retained products of conception. During incomplete abortion there is a danger of shock from excessive blood loss and sepsis. Complete abortion If complete abortion takes place spontaneously, a woman will have gone through all the stages described above, after which the bleeding stops completely and the abdominal pain ceases entirely. On examination, the uterus is smaller than the expected size for the stage of pregnancy and the os of the cervix is closed. There are no fetal heart sounds audible with a Doppler monitor and an ultrasound scan shows an empty uterus. In such a case, the woman may not require hospitalization. Missed abortion Missed abortion consists in retention of a fetus for several weeks after its death. Death of the fetus occurs unnoticed or after vaginal bleeding, as in threatened abortion, which then ceases. Pregnancy testing will be negative about a week after death of the fetus and ultrasound scan confirms the diagnosis. End notes 1. Shen Jin Ao 1774 The Jade Ruler of Gynaecology (Fu Ke Yu Chi), cited in Luo Yuan Kai 1979 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Nanjing College of Traditional Chinese Medicine, Nanjing, p. 84..
2. Foundations of Medicine 1575 (Yi Xue Ru Men), cited in Luo Yuan Kai 1986 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Shanghai Science and Technology Press, Shanghai, p. 132..
3. Shen Jin Ao 1774 The Jade Ruler of Gynaecology, cited in 1979 Gynaecology in Chinese Medicine, p. 84..
4. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian
), People’s Health Publishing House, Beijing, Vol. 3, p. 61. First published in 1742..
5. Cong Chun Yu 1989 Chinese Medicine Gynaecology (Zhong Yi Fu Ke Xue
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 135..
6. Golden Mirror of Medicine, pp 59–60..
7. Long Jiajun, Zhang Qi, Shen Kang, Lin Hongyang 1996 Dr Zhang Jian Zhai’s Experience in Treating Gynaecological Diseases (Zhang Jian Zhai Zhi Liao Fu Ke Bing Jing Yan) in Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi
), China Academy of Traditional Chinese Medicine, Beijing, No. 1, p. 17..
8. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p. 39. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
9. Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 20. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang) and published in 1729..
10. Chen You Bang 1990 Chinese Acupuncture Therapy (Zhong Guo Zhen Jiu Zhi Liao Xue
), China Scientific Publishing House, Beijing, p. 904..
11. Zhang Jing Yue 1986 The Complete Works of Jing Yue (Jing Yue Quan Shu
), Shanghai Science and Technology Press, Shanghai, p. 652. First published in 1624..
CHAPTER 32 Fetus not Growing
AETIOLOGY AND PATHOLOGY 491 IDENTIFICATION OF PATTERNS AND TREATMENT 491 Qi and Blood deficiency 491 Spleen- and Kidney-Yang deficiency 492 PROGNOSIS AND PREVENTION 493 WESTERN VIEW 493 In ancient times, Chinese doctors would have diagnosed the condition ‘Fetus not Growing’ entirely from the size of the pregnant woman’s abdomen which is, of course, a very unreliable indicator of fetal growth. In modern medicine, this condition is diagnosed on the basis of ultrasound scans (see the end of this chapter).
Aetiology and pathology The only cause of slow fetal growth is the mother’s deficient Blood and/or Kidneys failing to nourish the fetus properly. This deficiency may either be constitutional or derive from inadequate nourishment during pregnancy.
Identification of patterns and treatment There is essentially only one pattern in this condition and that is a deficiency of Blood and Kidneys in varying degrees. The Kidney deficiency may be of Yang or Yin.
Qi and Blood deficiency
Clinical manifestations Slow fetal growth, dizziness, blurred vision, tiredness, palpitations. Tongue: Pale and Thin. Pulse: Fine, Weak. Treatment principle Nourish Blood, tonify the Kidneys, strengthen the Directing and Penetrating Vessels. Acupuncture BL-20 Pishu, BL-23 Shenshu, ST-36 Zusanli, LIV-8 Ququan, BL-18 Ganshu, BL-17 Geshu, Ren-12 Zhongwan. All with reinforcing method; moxa can be used if there is Kidney-Yang deficiency. Explanation
– BL-20 and BL-23 tonify Blood and strengthen the Spleen and Kidneys. – ST-36, LIV-8 and BL-18 nourish Liver-Blood. – BL-17, with moxa cones, tonifies Blood. – Ren-12 tonifies Stomach and Spleen to produce Qi and Blood. Herbal treatment
a Prescription
– BA ZHEN TANG – Eight Precious Decoction Explanation This well-known formula, already explained, tonifies Qi and Blood. b Prescription
– YU TAI JIAN ZI TANG – Giving Birth to the Fetus and Strengthening the Baby Decoction Explanation
– Tu Si Zi tonifies Kidney-Yang and the Kidney-Essence. – Dang Shen, Bai Zhu, Fu Ling and Zhi Gan Cao tonify Qi. – Shu Di Huang, Chuan Xiong, Dang Gui and Bai Shao nourish Blood. Women’s Treasure remedy
– PRECIOUS SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which tonifies Qi and nourishes Blood. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Qi and Blood deficiency
Clinical manifestations
Slow fetal growth, dizziness, blurred vision, tiredness, palpitations. Tongue: Pale and Thin. Pulse: Fine, Weak. Treatment principle
Nourish Blood, tonify the Kidneys, strengthen the Directing and Penetrating Vessels. Acupuncture
BL-20 Pishu, BL-23 Shenshu, ST-36 Zusanli, LIV-8 Ququan, BL-18 Ganshu, BL-17 Geshu, Ren-12 Zhongwan. All with reinforcing method; moxa can be used if there is Kidney-Yang deficiency. Herbal treatment
Pre scriptions
• BA ZHEN TANGEight Precious Decoction
• YU TAI JIAN ZI TANGGiving Birth to the Fetus and Strengthening the Baby Decoction Women’s Treasure remedy
• PRECIOUS SEA
Spleen- and Kidney-Yang deficiency
Clinical manifestations Fetus not growing in the fifth and sixth months, tiredness, loose stools, poor appetite, backache, dizziness, tinnitus. Tongue: Pale. Pulse: Deep, Weak. Treatment principle Tonify the Spleen and Kidneys, strengthen the Directing and Penetrating Vessels, nourish the fetus. Acupuncture BL-20 Pishu, BL-23 Shenshu, ST-36 Zusanli, SP-3 Taibai, KI-3 Taixi. All with reinforcing method; moxa should be applied. Explanation
– BL-20, ST-36 and SP-3 tonify the Spleen. – BL-23 and KI-3 tonify the Kidneys. Herbal treatment
a Prescription
– WEN TU YU LIN TANG – Warming the Earth and Giving Birth to the Unicorn Decoction Explanation
– Ba Ji Tian and Fu Pen Zi tonify Kidney-Yang. – Bai Zhu, Ren Shen and Shan Yao tonify Spleen-Qi. – Shen Qu harmonizes the Stomach. b Prescription
– BU PI AN TAI YIN – Tonifying the Spleen and Calming the Fetus Decoction Explanation
– Huang Qi, Dang Shen, Bai Zhu and Fu Shen tonify Spleen-Qi. – Dang Gui nourishes Blood. – Tu Si Zi and Shan Zhu Yu tonify the Liver and Kidneys and the KidneyEssence. – Suan Zao Ren calms the Mind and is astringent which helps to prevent miscarriages. – Shen Qu helps digestion.
– Sheng Jiang and Da Zao harmonize. Three Treasures remedy
– STRENGTHEN THE ROOT This remedy is a variation of You Gui Wan Restoring the Right [Kidney] Pill and it tonifies Kidney-Yang and Spleen-Qi, nourishes Blood, warms the Uterus and strengthens the Governing, Directing and Penetrating Vessels. The tongue presentation appropriate to this remedy is a Pale, Swollen and wet body. Women’s Treasure remedy
– UNICORN PEARL This remedy tonifies Kidney-Yang and nourishes the Kidney-Essence. The tongue presentation appropriate to this remedy is a Pale and wet body. Summary Spleen- and Kidney-Yang deficiency
Clinical manifestations
Fetus not growing in the fifth and sixth months, tiredness, loose stools, poor appetite, backache, dizziness, tinnitus. Tongue: Pale. Pulse: Deep, Weak. Treatment principle
Tonify the Spleen and Kidneys, strengthen the Directing and Penetrating Vessels, nourish the fetus. Acupuncture
BL-20 Pishu, BL-23 Shenshu, ST-36 Zusanli, SP-3 Taibai, KI-3 Taixi. All with reinforcing method; moxa should be applied. Herbal treatment
Pre scriptions
• WEN TU YU LIN TANGWarming the Earth and Giving Birth to the Unicorn Decoction • BU PI AN TAI YINTonifying the Spleen and Calming the Fetus Decoction Three Treasures remedy
• STRENGTHEN THE ROOT Women’s Treasure remedy
• UNICORN PEARL
Prognosis and prevention Chinese medicine can be of help in the treatment of slow fetal growth, especially considering that Western medicine has no treatment to offer. A pregnant woman experiencing this problem should make absolutely sure that she has a diet rich in Blood-producing foods, especially meat products. As mentioned before, Chinese medicine maintains that meat products specifically nourish the Governing, Directing and Penetrating Vessels. Unless there are very strong ethical objections, if the prospective mother is vegetarian, she should be advised to take some meat for a limited period, considering it as a medicine. If she has aversion to eating meat, drinking chicken broth would be a good compromise. Ideally, the broth should be made from a hen and using the whole chicken, i.e. including head and feet. This should be mixed with vegetables such as onions, carrots, scallions and celery. Chinese herbs such as Huang Qi Radix Astragali, Dang Gui Radix Angelicae sinensis and Ren Shen Radix Ginseng can be added. She should also absolutely avoid overworking and take plenty of rest.
Western view Fetal growth may be measured according to uterus or fetus size. When measuring uterus size, one normally measures the distance between the symphysis pubis and the fundus of the uterus: the fundal height should increase by about 1 cm per week from the sixteenth week onwards. With an average-sized fetus, the distance between the symphysis pubis and the fundus of the uterus (fundal height) should equal in centimetres the number of weeks of pregnancy, give or take 2 cm. For example, at the twenty-fourth week of pregnancy, the fundal height should be between 22 and 26 cm. The above measurement can be distorted by several factors such as obesity, abdominal tenseness and the lie of the baby. A much more accurate measurement of fetal growth is provided by ultrasound scans, usually based on the measurement of the fetus’s abdominal circumference at liver height, biparietal diameter, cranial circumference and femoral length. Factors which may affect fetal growth include hypertension, diabetes, multiple pregnancy, previous growth-retarded baby and previous perinatal death.
CHAPTER 33 Oedema During Pregnancy
AETIOLOGY 495 PATHOLOGY 495 IDENTIFICATION OF PATTERNS AND TREATMENT 495 Spleen-Yang deficiency 496 Kidney-Yang deficiency 497 Stagnation of Qi 498 PROGNOSIS AND PREVENTION 499 WESTERN VIEW 499 In Chinese medicine, oedema in pregnancy was given different names according to its location. Zi zhong (
), meaning ‘oedema of pregnancy’, indicated oedema of the face and whole body together with
scanty urination. Zi man ( ), meaning ‘fullness of pregnancy’, indicated swelling of the body with abdominal distension and breathlessness. Zi Qi (
), meaning ‘Qi of pregnancy’, referred to oedema below the knees, with scanty urination, and was caused
by Dampness. Zhou jiao ( ), meaning ‘wrinkled foot’, indicated oedema of the feet from Dampness. Cui
jiao ( ), meaning ‘brittle foot’, referred to oedema of the feet from overflowing of Water.
Aetiology
Irregular diet Excessive consumption of greasy and dairy foods injures the Spleen-Yang: deficient Spleen-Yang fails to transform and transport fluids which accumulate under the skin in the form of oedema. Excessive physical work, exercise or lifting Excessive physical work and especially lifting may weaken Kidney-Yang: deficient Kidney-Yang fails to transform and excrete fluids which may accumulate under the skin and cause oedema. Emotional stress Worry, anger, frustration and resentment may all lead to stagnation of Qi: stagnant Qi fails to transform and transport Water which may accumulate in the form of oedema. This pathological process is aggravated after the fifth month of pregnancy when the fetus grows rapidly and it obstructs Qi.
Pathology The pathology of oedema of pregnancy can be differentiated into two basic types, one from deficiency, the other from excess; the former deficiency of Spleen- and/or Kidney-Yang and the latter stagnation of Qi. The oedema from Spleen- or Kidney-Yang deficiency is characterized by the accumulation of Water under the skin, while that from stagnation of Qi is characterized by the accumulation of Dampness under the skin. The main diagnostic difference is that in the former case there is pitting of the skin on pressure, while in the latter there is not.
Identification of patterns and treatment The main treatment principle is to tonify Spleen- and Kidney-Yang or move Qi and eliminate stagnation to treat the Root; to treat the Manifestation one needs to promote the transformation and excretion of fluids with diuretic herbs. Particular care should be taken with herbs that transform fluids in pregnancy: these should be used in small doses. In most cases, it might be advisable to include Kidney tonics that calm the fetus (such as Xu Duan Radix Dipsaci or Tu Si Zi Semen Cuscutae) to counterbalance the downward-draining effect of diuretic herbs. The patterns discussed are: • Spleen-Yang deficiency • Kidney-Yang deficiency • stagnation of Qi. It should be remembered that the acupuncture points in the upper abdomen (above the umbilicus) can be used only in the first 3 months of pregnancy.
Spleen-Yang deficiency
Clinical manifestations Oedema early in the pregnancy, swelling of face or whole body, yellowish and shiny skin, a feeling of oppression of the chest, breathlessness, tiredness, loose stools, cold limbs. Tongue: Pale, wet. Pulse: Weak. Treatment principle Strengthen the Spleen, tonify Yang, resolve oedema. Acupuncture BL-20 Pishu, Ren-12 Zhongwan, Ren-9 Shuifen, Ren-11 Jianli, ST-20 Chengman, ST-36 Zusanli, SP-3 Taibai, KI-7 Fuliu, BL-22 Sanjiaoshu. KI7, Ren-9, Ren-11, ST-20 and BL-22 should be needled with even method and the others with reinforcing method. Moxa is applicable. The abdominal points should not be used from the beginning of the second trimester of pregnancy onwards. Explanation
– BL-20, Ren-12, ST-36 and SP-3 tonify the Spleen. – KI-7 resolves oedema. – Ren-9, Ren-11 and ST-20, in combination, resolve oedema. – BL-22, Back-Transporting point of the Lower Burner, promotes the
transformation and excretion of fluids in the Lower Burner. Herbal treatment
a Prescription
– BAI ZHU SAN (from Quan Sheng Zhi Mi Fang) – Atractylodes Powder Explanation
– Bai Zhu tonifies the Spleen and dries Dampness. It also calms the fetus. – Fu Ling Pi, Chen Pi and Da Fu Pi drain Dampness and resolve oedema. – Sheng Jiang Pi harmonizes and resolves oedema. Modifications
• If oedema is severe and urination is scanty, add Ze Xie Rhizoma Alismatis. • If there is breathlessness and a feeling of oppression of the chest, add Xing Ren Semen Armeniacae and Hou Po Cortex Magnoliae officinalis. • If Dampness stagnates in the channels and causes stasis of Blood, add Dan Shen Radix Salviae miltiorrhizae.
• If there are pronounced symptoms of Yang deficiency, add Gui Zhi Ramulus Cinnamomi and Gan Jiang Rhizoma Zingiberis. • If there is poor appetite and loose stools, add Shan Yao Rhizoma Dioscoreae and Bian Dou Semen Lablab album. • If there is also Kidney-Yang deficiency, add Ba Ji Tian Radix Morindae officinalis. • If the abdomen is very distended with oedema and there is pronounced breathlessness with inability to lie down, this corresponds to the disease category of zi man (outlined above). In such a case, tonify the Spleen, resolve oedema, nourish Blood and calm the fetus, using the following formula. b Prescription
– LI YU TANG – Carp Decoction Explanation
– Carp tonifies the Spleen and resolves oedema. – Bai Zhu and Fu Ling tonify the Spleen and dry Dampness. – Dang Gui and Bai Shao nourish Blood. – Sheng Jiang harmonizes. c Prescription
– FU LING DAO SHUI TANG – Poria Conducting Water Decoction Explanation This formula, from the Golden Mirror of Medicine (1742), is for oedema in pregnancy from Spleen-Qi deficiency, Dampness and Lung-Qi not descending.1 – Bai Zhu tonifies Spleen-Qi. – Fu Ling, Zhu Ling, Ze Xie and Chen Pi resolve Dampness. – Mu Xiang, Bing Lang, Da Fu Pi and Sha Ren move Qi. – Sang Bai Pi and Zi Su Ye stimulate the descending of Lung-Qi. – Mu Gua resolves Wind-Dampness. Its sour taste also counterbalances the diuretic effect of all the herbs that resolve Dampness. d Prescription
– JIA JIAN BU ZHONG YI QI TANG – Modified Tonifying the Centre and Benefiting Qi Decoction Explanation This formula is recommended by Fu Qing Zhu for oedema in pregnancy from
Lung- and Spleen-Qi deficiency.2 – Ren Shen tonifies Qi and the Original Qi. – Huang Qi and Bai Zhu tonify Lung and Spleen-Qi, transform Water and dry Dampness. – Chai Hu and Sheng Ma raise the clear Qi: by doing so, they create the space below for impure fluids to be drained downwards. – Dang Gui nourishes Blood. – Fu Ling and Chen Pi resolve Dampness and oedema. – Gan Cao harmonizes. Summary Spleen-Yang deficiency
Clinical manife stations
Oedema early in the pregnancy, swelling of face or whole body, yellowish and shiny skin, a feeling of oppression of the chest, breathlessness, tiredness, loose stools, cold limbs. Tongue: Pale, wet. Pulse: Weak. Tre atme nt principle
Strengthen the Spleen, tonify Yang, resolve oedema. Acupuncture
BL-20 Pishu, Ren-12 Zhongwan, Ren-9 Shuifen, Ren-11 Jianli, ST-20 Chengman, ST-36 Zusanli, SP-3 Taibai, KI-7 Fuliu, BL-22 Sanjiaoshu. KI7, Ren-9, Ren-11, ST-20 and BL-22 should be needled with even method
and the others with reinforcing method. Moxa is applicable. The abdominal points should not be used from the beginning of the second trimester of pregnancy onwards. He rbal tre atme nt
Prescriptions
• BAI ZHU SAN (from Quan Sheng Zhi Mi Fang) Atractylodes Powder • LI YU TANGCarp Decoction • FU LING DAO SHUI TANGPoria Conducting Water Decoction • JIA JIAN BU ZHONG YI QI TANGModified Tonifying the Centre and Benefiting Qi Decoction
Kidney-Yang deficiency
Clinical manifestations Oedema early in the pregnancy, worse in the ankles, breathlessness, cold legs, backache. Tongue: Pale and wet. Pulse: Weak, Deep. Treatment principle Strengthen the Kidneys, tonify Yang, resolve Oedema. Acupuncture BL-23 Shenshu, Du-4 Mingmen, KI-7 Fuliu, KI-3 Taixi, ST-36 Zusanli, Ren-9 Shuifen, Ren-11 Jianli, ST-20 Chengman, BL-22 Sanjiaoshu. Ren-9, Ren-11, ST-20 and KI-7 with even method; the others with reinforcing method. Moxa is applicable. Explanation
– BL-23 tonifies Kidney-Yang. – Du-4, with direct moxa cones, strongly tonifies the Fire of the Gate of Life. This point is used only in severe cases. – KI-7, Ren-9, Ren-11 and ST-20 resolve oedema. – BL-22 promotes the transformation of fluids in the Lower Burner and resolves oedema.
– KI-3 tonifies the Kidneys. – ST-36 tonifies Qi and resolves oedema. Herbal treatment
Prescription
– ZHEN WU TANG – True Warrior Decoction Explanation
– Fu Zi strongly tonifies Yang and promotes the transformation of fluids. – Bai Zhu tonifies the Spleen and dries Dampness. – Fu Ling resolves Dampness and oedema. – Bai Shao nourishes the Yin and is in the formula to make the other herbs enter Yin and therefore move and transform fluids. – Sheng Jiang warms the Yang. Modifications The dosages indicated above are those from the original prescription. I would personally reduce them by at least a third. In particular, Fu Zi is slightly toxic and I would therefore reduce its daily dosage, especially in pregnancy,
to 2 g only, and also pre-cook it so as to reduce its toxicity further. If necessary, Fu Zi could be replaced by Gui Zhi Ramulus Cinnamomi. • If there are pronounced symptoms of Yang deficiency, add Ba Ji Tian Radix Morindae officinalis and Bu Gu Zhi Fructus Psoraleae. • If oedema is severe, add the formula Wu Pu Yin Five Skins Decoction. • If there are symptoms of Liver-Yang rising, add Tian Ma Rhizoma Gastrodiae and Gou Teng Ramulus Uncariae cum Uncis. • If there is backache, add Du Zhong Cortex Eucommiae. Summary Kidney-Yang deficiency
Clinical manife stations
Oedema early in the pregnancy, worse in the ankles, breathlessness, cold legs, backache. Tongue: Pale and wet. Pulse: Weak, Deep. Tre atme nt principle
Strengthen the Kidneys, tonify Yang, resolve Oedema. Acupuncture
BL-23 Shenshu, Du-4 Mingmen, KI-7 Fuliu, KI-3 Taixi, ST-36 Zusanli, Ren-9 Shuifen, Ren-11 Jianli, ST-20 Chengman, BL-22 Sanjiaoshu. Ren-9, Ren-11, ST-20 and KI-7 with even method; the others with reinforcing method. Moxa is applicable. He rbal tre atme nt
Prescription
• ZHEN WU TANGTrue Warrior Decoction
Stagnation of Qi
Clinical manifestations Oedema beginning towards the fourth month of pregnancy, first in the feet, no pitting, abdominal distension, irritability. Tongue: slightly Red on the sides. Pulse: Wiry. Treatment principle
– Move Qi and eliminate stagnation. Acupuncture
– T.B.-6 Zhigou, LIV-3 Taichong, LIV-14 Qimen, G.B.-34 Yanglingquan, ST-36 Zusanli, Ren-9 Shuifen, BL-22 Sanjiaoshu, BL-18 Ganshu. All with reducing method. Explanation
– T.B.-6, LIV-3, LIV-14 and G.B.-34 move Liver-Qi and eliminate stagnation. – ST-36 resolves oedema. This point can be used in any case of oedema because in this condition, the Defensive Qi is derailed from the space between skin and muscles and this space is flooded by Body Fluids: since the Stomach controls the Defensive Qi, needling ST-36 will restore the Defensive Qi into the space under the skin and drive fluids out. Chapter 35 of the
Spiritual Axis says: “Zusanli should be needled with reducing method in cases of oedema … no matter whether the condition is Full or Empty, the reducing technique is all- important.”3 – Ren-9 and BL-22 promote the transformation of fluids and resolve oedema. – BL-18 moves Liver-Qi and eliminates stagnation. Herbal treatment
Prescription
– XIAO YAO SAN and SI LING SAN – Free and Easy Wanderer Powder and Four ‘Ling’ Powder Explanation The first six herbs constitute the formula Xiao Yao San (minus Bai Zhu and Fu Ling which are already in the formula Si Ling San) which moves Liver-Qi, nourishes Blood and tonifies the Spleen. – Bai Zhu tonifies the Spleen and dries Dampness. – Fu Ling, Ze Xie and Zhu Ling drain Dampness and resolve oedema. Modifications
• If there is dizziness, abdominal distension and headache, add Tian Ma
Rhizoma Gastrodiae and Long Gu Fossilia Ossis mastodi. • If stagnant Qi has turned into Fire, add Shan Zhi Zi Fructus Gardeniae and Huang Qin Radix Scutellariae. • If there are symptoms of Phlegm, add Ban Xia Rhizoma Pinelliae preparatum, Yuan Zhi Radix Polygalae and Dong Gua Ren Semen Benincasae. Summary Stagnation of Qi
Clinical manife stations
Oedema beginning towards the fourth month of pregnancy, first in the feet, no pitting, abdominal distension, irritability. Tongue: slightly Red on the sides. Pulse: Wiry. Tre atme nt principle
Move Qi and eliminate stagnation. Acupuncture
T.B.-6 Zhigou, LIV-3 Taichong, LIV-14 Qimen, G.B.-34 Yanglingquan, ST36 Zusanli, Ren-9 Shuifen, BL-22 Sanjiaoshu, BL-18 Ganshu. All with reducing method. He rbal tre atme nt
Prescription
• XIAO YAO SAN and SI LING SANFree and Easy Wanderer Powder and Four ‘Ling’ Powder
Prognosis and prevention Oedema during pregnancy can be alleviated but it cannot be resolved completely, because the longer the pregnancy goes on, the weaker the Kidneys will become and therefore the more fluids will be retained. Also, the longer the pregnancy goes on, the greater the tendency for fluids to accumulate due to the sheer increase in the volume of fluids during pregnancy. Thus, when one is treating oedema during pregnancy, there is a force working increasingly against the treatment as the pregnancy progresses. For these reasons, although the treatment with both acupuncture and herbs can greatly alleviate the oedema, treatment should probably continue throughout the pregnancy. The pattern from Kidney-Yang deficiency is the most difficult to treat.
Western view A woman of average weight normally increases her extracellular fluid (excluding that in the fetus, placenta and amniotic fluid) by about 2500 ml during the course of her pregnancy. Oedema is not considered per se a dangerous sign in pregnancy by Western medicine unless it is accompanied by hypertension and proteinuria. Oedema of the feet may also be caused by pressure of the uterus on the pelvic veins: for this reason, oedema of the face or fingers, which cannot be explained by gravity, should alert us to the possibility of hypertension. If oedema is associated with hypertension and proteinuria, the woman should be monitored closely as this can herald a pre-eclampsia state. Preeclampsia and eclampsia will be discussed in Chapter 35 on dizziness in pregnancy and Chapter 36 on convulsions in pregnancy. End notes 1. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian
), People’s Health Publishing House, Beijing, Vol. 3, p. 55. First published in 1742..
2. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p. 31. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
3. Spiritual Axis 1981 (Ling Shu Jing
), People’s Health Publishing House, Beijing, p. 75. First published c. 100 BC..
CHAPTER 34 Anxiety During Pregnancy
AETIOLOGY 501 PATHOLOGY 501 IDENTIFICATION OF PATTERNS AND TREATMENT 501 Heart-Blood deficiency 501 Lung- and Heart-Qi stagnation 502 Liver-Qi stagnation 503 Liver-Fire 504 Empty-Heat from Yin deficiency 505 Phlegm-Fire harassing the Mind 506 PROGNOSIS AND PREVENTION 507 Anxiety
in
pregnancy
is
called
zi
fan
(
) which literally means ‘child mental restlessness’, intending by that ‘mental restlessness of pregnancy’. There is no discussion of such a problem in Western medicine and, for this reason, there will be no Western differentiation at the end of this chapter.
Aetiology
Overwork, Yin-deficient constitution If a woman overworks during pregnancy, this will aggravate a pre-existing condition of Yin deficiency because Blood, Essence and Yin are already taxed during pregnancy to nourish the fetus. Yin deficiency leads to EmptyHeat which harasses the Heart and Mind. Emotional problems, irregular diet Emotional problems such as worry, anger, resentment and frustration often lead to stagnation of Qi: stagnant Qi, after some time, may turn into Fire which harasses the Mind. Fire may also derive from a dietary irregularity, especially the excessive consumption of hot, pungent foods. Excessive consumption of greasy and dairy foods leads to the formation of Phlegm which may combine with Fire to both harass and cloud the Mind.
Pathology The pathology of anxiety in pregnancy essentially is related only to Heat in three variations: Full-Heat, Empty-Heat and Phlegm-Heat. However, apart from the above pathogenic factors, there may be another element: Qi rebelling in the Penetrating Vessel. Pregnancy leads to a disharmony of the Penetrating Vessel very easily and many minor symptoms of pregnancy can be so explained. Because in pregnancy some Blood and Essence in the mother’s Penetrating Vessel are diverted to nourishing the fetus, there is a deficiency below in the Penetrating Vessel and a stagnation above with Qi rebelling upwards. One of the main symptoms of Qi rebelling upwards in the Penetrating Vessel is what is called li ji which may be explained in different ways (see Ch. 7). One of its meanings is a feeling of anxiety, which, on a physical level, is experienced especially in the chest and throat.
Identification of patterns and treatment
Heart-Blood deficiency
Clinical manifestations Palpitations, anxiety, dizziness, pale face, insomnia, poor memory, tiredness. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle Nourish Heart-Blood, calm the Mind. Acupuncture HE-7 Shenmen, Ren-14 Juque, ST-36 Zusanli, KI-3 Taixi. All with reinforcing method. Moxa may be used. Explanation
– HE-7 and Ren-14 nourish Heart-Blood and calm the Mind. – ST-36 and KI-3 are used to nourish Blood in general. Herbal treatment
Prescription
– GUI PI TANG Variation – Tonifying the Spleen Decoction Variation Explanation The original formula nourishes Qi and Blood of Heart, Spleen and Liver and calms the Mind. It has been modified only slightly by removing Mu Xiang Radix Aucklandiae and adding Bai Zi Ren Semen Platycladi. Three Treasures remedy
– CALM THE SHEN This remedy is a variation of Gui Pi Tang for anxiety from Heart-Blood deficiency. Summary Heart-Blood deficiency
Clinical manifestations
Palpitations, anxiety, dizziness, pale face, insomnia, poor memory, tiredness. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle
Nourish Heart-Blood, calm the Mind. Acupuncture
HE-7 Shenmen, Ren-14 Juque, ST-36 Zusanli, KI-3 Taixi. All with reinforcing method. Moxa may be used. Herbal treatment
Pre scription
• GUI PI TANG Variation Tonifying the Spleen Decoction Variation Three Treasures remedy
• CALM THE SHEN
Lung- and Heart-Qi stagnation
Clinical manifestations Palpitations, anxiety, a feeling of distension or oppression of the chest, depression, a slight feeling of a lump in the throat, slight shortness of breath, sighing, sadness, chest and upper epigastric distension, slightly purple lips, pale complexion. Tongue: normal coloured or slightly Pale Purple on the sides in the chest area. Pulse: Empty but very slightly Overflowing on both Front positions. Treatment principle Move Qi in the Heart and Lung, relax the chest, calm the Mind. Acupuncture HE-5 Tongli, HE-7 Shenmen, P-6 Neiguan, Ren-15 Jiuwei, Ren-17 Shanzhong, LU-7 Lieque, ST-40 Fenglong. Even method. Explanation
– HE-5, HE-7 and P-6 move Heart-Qi and calm the Mind. – Ren-15 and Ren-17 relax the chest and calm the Mind. – LU-7 moves Lung-Qi. – ST-40, in combination with LU-7 and P-6, relaxes the chest and calms the Mind.
Herbal treatment
Prescription
– BAN XIA HOU PO TANG – Pinellia-Magnolia Decoction Three Treasures remedy
– OPEN THE HEART This remedy is a variation of Bam Xia Hou Po Tang. Summary Lung- and Heart-Qi stagnation
Clinical manifestations
Palpitations, anxiety, a feeling of distension or oppression of the chest, depression, a slight feeling of a lump in the throat, slight shortness of breath, sighing, sadness, chest and upper epigastric distension, slightly purple lips, pale complexion. Tongue: normal coloured or slightly Pale Purple on the sides in the chest area. Pulse: Empty but very slightly Overflowing on both Front positions. Treatment principle
Move Qi in the Heart and Lung, relax the chest, calm the Mind. Acupuncture
HE-5 Tongli, HE-7 Shenmen, P-6 Neiguan, Ren-15 Jiuwei, Ren-17 Shanzhong, LU-7 Lieque, ST-40 Fenglong. Even method. Herbal treatment
Pre scription
• BAN XIA HOU PO TANG Pinellia-Magnolia Decoction Three Treasures remedy
• OPEN THE HEART
Liver-Qi stagnation
Clinical manifestations Anxiety, irritability, worry, epigastric and abdominal distension. Tongue: normal or slightly Red on the sides. Pulse: Wiry. Treatment principle Pacify the Liver, move Qi, calm the Mind, settle the Ethereal Soul. Acupuncture P-6 Neiguan, T.B.-6 Zhigou, Du-24 Shenting, G.B.-13 Benshen, LIV-3 Taichong. All reducing or even method. Explanation
– P-6 and T.B.-6 move Liver-Qi. – Du-24 and G.B.-13 calm the Mind and settle the Ethereal Soul. – LIV-3 moves Liver-Qi, calms the Mind and settles the Ethereal Soul. Herbal treatment
Prescription
– XIAO YAO SAN – Free and Easy Wanderer Powder Explanation
– Bo He and Chai Hu gently move Liver-Qi. – Bai Zhu and Fu Ling tonify the Spleen and resolve Dampness. – Dang Gui and Bai Shao nourish Liver-Blood. – Gan Cao and Sheng Jiang harmonize. Three Treasures remedy
– FREEING THE MOON This remedy is a variation of Xiao Yao San. Summary Liver-Qi stagnation
Clinical manifestations
Anxiety, irritability, worry, epigastric and abdominal distension. Tongue: normal or slightly Red on the sides. Pulse: Wiry.
Treatment principle
Pacify the Liver, move Qi, calm the Mind, settle the Ethereal Soul. Acupuncture
P-6 Neiguan, T.B.-6 Zhigou, Du-24 Shenting, G.B.-13 Benshen, LIV-3 Taichong. All reducing or even method. Herbal treatment
Pre scription
• XIAO YAO SAN Free and Easy Wanderer Powder Three Treasures remedy
• FREEING THE MOON
Liver-Fire
Clinical manifestations Anxiety, mental restlessness, irritability, propensity to outburst of anger, a dry mouth, thirst, blood-shot eyes, dark urine, constipation, dizziness, tinnitus, dream- disturbed sleep. Tongue: Red body with redder sides, dry, yellow coating. Pulse: Wiry and Rapid. Treatment principle Drain Liver-Fire, calm the Mind and settle the Ethereal Soul. Acupuncture LIV-2 Xingjian, LIV-3 Taichong, BL-18 Ganshu, Du-18 Qiangjian, Du-24 Shenting, G.B.-13 Benshen, G.B.-15 Toulinqi, HE-7 Shenmen, P-7 Daling, LU-3 Tianfu. LIV-2, LIV-3 and G.B.-15 with reducing method, all the other points with even method. Explanation
– LIV-2 drains Liver-Fire. – LIV-3 pacifies the Liver and calms the Mind. – BL-18, Back-Transporting point of the Liver, clears Liver-Fire. – Du-18 calms the Mind, regulates the Liver and settles the Ethereal Soul.
– Du-24 and G.B.-13 calm the Mind and settle the Ethereal Soul in Liver disharmonies. G.B.-13 also treats jealousy and suspicion. – G.B.-15 clears Heat, brightens the eyes and settles the Ethereal Soul. – HE-7 and P-7 calm the Mind. P-7 is related to the Liver via the Terminal Yin channels. – LU-3 harmonizes Liver and Lungs and, according to An Explanation of Acupuncture Points (1654), is particularly indicated when Liver-Fire obstructs the Lungs causing forgetfulness. The book also says this point is indicated when the person “talks to ghosts”.1 Herbal treatment
Prescription
– XIE GAN AN SHEN WAN – Draining the Liver and Calming the Mind Pill Explanation
– Long Dan Cao is the Emperor herb to clear Liver-Fire. – Shan Zhi Zi and Huang Qin help the Emperor herb to clear Liver-Fire. – Bai Ji Li and Shi Jue Ming subdue Liver-Wind and Liver-Yang. Shi Jue Ming also clears Liver-Fire.
– Ze Xie and Che Qian Zi help to clear Fire via urination. – Dang Gui nourishes Liver-Blood and harmonizes the Liver. – Sheng Di Huang and Mai Men Dong nourish Yin. Sheng Di nourishes Liver-Yin and cools Blood. – Zhen Zhu Mu, Long Gu and Mu Li sink and calm the Mind and settle the Ethereal Soul. – Fu Shen and Yuan Zhi calm the Mind. – Suan Zao Ren and Bai Zi Ren nourish the Liver, calm the Mind and settle the Ethereal Soul. – Gan Cao harmonizes. This formula (a variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction) specifically drains Liver-Fire and calms the Mind. It addresses the mental restlessness and irritability deriving from LiverFire. Modification
• If there is also Heart-Fire (a very likely occurrence), add Zhu Ye Folium Phyllostachys nigrae and Lian Zi Xin Semen Nelumbinis. Three Treasures remedy
– SETTLING THE SOUL This remedy is a variation of Long Dan Xie Gan Tang that drains LiverFire, resolves Phlegm, calms the Mind and settles the Ethereal Soul. The tongue presentation appropriate to this remedy is a Red and Swollen body,
with redder sides and a sticky, yellow coating. Summary Liver-Fire
Clinical manifestations
Anxiety, mental restlessness, irritability, propensity to outburst of anger, a dry mouth, thirst, blood-shot eyes, dark urine, constipation, dizziness, tinnitus, dream-disturbed sleep. Tongue: Red body with redder sides, dry, yellow coating. Pulse: Wiry and Rapid. Treatment principle
Drain Liver-Fire, calm the Mind and settle the Ethereal Soul. Acupuncture
LIV-2 Xingjian, LIV-3 Taichong, BL-18 Ganshu, Du-18 Qiangjian, Du-24 Shenting, G.B.-13 Benshen, G.B.-15 Toulinqi, HE-7 Shenmen, P-7 Daling, LU-3 Tianfu. LIV-2, LIV-3 and G.B.-15 with reducing method, all the other points with even method. Herbal treatment
Pre scription
• XIE GAN AN SHEN WAN Draining the Liver and Calming the Mind Pill Three Treasures remedy
• SETTLING THE SOUL
Empty-Heat from Yin deficiency
Clinical manifestations Anxiety, mental restlessness, feeling fidgety especially in the evening, inability to lie down, palpitations, dry mouth and throat, feeling of heat in the evening, malar flush, night sweating. Tongue: Red without coating. Pulse: FloatingEmpty and Rapid. Treatment principle Clear Empty-Heat, nourish Yin, calm the Mind, calm the fetus. Acupuncture SP-1 Yinbai, KI-2 Rangu, KI-3 Taixi, KI-6 Zhaohai, KI-9 Zhubin, HE-7 Shenmen, HE-6 Yinxi, P-7 Daling, Ren-15 Jiuwei, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left). KI-3, KI-6 and KI-9 with reinforcing method; all the others with even method. Explanation
– SP-1 calms the Mind, clears Heat and calms the fetus. – KI-2 clears Empty-Heat. – KI-3, KI-6 and KI-9 all nourish the Kidneys. KI-6 is specific to nourish Kidney-Yin. KI-9 nourishes the Kidneys and calms the Mind with a special effect in relaxing the chest.
– HE-7, HE-6 and P-7 all calm the Mind. HE-6 also clears Empty-Heat. P-7 has a stronger calming action than the others. – Ren-15 calms the Mind and relaxes the chest which often feels very tight in anxiety. – SP-4 and P-6 regulate the Penetrating Vessel and subdue rebellious Qi. Herbal treatment
a. Prescription
– REN SHEN MAI DONG SAN – Ginseng-Ophiopogon Powder Explanation
– Ren Shen and Mai Men Dong tonify Qi and Yin of the Heart and Lungs. – Fu Ling resolves Dampness and is included to counterbalance the cloying nature of Yin tonics. – Huang Qin clears Heat and calms the Mind. – Zhi Mu and Sheng Di Huang nourish Kidney-Yin and clear Empty-Heat. – Zhu Ru resolves Phlegm-Heat and calms the Mind. – Zhi Gan Cao harmonizes.
b Prescription
– ZHI MU SAN Variation – Anemarrhena Powder Variation Explanation
– Zhi Mu and Mai Men Dong nourish Yin and clear Empty-Heat. – Gan Cao is here to calm the Mind and ‘moderate urgency’, hence its high dose. – Fu Ling resolves Dampness and is included to counteract the cloying nature of Yin tonics. – Huang Qin clears Heat and calms the Mind. – Huang Qi tonifies Qi. – Bei Sha Shen and Lian Zi Xin have been added to the original prescription to nourish Heart-Yin and calm the Mind. The difference between this formula and the previous one is that this formula nourishes more Heart-Yin while the previous one nourishes both Heart- and Kidney-Yin. Modifications These modifications apply to both the above formulae. • If there is severe mental restlessness, add Long Chi Fossilia Dentis
Mastodi and Fu Shen Sclerotium Poriae pararadicis. • If there are symptoms of Lung-Yin deficiency, add Bai He Bulbus Lilii, Zhi Mu Rhizoma Anemarrhenae (or increase its dosage if already in the formula), Tian Men Dong Radix Asparagi and Tian Hua Fen Radix Trichosanthis. Women’s Treasure remedy
– HEAVENLY EMPRESS This remedy is a variation of the formula Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill: it nourishes Heart- and Kidney-Yin, clears Heart Empty-Heat and calms the Mind. The tongue presentation appropriate to this remedy is a Red body without coating, with a redder tip, and with a central Heart crack. Summary Empty-Heat from Yin deficiency
Clinical manifestations
Anxiety, mental restlessness, feeling fidgety especially in the evening, inability to lie down, palpitations, dry mouth and throat, feeling of heat in the evening, malar flush, night sweating. Tongue: Red without coating. Pulse: FloatingEmpty and Rapid. Treatment principle
Clear Empty-Heat, nourish Yin, calm the Mind, calm the fetus.
Acupuncture
SP-1 Yinbai, KI-2 Rangu, KI-3 Taixi, KI-6 Zhaohai, KI-9 Zhubin, HE-7 Shenmen, HE-6 Yinxi, P-7 Daling, Ren-15 Jiuwei, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left). KI-3, KI-6 and KI-9 with reinforcing method; all the others with even method. Herbal treatment
Pre scriptions
• REN SHEN MAI DONG SAN Ginseng-Ophiopogon Powder • ZHI MU SAN Variation Anemarrhena Powder Variation Women’s Treasure remedy
• HEAVENLY EMPRESS
Phlegm-Fire harassing the Mind
Clinical manifestations Mental restlessness, agitation, phobias, anxiety, irritability, a feeling of oppression of the chest, dizziness, palpitation, nausea. Tongue: Red, Swollen and with a sticky, yellow coating. Pulse: Slippery and Rapid. Treatment principle Drain Fire, resolve Phlegm, calm the Mind, open the Mind’s orifices, calm the fetus. Acupuncture LIV-2 Xingjian, L.I.-11 Quchi, Ren-12 Zhongwan (if within the first three months of pregnancy), ST-40 Fenglong, SP-9 Yinlingquan, Ren-15 Jiuwei, ST-8 Touwei, G.B.-17 Zhengying and G.B.-18 Chengling. All with reducing method except for Ren-12 which should be needled with reinforcing method. Explanation
– LIV-2 drains Liver-Fire which is often the basis for the development of this pattern. – L.I.-11 clears Heat. – Ren-12 tonifies the Spleen to resolve Phlegm. – ST-40 and SP-9 resolve Phlegm.
– Ren-15 calms the Mind and relaxes the chest. – ST-8 resolves Phlegm from the head. – G.B.-17 and G.B.-18 calm the Mind and open the Mind’s orifices. Herbal treatment
Prescription
– ZHU LI TANG – Succus Bambusae Decoction Explanation
– Zhu Li resolves Phlegm-Heat and calms the Mind. – Mai Men Dong nourishes Heart- and Lung-Yin. – Huang Qin clears Heat and calms the Mind. – Fu Ling resolves Dampness and calms the Mind. – Fang Feng harmonizes the Stomach and helps to resolve Phlegm. Modifications
• If there is profuse yellow phlegm, remove Fang Feng and add Zhe Bei
Mu Bulbus Fritillariae thunbergii, Huang Lian Rhizoma Coptidis, Ban Xia Rhizoma Pinelliae preparatum and Gua Lou Fructus Trichosanthis. • If there is nausea and vomiting, add Ban Xia Rhizoma Pinelliae preparatum, Pi Pa Ye Folium Eriobotryae and Huo Xiang Herba Pogostemonis. Three Treasures remedy
– CLEAR THE SOUL This remedy is a variation of the formula Wen Dan Tang Warming the Gall Bladder Decoction and it resolves Phlegm-Heat, calms the Mind and settles the Corporeal Soul. It is indicates when the Heart and Lungs are obstructed by Phlegm-Heat, caused by longstanding worry, grief or sadness. Summary Phlegm-Fire harassing the Mind
Clinical manifestations
Mental restlessness, agitation, phobias, anxiety, irritability, a feeling of oppression of the chest, dizziness, palpitation, nausea. Tongue: Red, Swollen and with a sticky, yellow coating. Pulse: Slippery and Rapid. Treatment principle
Drain Fire, resolve Phlegm, calm the Mind, open the Mind’s orifices, calm the fetus. Acupuncture
LIV-2 Xingjian, L.I.-11 Quchi, Ren-12 Zhongwan (if within the first three months of pregnancy), ST-40 Fenglong, SP-9 Yinlingquan, Ren-15 Jiuwei, ST-8 Touwei, G.B.-17 Zhengying and G.B.-18 Chengling. All with reducing method except for Ren-12 which should be needled with reinforcing method. Herbal treatment
Pre scription
• ZHU LI TANG Succus Bambusae Decoction Three Treasures remedy
• CLEAR THE SOUL
Prognosis and prevention Both acupuncture and Chinese herbs are excellent to deal with anxiety during pregnancy. Acupuncture is probably to be preferred because, especially in the first 3 months of pregnancy, it is better to avoid prescribing herbs. Because it does not introduce any substance into the body, acupuncture is ideally suited to treat anxiety during pregnancy. Since, in addition to Heat, this problem is also closely related to a disharmony of the Penetrating Vessel, acupuncture can regulate and harmonize this vessel directly and effectively. Epigastric points on the Penetrating Vessel such as KI-21 Youmen and KI-20 Tonggu would be particularly useful as they subdue rebellious Qi of this vessel and calm the Mind. Depending on the severity of the condition, just a few sessions may suffice or it may be that the woman needs to be treated throughout her pregnancy. The pattern from Phlegm-Fire is more difficult to treat than the one from Empty-Heat, because Phlegm is hard to resolve and also obstructs the Mind’s orifices. Obstruction of the Mind, as happens with Phlegm, is more difficult to treat than unsettling of the Mind from Empty-Heat or Heat. End note 1. Yue Han Zhen 1990 An Explanation of Acupuncture Points (Jing Xue Jie
), People’s Health Publishing House, Beijing, pp 26–27. An Explanation of Acupuncture Points was first published in 1654..
CHAPTER 35 Dizziness During Pregnancy
AETIOLOGY 509 PATHOLOGY 509 IDENTIFICATION OF PATTERNS AND TREATMENT 509 Liver-Blood deficiency with Liver-Yang rising 509 Liver- and Kidney-Yin deficiency with Liver-Yang rising 510 Spleen deficiency with Liver-Yang rising and Phlegm 511 PROGNOSIS AND PREVENTION 512 WESTERN VIEW 512 Dizziness and vertigo, called zi yun, usually occur in the second and third trimesters of pregnancy. They occur with different degrees of severity: very severe vertigo can be a prodromal symptom of pre-eclampsia or eclampsia which, in Chinese medicine, corresponds to ‘convulsions in pregnancy’, zi xian. The latter will be discussed in Chapter 36.
Aetiology
Overwork Overwork leads to Liver- and Kidney-Yin deficiency which, in turn, may lead to Liver-Yang rising. This causes dizziness. Excessive physical work, irregular diet Excessive physical work may injure the Spleen; a deficient Spleen may fail to produce Blood which induces a deficiency of Liver-Blood: this, in turn, may lead to Liver-Yang rising and dizziness. On the other hand, a deficient Spleen may lead to the formation of Phlegm and this often causes dizziness.
Pathology The pathology of dizziness during pregnancy is due to a deficiency and an excess. The two main pathological conditions causing it are Liver-Yang rising and Phlegm. Liver-Yang rising may come from Liver- and Kidney-Yin deficiency or from Liver-Blood deficiency; Phlegm arises from Spleen deficiency. Liver-Yang rising and Phlegm are often combined especially when they occur against a background of Spleen deficiency. In fact, Spleen deficiency may lead to Liver-Blood deficiency and this, in turn, to Liver-Yang rising. On the other hand, when the Spleen fails to transform food properly, Phlegm may accumulate.
Identification of patterns and treatment The patterns discussed are: • Liver-Blood deficiency with Liver-Yang rising • Liver- and Kidney-Yin deficiency with Liver-Yang rising • Spleen deficiency with Liver-Yang rising and Phlegm.
Liver-Blood deficiency with Liver-Yang rising
Clinical manifestations Dizziness, blurred vision, tiredness, dry hair and skin, numbness and tingling of limbs. Tongue: Pale. Pulse: Choppy or Fine. Treatment principle Nourish Liver-Blood, subdue Liver-Yang. Acupuncture LIV-8 Ququan, ST-36 Zusanli, KI-3 Taixi, BL-17 Geshu, BL-18 Ganshu, LIV-3 Taichong, G.B.-20 Fengchi. All with reinforcing method except LIV-3 which should be needled with reducing method. Explanation
– LIV-8, ST-36 and KI-3 nourish Liver-Blood. – BL-17 and BL-18 in combination nourish Blood. They are particularly effective if direct moxa cones are applied to them. – LIV-3 subdues Liver-Yang. – G.B.-20 subdues Liver-Yang and treats dizziness. Herbal treatment
Prescription
– QI JU DI HUANG WAN Variation – Lycium-Chrysanthemum-Rehmannia Pill Variation Explanation
– Gou Qi Zi, Shu Di Huang, Shan Yao, Dang Gui, Bai Shao and Shou Wu tonify the Liver and Kidneys and nourish Liver-Blood. – Ju Hua, Tian Ma and Gou Teng subdue Liver-Yang. – Fu Ling balances the possible cloying effect of the Blood tonics. Three Treasures remedy
– BEND BAMBOO This remedy nourishes Liver-Blood and subdues Liver-Yang. Summary Liver-Blood deficiency with Liver-Yang rising
Clinical manifestations
Dizziness, blurred vision, tiredness, dry hair and skin, numbness and tingling of limbs. Tongue: Pale. Pulse: Choppy or Fine. Treatment principle
Nourish Liver-Blood, subdue Liver-Yang. Acupuncture
LIV-8 Ququan, ST-36 Zusanli, KI-3 Taixi, BL-17 Geshu, BL-18 Ganshu, LIV-3 Taichong, G.B.-20 Fengchi. All with reinforcing method except LIV-3 which should be needled with reducing method. Herbal treatment
Pre scription
• QI JU DI HUANG WAN Variation Lycium-Chrysanthemum-Rehmannia Pill Variation Three Treasures remedy
• BEND BAMBOO
Liver- and Kidney-Yin deficiency with Liver-Yang rising
Clinical manifestations Severe dizziness towards the later stages of pregnancy, tinnitus, insomnia, a feeling of heat in the evening, night sweating. Tongue: without coating; Red, if there is Empty-Heat. Pulse: Floating-Empty. Treatment principle Nourish Liver- and Kidney-Yin, subdue Liver-Yang. Acupuncture LIV-8 Ququan, KI-3 Taixi, KI-6 Zhaohai, BL-23 Shenshu, G.B.-20 Fengchi, T.B.-5 Waiguan, LIV-3 Taichong. G.B.-20, T.B.-5 and LIV-3 should be needled with even method and the others with reinforcing method. Explanation
– LIV-8, KI-3, KI-6 and BL-23 nourish the Liver and Kidneys. – G.B.-20 subdues Liver-Yang and treats dizziness. – T.B.-5 and LIV-3 subdue Liver-Yang rising. Herbal treatment
Prescription
– QI JU DI HUANG WAN – Lycium-Chrysanthemum-Rehmannia Pill Explanation This formula, already explained, is a variation of Liu Wei Di Huang Wan Six Ingredients Rehmannia Pill which nourishes Liver- and Kidney-Yin; its variation, with Gou Qi Zi and Ju Hua, also subdues Liver-Yang. Women’s Treasure remedy
– FEMALE TREASURE This remedy is a variation of Kun Bao Tang, a formula for women to nourish Liver- and Kidney-Yin, subdue Liver-Yang and clear Empty-Heat. Therefore, the tongue presentation appropriate to this remedy is a Red tongue without coating and possibly with redder sides. Summary Liver- and Kidney-Yin deficiency with Liver-Yang rising
Clinical manifestations
Severe dizziness towards the later stages of pregnancy, tinnitus, insomnia, a feeling of heat in the evening, night sweating. Tongue: without coating; Red, if
there is Empty-Heat. Pulse: Floating-Empty. Treatment principle
Nourish Liver- and Kidney-Yin, subdue Liver-Yang. Acupuncture
LIV-8 Ququan, KI-3 Taixi, KI-6 Zhaohai, BL-23 Shenshu, G.B.-20 Fengchi, T.B.-5 Waiguan, LIV-3 Taichong. G.B.-20, T.B.-5 and LIV-3 should be needled with even method and the others with reinforcing method. Herbal treatment
Pre scription
• QI JU DI HUANG WAN Lycium-Chrysanthemum-Rehmannia Pill Women’s Treasure remedy
• FEMALE TREASURE
Spleen deficiency with Liver-Yang rising and Phlegm
Clinical manifestations Dizziness with early onset during the pregnancy, swelling of fingers and ankles, tiredness, a feeling of oppression of the chest, expectoration of sputum, blurred vision, tingling of limbs. Tongue: Pale and Swollen. Pulse: Choppy if Liver-Blood deficiency predominates; Slippery if Phlegm predominates. Treatment principle Nourish Liver-Blood, tonify the Spleen, resolve Phlegm. Acupuncture LIV-8 Ququan, ST-36 Zusanli, SP-9 Yinlingquan, ST-40 Fenglong, BL-22 Sanjiaoshu, G.B.-20 Fengchi, T.B.-5 Waiguan, LIV-3 Taichong. LIV-8 and ST-36 should be needled with reinforcing method; the others with even method. Explanation
– LIV-8 and ST-36 tonify Liver-Blood. – SP-9, ST-40 and BL-22 resolve Phlegm. – G.B.-20 subdues Liver-Yang and treats dizziness. – T.B.-5 and LIV-3 subdue Liver-Yang.
Herbal treatment
a Prescription
– BAI ZHU SAN Variation – Atractylodes Powder Variation Explanation
– Bai Zhu tonifies the Spleen and dries Dampness. – Fu Ling Pi, Chen Pi and Da Fu Pi resolve Dampness and Phlegm. – Sheng Jiang harmonizes. – Gou Teng and Shi Jue Ming are added to the formula to subdue LiverYang and treat dizziness. b Prescription
– BAN XIA BAI ZHU TIAN MA TANG – Pinellia-Atractylodes-Gastrodia Decoction Explanation This formula resolves Phlegm, extinguishes Liver-Wind, subdues Liver-Yang
and mildly tonifies Spleen-Qi. If Spleen deficiency is pronounced, it should be modified with the addition of more Spleen tonics. Three Treasures remedy
– CLEAR YANG This remedy is a variation of Ban Xia Bai Zhu Tian Ma Tang. Summary Spleen deficiency with Liver-Yang rising and Phlegm
Clinical manifestations
Dizziness with early onset during the pregnancy, swelling of fingers and ankles, tiredness, a feeling of oppression of the chest, expectoration of sputum, blurred vision, tingling of limbs. Tongue: Pale and Swollen. Pulse: Choppy if Liver-Blood deficiency predominates; Slippery if Phlegm predominates. Treatment principle
Nourish Liver-Blood, tonify the Spleen, resolve Phlegm. Acupuncture
LIV-8 Ququan, ST-36 Zusanli, SP-9 Yinlingquan, ST-40 Fenglong, BL-22 Sanjiaoshu, G.B.-20 Fengchi, T.B.-5 Waiguan, LIV-3 Taichong. LIV-8 and ST-36 should be needled with reinforcing method; the others with even method.
Herbal treatment
Pre scriptions
• BAI ZHU SAN Variation Atractylodes Powder Variation • BAN XIA BAI ZHU TIAN MA TANG Pinellia-Atractylodes-Gastrodia Decoction Three Treasures remedy
• CLEAR YANG
Prognosis and prevention Dizziness during pregnancy responds well to treatment with acupuncture and herbs and most cases should be resolved within a few weeks of treatment. The pattern of Liver- and Kidney-Yin deficiency is more difficult to treat and is also the one that requires close monitoring because this type of dizziness may be a prodromal sign of pre-eclampsia or eclampsia. Thus, if a woman complaining of dizziness during pregnancy presents with the pattern of Liverand Kidney-Yin deficiency with Liver-Yang rising, it might be wise to continue the treatment to the end of term even if the dizziness is relieved.
Western view Dizziness during pregnancy is not a serious symptom from the Western point of view. It becomes serious only when it is accompanied by oedema and hypertension: the combination of these symptoms and signs may indicate that the woman may develop eclampsia. A pre-eclamptic state may also be heralded by dizziness accompanied by vomiting and headache, although many pregnant women may suffer from migraine headaches which would not be related to eclampsia. This condition will be discussed in the next chapter. Dizziness during pregnancy may also be due to hypotension (low blood pressure) which is, of course, not a dangerous sign. Pregnancy has a definite influence on blood pressure. Pooling of blood in the legs and lower part of the abdomen may induce a temporary cerebral ischaemia which may cause a slight dizziness and a faint feeling when the woman gets up from a supine position. There is disagreement as to what is a ‘normal’ level of blood pressure in pregnant women. Some clinics take a reading of 140/90 as the dividing line between physiology and pathology. In any case, if a rise in blood pressure is suspected, the blood pressure should be monitored very frequently as, in pregnancy, the blood pressure may rise quickly. Indeed, the standards of management of hypertension generally applied do not apply in pregnancy for two reasons. First of all, the standards of what is considered a ‘normal’ level of blood pressure are lower during pregnancy; for example, a reading of 140/90 may be normal in general practice but it may indicate danger in a pregnant woman especially if her blood pressure has reached that level suddenly. Second, the blood pressure fluctuates more rapidly in pregnancy and therefore needs to be monitored very frequently: for example, a reading of 160/110, which may require longterm management in general practice, would be a sign indicating the danger of imminent eclampsia.
CHAPTER 36 Convulsions During Pregnancy
AETIOLOGY 513 PATHOLOGY 513 IDENTIFICATION OF PATTERNS AND TREATMENT 513 Liver-Wind agitating within 513 Phlegm-Fire harassing upwards 515 Empty-Wind 516 PROGNOSIS AND PREVENTION 517 WESTERN VIEW 517 This condition is called zi xian which means ‘convulsions in pregnancy’: it clearly corresponds to eclampsia in Western medicine. It is a condition that occurs not only in pregnancy but also soon after childbirth. The main manifestations are severe dizziness, headache, vomiting, hypertension and, in its late stages, tremors of limbs, convulsions and coma.
Aetiology
Overwork Overwork injures Liver- and Kidney-Yin; when the Yin of these two organs is deficient, Liver-Yang may rise and Liver-Wind may develop from this. Liver-Wind causes severe dizziness, headache, hypertension, convulsions and coma. Irregular diet, emotional problems An excessive consumption of dairy or greasy foods injures the Spleen and leads to Phlegm. Phlegm may obstruct the Mind’s orifices and cause coma. Emotional problems often lead to Qi stagnation and stagnant Qi often turns into Fire after some time. Fire easily combines with Phlegm and may also lead to the development of internal Wind.
Pathology The pathology of ‘convulsions in pregnancy’ is first and foremost one of internal Wind typically causing severe dizziness, tremors and convulsions. Phlegm is often associated with it and causes unconsciousness by obstructing the Mind’s orifices. Underlying these two excess conditions, there will be a deficiency of Liver- and Kidney-Yin which leads to Liver-Wind, and a deficiency of the Spleen which leads to the formation of Phlegm.
Identification of patterns and treatment The patterns discussed are: • Liver-Wind agitating within • Phlegm-Fire harassing upwards • Empty-Wind.
Liver-Wind agitating within
Clinical manifestations Hypertension late in the pregnancy, headache, malar flush, a feeling of heat in the afternoon, tremor of limbs, convulsions, unconsciousness. Tongue: Red and peeled. Pulse: Rapid, Wiry. This pattern is characterized by Liver-Wind arising out of a background of Liver- and Kidney-Yin deficiency. Often, it is combined with some Phlegm: this is especially evident if the patient falls into unconsciousness. Treatment principle Extinguish Liver-Wind, nourish Liver- and Kidney-Yin. Acupuncture LIV-3 Taichong, G.B.-20 Fengchi, BL-62 Shenmai (on the right) and S.I.-3 Houxi (on the left), Du-16 Fengfu, Du-26 Renzhong, LIV-8 Ququan, KI-6 Zhaohai, KI-3 Taixi, BL-17 Geshu. BL-17, LIV-8, KI-6 and KI-3 with reinforcing method; the others with reducing method. Explanation
– LIV-3, G.B.-20 and Du-16 extinguish internal Wind. – BL-62 and S.I.-3 regulate the Yang Stepping Vessel and extinguish internal Wind. The Yang Stepping Vessel absorbs excesses of Yang which are there in the form of Wind, even though the Wind arises from Yin
deficiency. The Yang Stepping Vessel is particularly indicated if both Front pulse positions are Wiry and Full. – Du-26 extinguishes Wind and promotes resuscitation. – LIV-8, KI-6 and KI-3 nourish Liver and Kidneys. – BL-17, with reinforcing method or direct moxa, nourishes Blood. Herbal treatment
a. Prescription
– LING JIAO GOU TENG TANG – Cornu Antelopis-Uncaria Decoction Explanation
– Ling Jiao, Gou Teng, Sang Ye and Ju Hua extinguish Liver-Wind and stop convulsions. – Bai Shao and Sheng Di Huang nourish Liver- and Kidney-Yin. – Fu Shen calms the Mind. – Chuan Bei Mu and Zhu Ru resolve Phlegm. As mentioned above, there is often some Phlegm combined with Wind in this pattern. It is the Phlegm that causes the patient to become unconscious.
– Gan Cao harmonizes. Modifications
• If there is a headache and dizziness, add Tian Ma Rhizoma Gastrodiae, Bai Ji Li Fructus Tribuli and Shi Jue Ming Concha Haliotidis. • If there is oedema, add Zhu Ling Polyporus and Ze Xie Rhizoma Alismatis. • If there are digestive symptoms from Wood overacting on Earth, add Bai Zhu Rhizoma Atractylodis macrocephalae and Shan Zha Fructus Crataegi. • If there is a bitter taste, mental restlessness and dry throat, add Huang Qin Radix Scutellariae. • If there are symptoms of Kidney-Yang deficiency and backache, add Tu Si Zi Semen Cuscutae, Sang Ji Sheng Herba Taxilli and Du Zhong Cortex Eucommiae. b. Prescription
– DI SHEN ZI YIN FANG1 – Rehmannia-Glehnia Nourishing Yin Formula Explanation This formula is for high blood pressure from Kidney- and Liver-Yin deficiency and Liver-Wind.
– Sheng Di Huang, Bei Sha Shen, Gou Qi Zi and Mai Men Dong nourish Kidney-Yin. – Chuan Lian Zi moves Liver-Qi. – Sang Ji Shen and Bai Shao nourish Blood and pacify the Liver. – Dan Shen invigorates Blood. – Shi Jue Ming extinguishes Liver-Wind and subdues Liver-Yang. Compared with the previous formula, this formula has a stronger Yinnourishing action and it does not resolve Phlegm. Summary Liver-Wind agitating within
Clinical manife stations
Hypertension late in the pregnancy, headache, malar flush, a feeling of heat in the afternoon, tremor of limbs, convulsions, unconsciousness. Tongue: Red and peeled. Pulse: Rapid, Wiry. Tre atme nt principle
Extinguish Liver-Wind, nourish Liver- and Kidney-Yin. Acupuncture
LIV-3 Taichong, G.B.-20 Fengchi, BL-62 Shenmai (on the right) and S.I.-3 Houxi (on the left), Du-16 Fengfu, Du-26 Renzhong, LIV-8 Ququan, KI-6 Zhaohai, KI-3 Taixi, BL-17 Geshu. BL-17, LIV-8, KI-6 and KI-3 with reinforcing method; the others with reducing method. He rbal tre atme nt
Prescriptions
• LING JIAO GOU TENG TANG Cornu Antelopis-Uncaria Decoction • DI SHEN ZI YIN FANG Rehmannia-Glehnia Nourishing Yin Formula
Phlegm-Fire harassing upwards
Clinical manifestations Hypertension, oedema, slight tremor of limbs, mental confusion, unconsciousness, a feeling of oppression of the chest. Tongue: Swollen with a sticky coating. Pulse: Wiry and Slippery. Treatment principle Clear Heat, resolve Phlegm, open the Mind’s orifices. Acupuncture L.I.-11 Quchi, LIV-2 Xingjian, Ren-12 Zhongwan, Ren-9 Shuifen, BL-22 Sanjiaoshu, SP-9 Yinlingquan, ST-40 Fenglong, Du-26 Renzhong, P-5 Jianshi, P-8 Laogong. All with reducing method. Explanation
– L.I.-11 and LIV-2 clear Heat. – Ren-12, Ren-9, BL-22, SP-9 and ST-40 promote the transformation of fluids and resolve Dampness and Phlegm. – Du-26 promotes resuscitation. – P-5 resolves Phlegm from the Mind. – P-8 clears Heat and opens the Mind’s orifices.
Herbal treatment
a Prescription
– DI TAN TANG – Scouring Phlegm Decoction Explanation
– Ban Xia, Ju Hong and Fu Ling resolve Dampness and Phlegm. – Zhi Shi and Zhu Ru resolve Phlegm-Heat. Zhi Shi helps to resolve Phlegm by its downwards movement and by moving Qi. – Dan Nan Xing resolves Phlegm. – Shi Chang Pu opens the Mind’s orifices. – Ren Shen tonifies Qi. – Gan Cao harmonizes. This formula is essentially a variation of Wen Dan Tang Warming the Gall Bladder Decoction (the first five herbs) which resolves Phlegm-Heat. b. Prescription
– EMPIRICAL PRESCRIPTION by Dr Xia Gui Cheng2
Explanation
– Lian Qiao clears Heat. – Xuan Shen and Mu Dan Pi clear Heat and cool Blood. – Yu Jin and Shi Chang Pu open the Mind’s orifices. – Dan Nan Xing, Tian Zhu Huang and Zhu Li resolve Phlegm-Heat. – Ling Yang Jiao extinguishes internal Wind. The main difference between this formula and the previous one is that the present formula’s emphasis is on clearing Heat and resolving PhlegmHeat, whereas the previous one is more for Phlegm without Heat. Modifications These modifications apply to both formulae. • If there are signs of external Wind invasion, add Fang Feng Radix Saposhnikoviae, Qiang Huo Rhizoma seu Radix Notopterygii and Jiang Can Bombyx batryticatus. • If Phlegm is pronounced, add Tian Zhu Huang Concretio Bambusae silicea, Zhu Li Succus Bambusae and Ban Xia Rhizoma Pinelliae preparatum. • If there are signs of Heart- and Liver-Fire such as thirst, mental restlessness and red face, add Long Dan Cao Radix Gentianae, Shan Zhi Zi Fructus Gardeniae and Zhu Ye Folium Phyllostachys nigrae. • If convulsions occur after childbirth, add Tai Zi Shen Radix Pseudostellariae, Shu Di Huang Radix Rehmanniae preparata, Dang Gui
Radix Angelicae sinensis and Gou Qi Zi Fructus Lycii. • If there is also stasis of Blood (which frequently accompanies Phlegm), add Dan Shen Radix Salviae miltiorrhizae, Chi Shao Radix Paeoniae rubra and Tao Ren Semen Persicae. Summary Phlegm-Fire harassing upwards
Clinical manife stations
Hypertension, oedema, slight tremor of limbs, mental confusion, unconsciousness, a feeling of oppression of the chest. Tongue: Swollen with a sticky coating. Pulse: Wiry and Slippery. Tre atme nt principle
Clear Heat, resolve Phlegm, open the Mind’s orifices. Acupuncture
L.I.-11 Quchi, LIV-2 Xingjian, Ren-12 Zhongwan, Ren-9 Shuifen, BL-22 Sanjiaoshu, SP-9 Yinlingquan, ST-40 Fenglong, Du-26 Renzhong, P-5 Jianshi, P-8 Laogong. All with reducing method. He rbal tre atme nt
Prescriptions
• DI TAN TANG Scouring Phlegm Decoction • EMPIRICAL PRESCRIPTION by Dr Xia Gui Cheng
Empty-Wind
Clinical manifestations Slight tremor and twitching of limbs especially if occurring after delivery, dizziness, palpitations, sweating, pale face. Tongue: Pale, Short. Pulse: Fine, Scattered. This condition is characterized by severe Blood and Yin deficiency after delivery which generates Empty-Wind. Treatment principle Nourish Blood and Yin, extinguish Wind. Acupuncture ST-36 Zusanli, KI-3 Taixi, LIV-8 Ququan, G.B.-20 Fengchi, T.B.-5 Waiguan, Du-16 Fengfu. ST-36, SP-6, LIV-8 and KI-3 should be needled with reinforcing method and the others with even method. Explanation
– ST-36, LIV-8 and KI-3 nourish Blood and tonify the Liver and Kidneys. – G.B.-20, T.B.-5 and Du-16 extinguish Wind. Herbal treatment
a. Prescription
– SAN JIA FU MAI TANG – Three-Shell Restoring the Pulse Decoction Explanation
– Zhi Gan Cao tonifies Qi and stabilizes the pulse. – Sheng Di Huang and Mai Men Dong nourish Yin. – Bai Shao, Huo Ma Ren and E Jiao nourish Blood. – Mu Li, Bie Jia and Gui Ban nourish Yin and extinguish Wind. b. Prescription
– YANG XUE XI FENG FANG3 – Nourishing Blood and Extinguishing Wind Formula Explanation
– Ling Yang Jiao, Gou Teng, Jiang Can and Di Long extinguish Wind and stop convulsions. – Dang Gui, Chuan Xiong, Sheng Di Huang and Bai Shao, a modified version of the formula Si Wu Tang Four Substances Decoction, nourish
Blood. Compared with the previous formula, this formula nourishes Blood more than Yin and it has a stronger Wind-extinguishing action. Summary Empty-Wind
Clinical manife stations
Slight tremor and twitching of limbs especially if occurring after delivery, dizziness, palpitations, sweating, pale face. Tongue: Pale, Short. Pulse: Fine, Scattered. Tre atme nt principle
Nourish Blood and Yin, extinguish Wind. Acupuncture
ST-36 Zusanli, KI-3 Taixi, LIV-8 Ququan, G.B.-20 Fengchi, T.B.-5 Waiguan, Du-16 Fengfu. ST-36, SP-6, LIV-8 and KI-3 should be needled with reinforcing method and the others with even method. He rbal tre atme nt
Prescriptions
• SAN JIA FU MAI TANG Three-Shell Restoring the Pulse Decoction • YANG XUE XI FENG FANG Nourishing Blood and Extinguishing Wind Formula
Prognosis and prevention Convulsions in pregnancy is a condition that very few practitioners will ever encounter, first of all because it is quite rare in Western countries, and second because the woman would be hospitalized and receive Western treatment. However, the treatment with acupuncture and Chinese herbs could be integrated with Western treatment with good results. Chinese journals and texts regularly report such case histories. For example, the Chinese Medicine Gynaecology reports the following case history.
Case history
A 30-year-old woman suffered convulsions, hypertension, oedema and proteinuria during the last month of pregnancy. She was treated successfully with the following formula: • Sheng Di Huang Radix Rehmanniae 30 g • Mai Men Dong Rhizoma Ophiopogonis 10 g • Huai Niu Xi Radix Achyranthis bidentatae 10 g • Bai Shao Radix Paeoniae alba 10 g • Zi Shi Ying Fluoritum 10 g • Bei Sha Shen Radix Glehniae 10 g • Chuan Bei Mu Bulbus Fritillariae cirrhosae10 g • Ju Hua Flos Chrysanthemi 10 g • Jiang Can Bombyx batryticatus 10 g • Nu Zhen Zi Fructus Ligustri lucidi 10 g • Yu Zhu Rhizoma Polygonati odorati 10 g • Wu Gong Scolopendra subspinipes 2 pieces • Wu Shao She Zaocys dhumnades 6 g • Bing Lang Semen Arecae 10 g
Western view The clinical significance of oedema and hypertension as potential prodromal signs of imminent eclampsia has already been discussed in Chapter 33 on oedema and Chapter 35 on dizziness. Imminent eclampsia may manifest with proteinuria, hypertension and oedema. Other symptoms include headaches, scanty urine, vomiting and blurred vision. In particular, signs of an imminent eclamptic fit are a continually rising blood pressure, increasing oedema and severe proteinuria. If these symptoms and signs are present, the woman should be treated urgently to prevent eclampsia. Western treatment consists in the administration of diazepam (because it raises the threshold at which a fit occurs), hypotensives and diuretics. Full-blown eclampsia is one of the most serious complications of pregnancy: it can occur before, during or soon after delivery. In the United Kingdom, it occurs in less than 1/1000 pregnancies. In the USA, the incidence of pre-eclampsia is about 5% of pregnancies. The incidence of eclampsia is considered to be about 5–7 cases per 10 000 deliveries. When it does occur, fetal mortality is high, reaching up to 30%, while the mother’s mortality is 2–3%. Eclampsia, preceded by the abovementioned symptoms and signs, consists in the occurrence of major epileptiform convulsions. The risks from eclampsia include abruptio placentae (premature separation of the placenta), cerebral haemorrhage, disseminated intravascular coagulation and renal necrosis; if the woman is comatose, there is the danger of asphyxia and pneumonia. Western treatment consists in the administration of hypotensives and sedatives. End notes 1. Hu Xi Ming 1990 Great Treatise of Secret Formulae in Chinese Medicine (Zhong Guo Zhong Yi Mi Fang Da Quan
), Culture Publishing House, Shanghai, Vol. 2, p. 28..
2. Xia Gui Cheng 1988 Concise Traditional Chinese Gynaecology, Jiangsu Science and Technology Publishing House, p. 190..
3. Great Treatise of Secret Formulae in Chinese Medicine, Vol. 2, p. 2..
CHAPTER 37 Feeling of Suffocation During Pregnancy
AETIOLOGY AND PATHOLOGY 519 IDENTIFICATION OF PATTERNS AND TREATMENT 519 Stagnation of Qi with disharmony of Liver and Spleen 519 Stagnation of Qi with deficiency of Blood and Kidneys 521 PROGNOSIS AND PREVENTION 522 This condition is called zi xuan in Chinese, xuan meaning ‘suspended’ or ‘anxious’, and also tai qi shang ni, which means ‘fetus’s Qi rebelling upwards’. It includes a feeling of tightness of the chest, anxiety, breathlessness and mental restlessness.
Aetiology and pathology The aetiology of this condition is essentially emotional and from overwork. Overwork injures the Kidneys and leads to a weakening of the Directing and Penetrating Vessels. This may cause a deficiency of Blood and/or Yin in these vessels. On the other hand, emotional problems such as worry and fear may lead to stagnation of Qi of the Heart and Lungs and manifest with anxiety, breathlessness and a feeling of tightness of the chest. From the point of view of pathology, this condition is essentially a disharmony of the Penetrating Vessel (Chong Mai). As the pregnancy progresses, the changes occurring in the Sea of Blood and the Kidneys affect the ‘root’ of the Penetrating Vessel which may become unstable: its Qi rebels upwards and causes the feeling of suffocation. On the other hand, the increasing size of the fetus causes a stagnation of Qi in the abdomen which affects the Penetrating Vessel and gives rise there to rebellious Qi. This typically affects the chest and causes a feeling of anxiety and a sensation of tightness there: these are, in fact, symptoms of the Penetrating Vessel’s li ji, i.e. ‘internal urgency’. This situation is further aggravated if there is a Blood and/or Kidney deficiency: this affects the Penetrating Vessel and it creates a deficiency in the Lower Burner which worsens the situation of rebellious Qi in this vessel. For this reason, the old name of ‘fetus’s Qi rebelling upwards’ describes the pathology of this condition well, especially considering that the character for ni in tai qi shang ni is the same as that for rebellious Qi of the Penetrating Vessel. Thus, the main patterns appearing in this condition are stagnation of Qi and deficiency of Blood and/or Kidneys.
Identification of patterns and treatment The main patterns include stagnation of Qi, deficiency of Blood, deficiency of the Kidneys and disharmony of the Penetrating Vessel. Two main conditions may be distinguished: • stagnation of Qi with disharmony of Liver and Spleen • stagnation of Qi with deficiency of Blood and Kidneys.
Stagnation of Qi with disharmony of Liver and Spleen
Clinical manifestations A feeling of suffocation, a feeling of anxiety, a feeling of tightness of the chest, mental restlessness, irritability, insomnia, inability to lie down, a feeling of energy rising from the lower abdomen towards the chest and throat, a feeling of being breathless (rather than actual breathlessness), tiredness. Tongue: Pale. Pulse: slightly Wiry. Treatment principle Move Qi, eliminate stagnation, subdue rebellious Qi, harmonize the Penetrating Vessel, tonify the Kidneys, calm the Mind, calm the fetus. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), LU-7 Lieque, Ren-17 Shanzhong, LIV-3 Taichong, P-7 Daling, Ren-15 Jiuwei, Du-24 Shenting, ST-37 Shangjuxu, ST-40 Fenglong, KI-3 Taixi, BL-23 Shenshu, BL-51 Huangmen. All with even method except for KI-3 which should be reinforced. Moxa is applicable if there is Yang deficiency. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel and subdue rebellious Qi. – LU-7 relieves breathlessness and treats emotional problems from worry and sadness.
– Ren-17 (needles horizontally downwards) makes Qi descend and relieves tightness of the chest. – LIV-3 moves Qi, pacifies the Liver and eliminates stagnation. – P-7, Ren-15 and Du-24 calm the Mind. Ren-15 also relieves tightness of the chest. – ST-37 relieves tightness of the chest and draws Qi downward. – ST-40 relieves tightness of the chest and harmonizes the Penetrating Vessel. – KI-3 and BL-23 tonify the Kidneys. – BL-51 regulates the Triple Burner as it emerges from the space between the Kidneys and it subdues rebellious Qi affecting the chest and breasts. Herbal treatment
a Prescription
– HUA GAN JIAN – Transforming the Liver Decoction Explanation
– Qing Pi and Chen Pi move Qi, pacify the Liver, eliminate stagnation and subdue rebellious Qi in the Penetrating Vessel.
– Bai Shao nourishes Blood, pacifies the Liver and calms the Mind. – Mu Dan Pi and Shan Zhi Zi clear Liver-Heat which may derive from the transformation of stagnant Qi into Heat. – Ze Xie resolves Dampness. – Chuan Bei Mu restores the descending of Lung-Qi and relieves tightness of the chest. b. Prescription
– ZI SU YIN Variation – Perilla Decoction Variation Explanation
– Zi Su Ye, Chen Pi and Da Fu Pi harmonize the Stomach, subdue rebellious Qi, pacify the Liver and eliminate stagnation. Zi Su Ye also calms the fetus. – Bai Shao and Dang Gui nourish Blood and tonify the Penetrating Vessel. – Chuan Xiong invigorates Blood. – Ren Shen tonifies Qi and the Original Qi. – Gan Cao harmonizes. – Huang Qin clears Heat and calms the fetus.
c. Prescription
– EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan1 Explanation
– Dang Gui, Shu Di Huang and Bai Shao nourish Blood and pacify the Liver. – Zhi Ke, Xiang Fu, Chen Pi and Da Fu Pi move Qi and eliminate stagnation. – Chuan Xiong invigorates Blood. – Huang Qin and Zi Su Ye calm the fetus. – Hua Shi resolves Dampness. Dr Chen recommends this formula for a feeling of suffocation occurring in the seventh or eighth month. Summary Stagnation of Qi with disharmony of Liver and Spleen
Clinical manife stations
A feeling of suffocation, a feeling of anxiety, a feeling of tightness of the chest, mental restlessness, irritability, insomnia, inability to lie down, a feeling of energy rising from the lower abdomen towards the chest and throat, a feeling of being breathless (rather than actual breathlessness), tiredness. Tongue:
Pale. Pulse: slightly Wiry. Tre atme nt principle
Move Qi, eliminate stagnation, subdue rebellious Qi, harmonize the Penetrating Vessel, tonify the Kidneys, calm the Mind, calm the fetus. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), LU-7 Lieque, Ren-17 Shanzhong, LIV-3 Taichong, P-7 Daling, Ren-15 Jiuwei, Du-24 Shenting, ST-37 Shangjuxu, ST-40 Fenglong, KI-3 Taixi, BL-23 Shenshu, BL-51 Huangmen. All with even method except for KI-3 which should be reinforced. Moxa is applicable if there is Yang deficiency. He rbal tre atme nt
Prescriptions
• HUA GAN JIAN Transforming the Liver Decoction • ZI SU YIN Variation Perilla Decoction Variation • EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan
Stagnation of Qi with deficiency of Blood and Kidneys
Clinical manifestations A feeling of suffocation, a feeling of anxiety, a feeling of tightness of the chest, mental restlessness, irritability, insomnia, inability to lie down, a feeling of energy rising from the lower abdomen towards the chest and throat, a feeling of being breathless (rather than actual breathlessness), tiredness, blurred vision, dizziness, backache, frequent urination, depression. Tongue: Pale. Pulse: slightly Wiry and Weak on both Rear positions. Treatment principle Move Qi, eliminate stagnation, subdue rebellious Qi, harmonize the Penetrating Vessel, nourish Blood, tonify the Kidneys, calm the Mind, calm the fetus. Acupuncture The same as for the previous pattern, except that the emphasis should be on nourishing Blood and tonifying the Kidneys. Herbal treatment
a. Prescription
– E JIAO YANG XUE TANG
– Colla Corii Asini Nourishing Blood Decoction Explanation
– Ejiao and Sang Ji Sheng nourish Blood and calm the fetus. – Sheng Di Huang and Nu Zhen Zi nourish Kidney-Yin. – Bei Sha Shen and Mai Men Dong nourish Lung-Yin. – Han Lian Cao clears Empty-Heat. b. Prescription
– EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan2 Explanation
– Da Fu Pi and Chen Pi move Qi and eliminate stagnation. – Bai Zhu and Ren Shen tonify Qi and the Original Qi. – Bai Shao and Dang Gui nourish Blood and pacify the Liver. – Zi Su Ye calms the fetus. – Gan Cao harmonizes. Dr Chen recommends this formula for a feeling of suffocation occurring during the eighth or ninth month from stagnation of Qi against a background of deficiency of Qi and Blood.
Women’s Treasure remedy
– PENETRATING VESSEL This remedy nourishes the Blood and the Kidneys, strengthens the Uterus and subdues rebellious Qi in the Penetrating Vessel. Summary Stagnation of Qi with deficiency of Blood and Kidneys
Clinical manifestations
A feeling of suffocation, a feeling of anxiety, a feeling of tightness of the chest, mental restlessness, irritability, insomnia, inability to lie down, a feeling of energy rising from the lower abdomen towards the chest and throat, a feeling of being breathless (rather than actual breathlessness), tiredness, blurred vision, dizziness, backache, frequent urination, depression. Tongue: Pale. Pulse: slightly Wiry and Weak on both Rear positions. Treatment principle
Move Qi, eliminate stagnation, subdue rebellious Qi, harmonize the Penetrating Vessel, nourish Blood, tonify the Kidneys, calm the Mind, calm the fetus. Acupuncture
The same as for the previous pattern, except that the emphasis should be on nourishing Blood and tonifying the Kidneys.
Herbal treatment
Pre scriptions
• E JIAO YANG XUE TANG Colla Corii Asini Nourishing Blood Decoction • EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan Women’s Treasure remedy
• PENETRATING VESSEL
Prognosis and prevention Acupuncture and Chinese herbs are both very effective in relieving the condition of feeling of suffocation in pregnancy. If there is a background of Kidney-Yin deficiency, it will be more difficult to treat, but most cases should be cleared in a few weeks. There is no Western view of this condition. End notes 1. Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 19. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang) and published in 1729..
2. Ibid., p. 19..
CHAPTER 38 Aphonia During Pregnancy
AETIOLOGY AND PATHOLOGY 523 IDENTIFICATION OF PATTERNS AND TREATMENT 523 Kidney-Yin deficiency 523 PROGNOSIS AND PREVENTION 524 Loss of voice or hoarseness occurring towards the end of pregnancy is called zi yin, which means ‘loss of voice in pregnancy’.
Aetiology and pathology The aetiology of this condition is always related to Yin deficiency. It occurs towards the end of the pregnancy because, due to the Yin deficiency of the Kidneys, the Uterus channel (Bao Luo), which pertains to the Kidneys, becomes ‘detached’. In fact, one of the earliest references to the Uterus channel is in connection with aphonia in pregnancy. Chapter 47 of the Simple Questions says: The Yellow Emperor asked: In the ninth month of pregnancy some women develop aphonia, how does this happen? Chi Po replied: It is because the Uterus Channel becomes cut off. The Yellow Emperor asked: How do you explain that? Chi Po replied: The Uterus channel is connected to the Kidneys which pertains to Lesser Yin; the Kidney channel reaches the root of the tongue, hence the woman cannot speak.1 The pathology of aphonia in pregnancy is always related to Yin deficiency of the Kidneys and possibly Lungs.
Identification of patterns and treatment There is only one pattern and that is Kidney-Yin deficiency.
Kidney-Yin deficiency
Clinical manifestations Aphonia or hoarseness towards the end of pregnancy, dry throat, malar flush, a feeling of heat in the evening, dizziness, tinnitus. Tongue: without coating; Red in case of Empty-Heat. Pulse: Floating-Empty. Treatment principle Nourish Kidney-Yin, ease the throat. Acupuncture LU-7 Lieque with KI-6 Zhaohai, Ren-23 Lianquan. All with even method. Explanation
– LU-7 Lieque and KI-6 regulate the Directing Vessel which starts from the Kidneys and goes through the throat. KI-6 also nourishes Kidney-Yin and benefits the throat. – Ren-23 eases the throat and treats aphonia. Herbal treatment
Prescription
– LIU WEI DI HUANG WAN Variation – Six-Ingredient Rehmannia Pill Variation Explanation This well-known formula, already explained, nourishes Kidney-Yin. – Bei Sha Shen, Mai Men Dong, Tian Men Dong and Lian Zi Xin were added to nourish Lung-Yin and benefit the throat. Three Treasures remedies
– NOURISH THE ROOT This remedy is a variation of Zuo Gui Wan Restoring the Left [Kidney] Pill which nourishes Kidney-Yin and strengthens the Directing and Penetrating Vessels. The tongue presentation appropriate to this remedy is a Red body without coating. – JADE SPRING This remedy is a variation of Sha Shen Mai Dong Tang GlehniaOphiopogon Decoction which nourishes Lung- and Stomach-Yin. It is used in preference to the previous remedy when there is a deficiency of Lung- and Stomach-Yin rather than Kidney-Yin. Summary Kidney-Yin deficiency
Clinical manifestations
Aphonia or hoarseness towards the end of pregnancy, dry throat, malar flush, a feeling of heat in the evening, dizziness, tinnitus. Tongue: without coating; Red in case of Empty-Heat. Pulse: Floating-Empty. Treatment principle
Nourish Kidney-Yin, ease the throat. Acupuncture
LU-7 Lieque with KI-6 Zhaohai, Ren-23 Lianquan. All with even method. Herbal treatment
Pre scription
• LIU WEI DI HUANG WAN Variation Six-Ingredient Rehmannia Pill Variation Three Treasures remedies
• NOURISH THE ROOT • JADE SPRING
Prognosis and prevention This condition is easy to treat, especially with herbs. It should be cleared with a few decoctions. In such a case, it would be important for the patient to take decoctions rather than a powder or tablets as they would soothe the throat directly. Pears are also highly recommended as this fruit nourishes Yin and benefits the throat. There is no Western view of this condition. End note 1. 1979 The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen
), People’s Health Publishing House, Beijing, p. 259. First published c. 100 BC..
CHAPTER 39 Cough During Pregnancy
AETIOLOGY 525 PATHOLOGY 525 IDENTIFICATION OF PATTERNS AND TREATMENT 525 Lung-Qi deficiency 525 Lung-Yin deficiency 526 Phlegm-Heat in the Lungs 527 PROGNOSIS AND PREVENTION 528 Cough in pregnancy is a condition that is characterized not only by a persistent cough but also by mental restlessness and a feeling of heat.
Aetiology
Overwork Overwork may injure Yin; as in pregnancy the Kidneys are taxed from nourishing the fetus, Kidney-Yin may develop easily. If the woman also has emotional problems such as worry, grief or sadness, the Yin deficiency will affect the Lungs also, causing a persistent cough. Irregular diet, emotional problems Excessive consumption of dairy and greasy foods injures the Spleen and leads to the formation of Phlegm; this may settle in the Lungs and prevent the proper descending of Lung-Qi, causing a cough. Emotional problems such as anger, frustration, resentment and worry may lead to Qi stagnation which, with time, may generate Fire. Fire combines with Phlegm easily and it may injure Lung-Yin, causing a cough.
Pathology Thus, the pathology of cough in pregnancy consists in Lung-Qi deficiency, Lung-Yin deficiency or Phlegm-Heat obstructing the Lungs. The two patterns may also coexist as the Fire within Phlegm-Heat may injure Lung-Yin and lead to Yin deficiency. A cough from Lung-Yin deficiency is of course a dry cough with dryness of the throat, while a cough from Phlegm-Heat will be productive of yellow sputum.
Identification of patterns and treatment The treatment principle in cough in pregnancy is either to nourish Lung-Yin and moisten the Lungs or to resolve Phlegm and clear Heat and, in both cases, to restore the descending of Lung-Qi. In addition to these treatment principles, one should also adopt the principle of calming the fetus as a persistent cough in pregnancy may lead to miscarriage. Particular care should be exercised when prescribing herbs that make Qi descend, or dry, pungent herbs that resolve Phlegm, or herbs that drain Dampness through urination during pregnancy, as all these types of herbs may cause miscarriage if used in excess. The patterns discussed are: • Lung-Qi deficiency • Lung-Yin deficiency • Phlegm-Heat in the Lungs.
Lung-Qi deficiency
Clinical manifestations Mild cough, shortness of breath, tiredness, weak voice, propensity to catching colds. Tongue: Pale. Pulse: Empty. Treatment principle Tonify Qi, strengthen the Lungs, restore the descending of Lung-Qi. Acupuncture LU-7 Lieque, LU-9 Taiyuan, BL-13 Feishu, Ren-12 Zhongwan (if within 3 months of pregnancy), ST-36 Zusanli, ST-37 Shangjuxu. All with reinforcing method. Explanation
– LU-7 restores the descending of Lung-Qi. – LU-9 and BL-13 tonify Lung-Qi. – Ren-12 tonifies Stomach- and Lung-Qi (the Lung channel begins at this point). – ST-37 opens the chest and restores the descending of Lung-Qi. Herbal treatment
Prescription
– BU FEI TANG – Tonifying the Lungs Decoction Explanation This formula tonifies Lung-Qi, restores the descending of Lung-Qi and stops cough. Summary Lung-Qi deficiency
Clinical manife stations
Mild cough, shortness of breath, tiredness, weak voice, propensity to catching colds. Tongue: Pale. Pulse: Empty. Tre atme nt principle
Tonify Qi, strengthen the Lungs, restore the descending of Lung-Qi. Acupuncture
LU-7 Lieque, LU-9 Taiyuan, BL-13 Feishu, Ren-12 Zhongwan (if within three months of pregnancy), ST-36 Zusanli, ST-37 Shangjuxu. All with reinforcing method. He rbal tre atme nt
Prescription
• BU FEI TANG Tonifying the Lungs Decoction
Modifications
• If there is Spleen-Qi deficiency, add Bai Zhu Rhizoma Atractylodis macrocephalae. • If there is Kidney-Yang deficiency, add Xu Duan Radix Dipsaci and Hu Tao Rou Semen Juglandis.
Lung-Yin deficiency
Clinical manifestations A dry, persistent cough that starts during the second trimester and is worse in the evenings, a dry throat, thirst with desire to drink in small sips, night sweating. Tongue: without coating and cracked; the body may be Red if there is Empty-Heat or normal if there is no Empty-Heat. Pulse: FloatingEmpty, or Fine-Rapid if there is Empty-Heat. Treatment principle Nourish Lung-Yin, restore the descending of Lung-Qi, moisten the Lungs, calm the fetus. Acupuncture LU-9 Taiyuan, Ren-17 Shanzhong, KI-6 Zhaohai, BL-13 Feishu, BL-43 Gaohuangshu. All with reinforcing method. Explanation
– LU-9 nourishes Lung-Yin. – Ren-17, needled horizontally downwards, restores the descending of Lung-Qi. – KI-6 nourishes Yin and benefits the throat. – BL-13, Back-Transporting point of the Lungs, restores the descending
of Lung-Qi. – BL-43 nourishes Lung-Yin and stops cough from Yin deficiency. It is particularly indicated for chronic problems. Herbal treatment
Prescription
– BAI HE GU JIN TANG – Lilium Consolidating Metal Decoction Explanation
– Bai He and Mai Men Dong nourish Lung-Yin. – Xuan Shen, Sheng Di Huang and Shu Di Huang nourish Kidney-Yin. – Dang Gui and Bai Shao nourish Blood and moisten. – Jie Geng and Chuan Bei Mu restore the descending of Lung-Qi. – Gan Cao harmonizes. Summary Lung-Yin deficiency
Clinical manife stations
A dry, persistent cough that starts during the second trimester and is worse in the evenings, a dry throat, thirst with desire to drink in small sips, night sweating. Tongue: without coating and cracked; the body may be Red if there is Empty-Heat or normal if there is no Empty-Heat. Pulse: FloatingEmpty, or Fine-Rapid if there is Empty-Heat. Tre atme nt principle
Nourish Lung-Yin, restore the descending of Lung-Qi, moisten the Lungs, calm the fetus. Acupuncture
LU-9 Taiyuan, Ren-17 Shanzhong, KI-6 Zhaohai, BL-13 Feishu, BL-43 Gaohuangshu. All with reinforcing method. He rbal tre atme nt
Prescription
• BAI HE GU JIN TANG Lilium Consolidating Metal Decoction
Phlegm-Heat in the Lungs
Clinical manifestations Cough that is productive of yellow sputum, a feeling of oppression of the chest. Tongue: Swollen with a sticky, yellow coating. Pulse: Slippery and Rapid. Treatment principle Resolve Phlegm, clear Heat, tonify the Spleen, calm the fetus. Acupuncture SP-9 Yinlingquan, ST-40 Fenglong, BL-20 Pishu, LU-5 Chize, LU-6 Kongzui. All with even method, except for BL-20 which should be needled with reinforcing method. Explanation
– SP-9 and ST-40 resolve Phlegm. – BL-20 tonifies the Spleen to resolve Phlegm. – LU-5 resolves Phlegm-Heat from the Lungs. – LU-6, Accumulation point, stops cough. Herbal treatment
a Prescription
– XIAO XIAN XIONG TANG Variation – Small Sinking [Qi of the] Chest Decoction Variation Explanation
– Huang Lian clears Heat and dries Dampness. – Ban Xia resolves Phlegm. – Gua Lou resolves Phlegm-Heat. – Chuan Bei Mu was added to restore the descending of Lung-Qi and stop cough. b Prescription
– QING JIN JIANG HUO TANG Variation – Clearing Metal and Lowering Fire Decoction Variation Explanation
– Huang Qin clears Heat and calms the fetus.
– Xing Ren, Chuan Bei Mu and Jie Geng restore the descending of LungQi and stop cough. – Qian Hu, Gua Lou, Chen Pi, Fu Ling and Ban Xia resolve Phlegm-Heat. – Shi Gao clears Heat. This could be removed as it is too cold and pungent to be given during pregnancy. – Zhi Ke moves Qi and helps to resolve Phlegm. – Zhi Gan Cao and Sheng Jiang harmonize. – Sang Ye and Pi Pa Ye were added to restore the descending of Lung-Qi and stop cough. c Prescription
– ZHI JIE ER CHEN TANG – Aurantium-Platycodon Two Old Decoction Explanation
– This formula, from the Golden Mirror of Medicine (1742), is for cough in pregnancy from Damp-Phlegm with expectoration of white, sticky sputum.1 The first six herbs constitute the formula Er Chen Tang which resolve Damp-Phlegm. – Zhi Ke moves Qi which helps to resolve Phlegm. – Jie Geng resolves Phlegm and restores the descending of Lung-Qi.
To compare and contrast the above three formulae for cough in pregnancy, the first one, Xiao Xian Xiong Tang, purely resolves Phlegm-Heat and does not have a strong Lung-Qi-descending action: it is therefore indicated if Phlegm and Heat predominate and the woman has a lot of mucus while the cough is not too severe. The second one, Qing Jin Jiang Huo Tang, has a stronger effect in resolving Phlegm and, in addition, it also strongly promotes the descending of Lung-Qi to stop coughing. The third one, Zhi Jie Er Chen Tang, resolves Damp-Phlegm rather than Phlegm-Heat. Summary Phlegm-Heat in the lungs
Clinical manife stations
Cough that is productive of yellow sputum, a feeling of oppression of the chest. Tongue: Swollen with a sticky, yellow coating. Pulse: Slippery and Rapid. Tre atme nt principle
Resolve Phlegm, clear Heat, tonify the Spleen, calm the fetus. Acupuncture
SP-9 Yinlingquan, ST-40 Fenglong, BL-20 Pishu, LU-5 Chize, LU-6 Kongzui. All with even method, except for BL-20 which should be needled with reinforcing method. He rbal tre atme nt
Prescriptions
• XIAO XIAN XIONG TANG Variation Small Sinking [Qi of the] Chest
Decoction Variation • QING JIN JIANG HUO TANG Variation Clearing Metal and Lowering Fire Decoction Variation • ZHI JIE ER CHEN TANG Aurantium-Platycodon Two Old Decoction
Prognosis and prevention Cough in pregnancy responds well to treatment, and especially with herbs rather than with acupuncture. The pattern from Yin deficiency is more difficult to treat than the one from Phlegm-Fire. Although most cases will react to treatment, the woman needs to be patient as some cases of cough can be quite stubborn and resistant to treatment. On average, the treatment should give good results in about one month. If the woman suffers from the pattern of Phlegm-Heat, it is important for her to refrain from eating too many dairy foods or greasy foods; she should also abstain from eating spicy, hot foods. There is no Western view of this condition. End note 1. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian
), People’s Health Publishing House, Beijing, Vol. 3, p. 57. First published in 1742..
CHAPTER 40 Urinary Syndrome During Pregnancy
AETIOLOGY 529 PATHOLOGY 529 IDENTIFICATION OF PATTERNS AND TREATMENT 529 Heart-Fire 529 Damp-Heat in the Bladder 530 Kidney-Yin deficiency and Empty-Heat 531 PROGNOSIS AND PREVENTION 532 WESTERN VIEW 532 This condition includes frequency, pain and urgency of urination. It was called zi lin, i.e. ‘lin’ disease in pregnancy, ‘lin’ being Urinary Syndrome.
Aetiology
Emotional problems Anger, worry, frustration, resentment and hatred may all lead to stagnation of Qi: this may affect the Bladder function directly or stagnant Qi may turn into Fire, specifically Heart- and Liver-Fire which may infuse down to the Bladder. Overwork Overwork injures Yin and may cause Kidney-Yin deficiency: this leads to Empty-Heat which may affect the Bladder causing Urinary Syndrome. Irregular diet Excessive consumption of dairy or greasy foods injures the Spleen and leads to Dampness: Dampness infuses downwards to the Bladder and may cause Urinary Syndrome. Excessive sexual activity during pregnancy Excessive sexual activity, especially in the first or third trimester, may lead to stagnation of Qi in the lower genital system and to Urinary Syndrome.
Pathology The pathology of urinary problems in pregnancy is usually related to Heat: this can be either Full-Heat, in the form of Heart-Fire or Bladder DampHeat, or Empty-Heat from Yin deficiency. Heart-Fire causes Urinary Syndrome when it is transmitted to the Small Intestine, to which the Heart is connected within the Fire element, and from the Small Intestine to the Bladder, to which the Small Intestine is connected within the Greater Yang channel system.
Identification of patterns and treatment The patterns discussed are: • Heart-Fire • Damp-Heat in the Bladder • Kidney-Yin deficiency and Empty-Heat.
Heart-Fire
Clinical manifestations Scanty, dark urine, burning on urination, difficult urination, red face, thirst, insomnia, mental restlessness, agitation. Tongue: Red with redder tip or normal coloured with a Red tip; in both cases there may be Red points on the tip. Pulse: Overflowing on the left Front position. Treatment principle Drain Heart-Fire and Small Intestine-Fire, clear Heat in the Bladder, calm the fetus. Acupuncture HE-8 Shaofu, S.I.-2 Qiangu, S.I.-5 Yanggu, BL-28 Pangguangshu, BL-32 Ciliao, BL-15 Xinshu, BL-27 Xiaochangshu, SP-9 Yinlingquan. All with even method. No moxa. Explanation
– HE-8 and BL-15 clear Heart-Fire. – S.I.-2, S.I.-5 and BL-27 clear Small Intestine-Heat. – BL-28 and BL-32 clear Bladder-Heat. – SP-9 clears Heat and resolves Dampness from the Lower Burner.
Herbal treatment
Prescription
– DAO CHI SAN – Eliminating Redness Powder Explanation This formula drains Heart-Fire and resolves Damp-Heat in the Bladder. – Sheng Di Huang clears Heat and cools Blood. – Mu Tong clears Heart-Heat and also Bladder Damp-Heat. This herb is supposed to be contraindicated in pregnancy: in addition to that, its use is illegal in Europe and the USA. It should be replaced with Tong Cao Medulla Tetrapanacis. – Gan Cao resolves Toxic-Heat and stops pain. – Zhu Ye clears Heart-Heat. Summary Heart-Fire
Clinical manife stations
Scanty, dark urine, burning on urination, difficult urination, red face, thirst,
insomnia, mental restlessness, agitation. Tongue: Red with redder tip or normal coloured with a Red tip; in both cases there may be Red points on the tip. Pulse: Overflowing on the left Front position. Tre atme nt principle
Drain Heart-Fire and Small Intestine-Fire, clear Heat in the Bladder, calm the fetus. Acupuncture
HE-8 Shaofu, S.I.-2 Qiangu, S.I.-5 Yanggu, BL-28 Pangguangshu, BL-32 Ciliao, BL-15 Xinshu, BL-27 Xiaochangshu, SP-9 Yinlingquan. All with even method. No moxa. He rbal tre atme nt
Prescription
• DAO CHI SAN Eliminating Redness Powder
Damp-Heat in the Bladder
Clinical manifestations Difficult urination with slight retention, frequency and burning of urination, slightly turbid urine, yellowish complexion, thirst with no desire to drink, a feeling of heaviness. Tongue: yellow, sticky coating on the root with Red points. Pulse: Slippery on the left Rear position. Treatment principle Clear Heat, resolve Dampness, promote urination. Acupuncture SP-9 Yinlingquan, BL-32 Ciliao, BL-28 Pangguangshu, BL-22 Sanjiaoshu. All with even method, no moxa. Explanation
– SP-9, BL-32 and BL-28 resolve Damp-Heat from the Bladder. – BL-22, Back-Transporting point of the Triple Burner, promotes the transformation of fluids in the Lower Burner. Herbal treatment
Prescription
– JIA WEI WU LIN SAN – Augmented Five ‘Lin’ Powder Explanation
– Fu Ling, Ze Xie, Che Qian Zi, Hua Shi and Mu Tong resolve Dampness from the Bladder, clear Heat and promote urination. It would be advisable to remove Che Qian Zi from the formula as it is contraindicated in pregnancy. Mu Tong is also contraindicated in pregnancy and it can actually be removed from this formula without altering it substantially. – Dang Gui nourishes Blood. – Gan Cao stops pain and ‘moderates urgency’. – Chi Shao invigorates Blood. – Shan Zhi Zi resolves Damp-Heat. – Sheng Di Huang clears Heat and cools Blood. Summary Damp-Heat in the Bladder
Clinical manife stations
Difficult urination with slight retention, frequency and burning of urination, slightly turbid urine, yellowish complexion, thirst with no desire to drink, a feeling of heaviness. Tongue: yellow, sticky coating on the root with Red
points. Pulse: Slippery on the left Rear position. Tre atme nt principle
Clear Heat, resolve Dampness, promote urination. Acupuncture
SP-9 Yinlingquan, BL-32 Ciliao, BL-28 Pangguangshu, BL-22 Sanjiaoshu. All with even method, no moxa. He rbal tre atme nt
Prescription
• JIA WEI WU LIN SAN Augmented Five ‘Lin’ Powder
Kidney-Yin deficiency and Empty-Heat
Clinical manifestations Frequent, scanty urination, slight burning on urination, dark urine, malar flush, feeling of heat in the evening, backache, dizziness, tinnitus. Tongue: Red without coating except for a yellow coating on the root. Pulse: FloatingEmpty. Treatment principle Nourish Kidney-Yin, clear Empty-Heat, calm the fetus. Acupuncture KI-10 Yingu, KI-6 Zhaohai, KI-3 Taixi, KI-2 Rangu, BL-28 Pangguangshu, SP-9 Yinlingquan. All with even method, no moxa. Explanation
– KI-10, KI-6 and KI-3 nourish Kidney-Yin. – KI-2 clears Kidney Empty-Heat. – BL-28 clears Bladder-Heat. – SP-9 clears Heat from the urinary system. Herbal treatment
Prescription
– ZHI BO DI HUANG WAN (also called BA WEI DI HUANG WAN) Variation – Anemarrhena-Phellodendron-Rehmannia Pill Variation Explanation The first eight herbs constitute the formula Zhi Bo Di Huang Wan (a variation of Liu Wei Di Huang Wan Six Ingredients Rehmannia Pill) which nourishes Kidney and Liver-Yin, clears Empty-Heat and resolves Damp-Heat from the Bladder and Kidneys. – Bian Xu was added to resolve Damp-Heat from the Bladder and alleviate urinary burning. Summary Kidney-Yin deficiency and Empty Heat
Clinical manife stations
Frequent, scanty urination, slight burning on urination, dark urine, malar flush, feeling of heat in the evening, backache, dizziness, tinnitus. Tongue: Red without coating except for a yellow coating on the root. Pulse: FloatingEmpty. Tre atme nt principle
Nourish Kidney-Yin, clear Empty-Heat, calm the fetus. Acupuncture
KI-10 Yingu, KI-6 Zhaohai, KI-3 Taixi, KI-2 Rangu, BL-28 Pangguangshu, SP-9 Yinlingquan. All with even method, no moxa. He rbal tre atme nt
Prescription
• ZHI BO DI HUANG WAN (also called BA WEI DI HUANG WAN) Variation Anemarrhena-Phellodendron-Rehmannia Pill Variation
Prognosis and prevention Urinary Syndrome in pregnancy can be quite difficult to treat because several of the herbs that drain Damp-Heat from the Bladder and treat this condition are contraindicated in pregnancy, e.g. Qu Mai Herba Dianthi, Che Qian Zi Semen Plantaginis and Mu Tong Caulis Akebiae. Other herbs that treat Urinary Syndrome should be used ‘with caution’ in pregnancy, e.g. Yi Yi Ren Semen Coicis, Hua Shi Talcum, Tong Cao Medulla Tetrapanacis and Dong Kui Zi Fructus Malvae. However, these contraindications or precautions often show extreme caution and usually no harm derives even from the use of one of the above herbs in pregnancy: for example, two of the formulae mentioned in this very chapter contain Mu Tong. This is not to say that the above precautions should be ignored; it is much better to err on the side of caution, especially when treating pregnant women. Generally speaking, both acupuncture and herbal medicine can be of great help in treating urinary syndrome during pregnancy, certainly more than Western medicine that has only antibiotics to offer. Results can be expected within 2 or 3 weeks of beginning but treatment might have to be continued until the end of the pregnancy: the pattern from Yin deficiency and EmptyHeat is more difficult to treat and will take longer to react to treatment. A woman who is prone to Urinary Syndrome should definitely avoid eating spicy, hot foods.
Western view Pregnancy predisposes women to urinary tract infection because progesterone produces atony of the muscles of the renal pelvis and ureters. In addition to this, the mechanical pressure of the uterus on the ureters is such that the rate of flow of urine is reduced and bacterial growth is encouraged. When the urine is infected and causes cystitis, one must always treat this infection seriously, as in pregnant women there is a higher likelihood of the renal pelvis or parenchyma being involved, leading to pyelitis or pyelonephritis. The commonest bacteria involved in cystitis is Escherichia coli. However, in many cases of women with symptoms of cystitis, no pathogenic organism is found in the urine. Western medicine has no answer to these cases and Chinese medicine does. Many pregnant women have a silent bacteriuria, i.e. there are some bacteria in the urine but no symptoms. This is often the result of a previous urinary infection treated with antibiotics but not cleared completely. Figure 40.1 illustrates this process.
Figure 40.1 Cystitis, bacteriuria and pyelonephritis in pregnancy.
(Reproduced with kind permission from Garrey, Govan, Hodge & Callander, Obstetrics Illustrated, 4th edition, Churchill Livingstone, 1989, p. 143.)
CHAPTER 41 Retention of Urine During Pregnancy
AETIOLOGY 533 PATHOLOGY 533 IDENTIFICATION OF PATTERNS AND TREATMENT 534 Spleen-Qi deficient and sinking 534 Kidney-Qi deficient and sinking 535 Damp-Heat in the Bladder 536 PROGNOSIS AND PREVENTION 537 This condition is characterized by difficult urination, slight retention of urine, an uncomfortable feeling in the lower abdomen and a feeling of irritability.
Aetiology
Excessive physical exercise Excessive physical exercise injures the muscles and the Spleen and may lead to Spleen-Qi deficiency. When Spleen-Qi is deficient, it may also sink leading to a slight prolapse of the internal organs. In pregnancy, this is aggravated by the pressure of the growing fetus on the bladder which, together with Spleen-Qi deficiency, may lead to a slight retention of urine. The Medical Collection of Four Families from Meng He says: Urinary problems in pregnancy are due to the fetus weighing down, pressing on the bladder, leading to urinary problems (which could be retention or incontinence). To treat it, one must raise Qi and lift the fetus.1 Excessive sexual activity, excessive standing or lifting Excessive sexual activity during the last trimester of pregnancy or excessive lifting and standing may injure the Kidneys and lead to the sinking of KidneyQi. In pregnancy, the pressure of the growing fetus on the bladder, together with the sinking of Kidney-Qi, may cause retention of urine. External Dampness External Dampness may invade the channels of the legs: in women, it easily settles in the urinary passages. Here, Dampness obstructs the transformation and transportation of urine and may cause retention. Irregular diet
Excessive consumption of dairy foods and greasy foods easily leads to Dampness. This often settles in the urinary passages and obstructs them in the same way as described above.
Pathology The pathology of retention of urine in pregnancy is characterized by a combination of interacting physical and energetic components. The sinking of Spleen-Qi and/or Kidney-Qi may lead to the fetus dropping down slightly and pressing on the bladder; vice versa, the downward pressure of the growing fetus may lead to the sinking of Spleen- and/or Kidney-Qi. Although normally retention of urine may be due to either Full or Empty causes, in pregnancy it is always due to Empty causes; these may be deficiency and sinking of Spleen-Qi or Kidney-Qi. Thus, the treatment consists in tonifying and raising Spleen- or Kidney-Qi and stimulating the Bladder’s function of Qi transformation.
Identification of patterns and treatment The patterns discussed are: • Spleen-Qi deficient and sinking • Kidney-Qi deficient and sinking • Damp-Heat in the Bladder.
Spleen-Qi deficient and sinking
Clinical manifestations Frequent but scanty urination, discomfort in the lower abdomen, a bearingdown sensation, restlessness with inability to sit or lie down, pale complexion, tiredness, shortness of breath. Tongue: Pale. Pulse: Weak. Treatment principle Tonify Spleen-Qi, raise Yang, lift the fetus. Acupuncture BL-20 Pishu, Du-20 Baihui, ST-36 Zusanli, BL-28 Pangguangshu. All with reinforcing method. Explanation
– BL-20 tonifies Spleen-Qi. – Du-20 and ST-36 tonify and raise Qi. – BL-28 tonifies the Bladder and its function of Qi transformation. Herbal treatment
a Prescription
– YI QI DAO NI TANG – Benefiting Qi and Conducting Turbidity Decoction Explanation
– Dang Shen, Bai Zhu, Bian Dou and Fu Ling tonify and raise Spleen-Qi. – Sheng Ma and Jie Geng, in combination with Qi tonics, raise Qi. – Wu Yao, Gui Zhi and Tong Cao move Qi in the hypogastrium, warm the Bladder and promote the transformation of Water. Tong Cao should be used with caution in pregnancy and it should therefore be used in a very small dose. b Prescription
– YI QI LI SHUI TANG – Benefiting Qi and Transforming Water Decoction Explanation
– Huang Qi, Dang Shen and Bai Zhu tonify and raise Qi. – Sheng Ma, in combination with Huang Qi, raises Qi. – Tong Cao opens the Water passages and removes obstructions from the Connecting channels.
– Gui Zhi, in combination with Tong Cao, opens the Water passages by tonifying the Minister Fire and warming the channels; Heat is necessary to transform Water. – Che Qian Cao and Ze Xie drain Dampness from the Lower Burner. – Yi Mu Cao and Dang Gui invigorate and nourish Blood. – Wu Yao moves Qi, which helps to open the Water passages in the Lower Burner. – Gu Ya promotes digestion. Compared with the previous formula, this formula has a more complex action and might actually be more suitable after childbirth. In fact, besides tonifying and raising Qi, it drains Dampness from the urinary system and it nourishes and invigorates Blood. Strictly speaking, Tong Cao and Che Qian Cao are forbidden in pregnancy, so they should be either removed or used in a very small dose. Three Treasures remedies
– TONIFY QI AND EASE THE MUSCLES This remedy is a variation of the formula Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction which tonifies and raises Spleen-Qi. It has been modified with the addition of herbs which resolve Dampness: it is therefore particularly indicated if there is Dampness. The tongue presentation appropriate to this remedy is a Pale body with a sticky, white coating. – SEPARATE CLEAR AND TURBID This remedy promotes the transformation and separation of fluids in the Bladder and also tonifies and lifts Spleen- and Kidney-Qi: it is specific to treat urinary difficulty deriving from Qi deficiency and Dampness in the
urinary passages. The tongue presentation appropriate to this remedy is a Pale body. Strictly speaking, Qu Mai and Che Qian Zi are forbidden in pregnancy, so this remedy should be used in a very small dose (e.g. one or two tablets a day). Summary Spleen-Qi deficient and sinking
Clinical manifestations
Frequent but scanty urination, discomfort in the lower abdomen, a bearingdown sensation, restlessness with inability to sit or lie down, pale complexion, tiredness, shortness of breath. Tongue: Pale. Pulse: Weak. Treatment principle
Tonify Spleen-Qi, raise Yang, lift the fetus. Acupuncture
BL-20 Pishu, Du-20 Baihui, ST-36 Zusanli, BL-28 Pangguangshu. All with reinforcing method. Herbal treatment
Pre scriptions
• YI QI DAO NI TANG Benefiting Qi and Conducting Turbidity Decoction • YI QI LI SHUI TANG Benefiting Qi and Transforming Water Decoction
Three Treasures remedies
• TONIFY QI AND EASE THE MUSCLES • SEPARATE CLEAR AND TURBID
Kidney-Qi deficient and sinking
Clinical manifestations Frequent but scanty urination, pale urine, flow of micturition interrupted, uncomfortable sensation in hypogastrium which is worse when sitting, feeling cold, backache, tiredness. Tongue: Pale and wet. Pulse: Deep, Weak. Treatment principle Tonify and warm Kidney-Yang, promote the transformation of Water, warm the Bladder, calm the fetus. Acupuncture BL-23 Shenshu, Du-20 Baihui, ST-36 Zusanli, KI-3 Taixi, KI-7 Fuliu, BL63 Jinmen, BL-28 Pangguangshu, Du-4 Mingmen. All with reinforcing method, except for KI-7 and BL-63 which should be needled with even method. Moxa should be used. Explanation
– BL-23 tonifies Kidney-Yang. It should be tonified with moxa cones. – Du-20 and ST-36 tonify and raise Qi. – KI-3, Source point, tonifies the Kidneys. – KI-7 and BL-63 promote the transformation of Water and stimulate the Bladder’s function of Qi transformation.
– BL-28, with moxa cones, warms the Bladder and promotes its function of Qi transformation. – Du-4, with moxa cones, strongly warms the Fire of the Gate of Life. This point should be used with caution and only when the symptoms of Cold from Yang deficiency are very pronounced. Herbal treatment
Prescription
– JIN GUI SHEN QI WAN Variation – Golden Chest Kidney-Qi Pill Variation Explanation The first eight herbs constitute the formula Jin Gui Shen Qi Wan, already explained, which tonifies and warms Kidney-Yang. Please note that Fu Zi Radix Aconiti lateralis preparata is contraindicated in pregnancy and can be removed. In any case, this herb may be illegal in some countries. – Ba Ji Tian and Tu Si Zi tonify Kidney-Yang: Tu Si Zi also calms the fetus. Three Treasures remedy
– STRENGTHEN THE ROOT This remedy is a variation of the formula You Gui Wan Restoring the Right [Kidney] Pill which tonifies and warms Kidney-Yang and strengthens
the Governing Vessel. The tongue presentation appropriate to this remedy is a Pale and wet body. I have not recommended the prepared remedy Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill because it contains Fu Zi Radix Aconiti lateralis preparata which is contraindicated in pregnancy. However, there are on the market variations of Jin Gui Shen Qi Wan without Fu Zi: if these can be obtained, then this remedy would be suitable. Summary Kidney-Qi deficient and sinking
Clinical manifestations
Frequent but scanty urination, pale urine, flow of micturition interrupted, uncomfortable sensation in hypogastrium which is worse when sitting, feeling cold, backache, tiredness. Tongue: Pale and wet. Pulse: Deep, Weak. Treatment principle
Tonify and warm Kidney-Yang, promote the transformation of Water, warm the Bladder, calm the fetus. Acupuncture
BL-23 Shenshu, Du-20 Baihui, ST-36 Zusanli, KI-3 Taixi, KI-7 Fuliu, BL63 Jinmen, BL-28 Pangguangshu, Du-4 Mingmen. All with reinforcing method, except for KI-7 and BL-63 which should be needled with even method. Moxa should be used. Herbal treatment
Pre scription
• JIN GUI SHEN QI WAN Variation Golden Chest Kidney-Qi Pill Variation Three Treasures remedy
• STRENGTHEN THE ROOT
Damp-Heat in the Bladder
Clinical manifestations Difficult urination, dark and turbid urine, irritability, a feeling of heaviness in the lower abdomen, poor appetite, a sticky taste. Tongue: thick, sticky, yellow coating on the root with Red spots. Pulse: Slippery and slightly Wiry on the left Rear position. Treatment principle Resolve Dampness, clear Heat, promote the transformation of Water, calm the Mind, calm the fetus. Acupuncture BL-28 Pangguangshu, BL-32 Ciliao, BL-53 Baohuang, BL-22 Sanjiaoshu, SP-9 Yinlingquan, BL-63 Jinmen. All with even method, no moxa. Explanation
– BL-28, BL-32 and BL-53 resolve Dampness from the Bladder. – BL-22 promotes the transformation of fluids in the Lower Burner. – SP-9 resolves Damp-Heat in the Lower Burner. – BL-63, Accumulation point, removes obstructions from the Bladder. Herbal treatment
a Prescription
– DONG KUI ZI SAN Variation – Fructus Malvae Powder Variation Explanation The first four herbs constitute the formula Dong Kui Zi San which is specific for urinary retention during pregnancy according to the Great Dictionary of Chinese Formulae.2 Dong Kui Zi and Fu Ling, in combination, also constitute a formula of the same name, Dong Kui Zi San. The dosages of the first four herbs are those from the original formula: I would personally at least halve them and not use Mu Tong. Although Mu Tong and Dong Kui Zi are contraindicated in pregnancy, this formula is considered specific for retention of urine in pregnancy. I would replace Mu Tong with Tong Cao Medulla Tetrapanacis. – Dong Kui Zi, Hua Shi, Mu Tong and Fu Ling resolve Damp-Heat from the Bladder. – Shan Zhi Zi clears Heat and resolves Dampness. Note: Dong Kui Zi, Shan Zhi Zi and Hua Shi can also be used externally as a wash. b Prescription
– ZI SHEN TANG3
– Nourishing the Kidneys Decoction Explanation
– Zhu Ling and Fu Ling drain Dampness. – Che Qian Zi, Mu Tong, Huang Bo and Hua Shi drain Damp-Heat. – Zhi Mu clears Heat. – Rou Gui is used here to tonify the Minister Fire to promote the transformation of Water. – Jie Geng is used here to vent the Upper Burner which promotes the excretion of fluids in the Lower Burner. This use is comparable to the hole in a teapot lid which facilitates the pouring of tea. Strictly speaking, Che Qian Zi and Mu Tong are contraindicated in pregnancy, so they should either be removed or used in a very small dose. Summary Damp-Heat in the Bladder
Clinical manife stations
Difficult urination, dark and turbid urine, irritability, a feeling of heaviness in the lower abdomen, poor appetite, a sticky taste. Tongue: thick, sticky, yellow coating on the root with Red spots. Pulse: Slippery and slightly Wiry on the left Rear position. Tre atme nt principle
Resolve Dampness, clear Heat, promote the transformation of Water, calm
the Mind, calm the fetus. Acupuncture
BL-28 Pangguangshu, BL-32 Ciliao, BL-53 Baohuang, BL-22 Sanjiaoshu, SP-9 Yinlingquan, BL-63 Jinmen. All with even method, no moxa. He rbal tre atme nt
Prescriptions
• DONG KUI ZI SAN Variation Fructus Malvae Powder Variation • ZI SHEN TANG Nourishing the Kidneys Decoction
Prognosis and prevention Difficulty in urination responds well to treatment with both acupuncture and/or herbs. In my experience, the three patterns described above often occur in combination, e.g. Spleen-Qi deficiency with Dampness or KidneyQi deficiency with Dampness. When selecting a formula, one must therefore decide whether the deficiency or the Dampness is predominant. The pattern from Damp-Heat is the most difficult to treat. Generally speaking, with a combination of acupuncture and herbs, good results should be obtained within days. There is no Western view of this condition. End notes 1. Zhang Yuan Kai (ed.) 1985 Medical Collection of Four Families from Meng He (Meng He Si Jia Yi Ji
), Jiangsu Science Publishing House, Nanjing, p. 212..
2. Peng Huai Ren 1994 Great Dictionary of Chinese Medicine Formulae (Zhong Yi Fang Ji Da Ci Dian
), People’s Health Publishing House, Beijing, p. 543..
3. Hu Xi Ming 1990 Great Treatise of Secret Formulae in Chinese Medicine (Zhong Guo Zhong Yi Mi Fang Da Quan
), Culture Publishing House, Shanghai, Vol. 2, p. 69..
CHAPTER 42 Constipation During Pregnancy
AETIOLOGY AND PATHOLOGY 539 IDENTIFICATION OF PATTERNS AND TREATMENT 540 Blood deficiency 540 Kidney-Yang deficiency 541 Kidney-Yin deficiency 542 Liver-Qi stagnation 543 PROGNOSIS AND PREVENTION 543 Constipation during pregnancy is a common complaint. From a Western perspective, this is due to the relaxant effect of progesterone on smooth muscles, to pelvic hyperaemia and to pressure of the enlarged uterus. From a Chinese point of view, constipation during pregnancy may be due either to a deficiency, usually of Blood and/or Kidneys, or to an excess, usually stagnation of Qi. The deficiency pathology is easily explained as the mother’s Blood and Kidney energy nourish the growing fetus and if she suffered from a pre-existing Blood or Kidney deficiency, this may cause constipation. The excess pathology is due to an imbalance within the Penetrating Vessel (Chong Mai) with rebellious Qi flowing upwards and stagnating in the abdomen: this is a common pathology during pregnancy, especially in the first 3 months. The treatment of constipation during pregnancy, whether it is with acupuncture or herbs, is fraught with difficulties. In fact, the basic treatment principles in constipation are to move downwards (through purgation) or to
promote the downward movement of Qi, both of which are absolutely forbidden during pregnancy. If acupuncture is used, there is the added difficulty that no points in the abdomen can be used. A common complication of constipation during pregnancy is the development of haemorrhoids: this is discussed at the end of Chapter 50 on constipation after childbirth and the reader is referred to that; however, pay attention to avoiding any herb or acupuncture point that is contraindicated in pregnancy.
Aetiology and pathology
Irregular diet Diet is of course an important cause of constipation. Excessive consumption of hot foods dries up the fluids of Stomach and Intestines and may cause constipation by drying up the stools so that they cannot be moved properly. Conversely, excessive consumption of cold foods may block the Spleen function of transportation so that stools cannot be moved downwards. Apart from the nature of foods eaten, lack of fibre in food is of course a major cause of constipation in Western industrialized countries. Lack of fibre in the diet is a modern cause of disease not contemplated in the old classics of Chinese medicine as it would not have been a problem in the times at which they were written. The importance of this factor has, however, lessened considerably over the past 10 years or so as awareness about the importance of fibre in the diet has increased tremendously. Emotional stress Emotional stress affects the bowel movements mostly through the Liver and Spleen. Emotional problems such as anger, resentment or frustration over a long period of time may cause stagnation of Liver-Qi. Stagnant Liver-Qi obstructs the smooth flow of Qi in the Lower Burner and leads to constipation and abdominal distension and pain. This is constipation of an excess nature. Excessive mental work, too much thinking and worrying, and brooding all affect the Spleen and slow down its transportation of food in the Intestines, leading to constipation. This is constipation of a deficient nature and is not accompanied by distension and pain.
Lack of exercise Lack of exercise is another very important cause of constipation in Western industrialized societies. Exercise stimulates the peristalsis of the Large Intestine and, from a Chinese perspective, lack of exercise weakens SpleenQi and may also cause stagnation of Liver-Qi. Deficient Spleen-Qi over a long period of time fails to provide Qi to move the stools and therefore may result in constipation, while stagnant Liver-Qi may cause it by failing to move Qi in the Intestines. Overwork Excessive physical work weakens the Spleen and injures muscles. Deficient Spleen-Qi fails to move the stools in the Large Intestine and may cause constipation. Overwork in the sense of working long hours without adequate rest for many years weakens the Kidneys. If it weakens Kidney-Yin, it may cause constipation from dryness. If it weakens Kidney-Yang, it may cause constipation by leading to internal Cold.
Identification of patterns and treatment The patterns discussed are: • Blood deficiency • Kidney-Yang deficiency • Kidney-Yin deficiency • Liver-Qi stagnation.
Blood deficiency
Clinical manifestations Constipation during pregnancy, difficult defaecation with dry stools, pale complexion, dizziness, blurred vision, tiredness, depression. Tongue: Pale and Thin. Pulse: Choppy. Treatment principle Nourish Blood, strengthen the Liver, moisten the Intestines. Acupuncture LIV-8 Ququan, ST-36 Zusanli. Both with reinforcing method. Explanation
– LIV-8 nourishes Liver-Blood. – ST-36 tonifies Qi and Blood. Herbal treatment
Prescription
– SI WU TANG Variation – Four Substances Decoction Variation Explanation The first four herbs constitute the formula Si Wu Tang which nourishes Blood. Make sure to use only the ‘body’ of Dang Gui. I have reduced the dosage of Chuan Xiong. – Rou Cong Rong tonifies the Kidneys and promotes the bowel movement. – Bai Zi Ren nourishes Blood, calms the Mind and promotes the bowel movement. – Shou Wu nourishes Blood and body fluids. Modifications
• If there is also Yin deficiency, add Sheng Di Huang Radix Rehmanniae. • If there is also Qi deficiency, add Dang Shen Radix Codonopsis and Shan Yao Rhizoma Dioscoreae. • If the Qi deficiency is pronounced with sweating and a pulse that is Empty but Floating, add Huang Qi Radix Astragali and Ren Shen Radix Ginseng, the latter in a fairly high dose (i.e. at least 9 g). Women’s Treasure remedy
– PRECIOUS SEA
This remedy nourishes Blood in general and moistens dryness. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Blood deficiency
Clinical manifestations Constipation during pregnancy, difficult defaecation with dry stools, pale complexion, dizziness, blurred vision, tiredness, depression. Tongue: Pale and Thin. Pulse: Choppy. Treatment principle Nourish Blood, strengthen the Liver, moisten the Intestines. Acupuncture LIV-8 Ququan, ST-36 Zusanli. Both with reinforcing method. Herbal treatment
Prescription
• SI WU TANG Variation Four Substances Decoction Variation
Women’s Treasure remedy
• PRECIOUS SEA
Kidney-Yang deficiency
Clinical manifestations Difficulty in defaecation, exhaustion and sweating after defaecation, stools not dry, sore back and knees, feeling cold, frequent, pale urination. Tongue: Pale and wet. Pulse: Deep and Weak. This is a pattern of mostly Kidney-Yang deficiency. Normally, when Kidney-Yang is deficient, the stools are loose. However, it may also have the opposite effect when the deficient Kidney-Yang fails to move Qi in the Intestines and the bowels do not move. In addition, when Kidney-Yang is deficient, internal Cold results and this contracts the muscles in the Lower Burner, again impairing the normal bowel peristalsis. Treatment principle Tonify the Kidneys, warm the Lower Burner and moisten the Intestines. Acupuncture ST-36 Zusanli, BL-23 Shenshu, BL-25 Dachangshu, KI-7 Fuliu. Reinforcing method; moxa should be used. Explanation
– ST-36, with moxa on the needle, tonifies Yang and promotes the bowel movement. – BL-23 and KI-7 tonify Kidney-Yang. Direct moxa may be used on BL-
23. – BL-25 stimulates the Intestines and promotes the bowel movement. Herbal treatment
Prescription
– JI CHUAN JIAN – Benefiting the River Decoction Explanation
– Dang Gui moistens the Intestines and promotes the bowel movement. – Niu Xi has a descending movement and therefore promotes the bowel movement. – Rou Cong Rong tonifies Kidney-Yang and promotes the bowel movement. It is one of the very few Kidney-Yang tonics which promote the bowel movement. – Ze Xie drains Dampness via urination: it therefore has a downwards movement and helps Rou Cong Rong to move downwards. Because it also clears Empty-Heat, it prevents excessive heating from Rou Cong Rong. – Zhi Ke moves Qi in the lower abdomen and helps the other herbs to stimulate the bowels.
– Sheng Ma has an ascending movement and it raises clear Yang to the top. Raising the clear Yang towards the upper part of the body makes it easier for the impure Qi to flow downwards, and this therefore stimulates the bowel movement. Summary Kidney-Yang deficiency
Clinical manife stations
Difficulty in defaecation, exhaustion and sweating after defaecation, stools not dry, sore back and knees, feeling cold, frequent, pale urination. Tongue: Pale and wet. Pulse: Deep and Weak. Tre atme nt principle
Tonify the Kidneys, warm the Lower Burner and moisten the Intestines. Acupuncture
ST-36 Zusanli, BL-23 Shenshu, BL-25 Dachangshu, KI-7 Fuliu. Reinforcing method; moxa should be used. He rbal tre atme nt
Prescription
• JI CHUAN JIAN Benefiting the River Decoction
Kidney-Yin deficiency
Clinical manifestations Dry stools, thirst with desire to sip water, dry mouth and throat especially in the evening, sore back and knees, dizziness, tinnitus, night sweating. Tongue: without coating, cracks; Red if there is Empty-Heat. Pulse: Floating-Empty. This condition is more frequent in women with Kidney-Yin deficiency. The tongue will lack a coating completely and will be Red only if there is Empty-Heat; in less serious cases, it may only partially lack coating or have a rootless coating; and in still milder cases, it may have a normal colour with a dry, rootless coating. Treatment principle Nourish Yin, tonify the Kidneys and moisten the Intestines. Acupuncture ST-36 Zusanli, KI-3 Taixi, KI-6 Zhaohai, BL-23 Shenshu, BL-25 Dachangshu. Reinforcing method, no moxa. Explanation
– ST-36 promotes bowel movement. – KI-3 and KI-6 nourish Kidney-Yin. KI-6 also promotes bowel movement.
– BL-23 tonifies the Kidneys. – BL-25 promotes bowel movement. Herbal treatment
a Prescription
– ZENG YE TANG – Increasing Fluids Decoction Explanation All these three herbs nourish Stomach- and Kidney-Yin. This formula originally was for dryness in the Intestines after a Bright Yang-Organ pattern condition in the course of a febrile disease. Such a pattern is characterized by Fire which dries up the body fluids and causes severe dryness in the Intestines and therefore constipation. Apart from its original use, this formula may be used simply to nourish Yin and moisten the Intestines in chronic constipation from Yin deficiency. b Prescription
– TONG YOU TANG – Penetrating the Deep Decoction Explanation
– Sheng Di Huang and Shu Di Huang nourish Yin and Blood. – Dang Gui nourishes Blood and moistens the Intestines. – Sheng Ma raises the clear Yang and, by so doing, helps the impure Qi to descend. This helps to stimulate the bowel movement. – Zhi Gan Cao harmonizes. Summary Kidney-Yin deficiency
Clinical manife stations
Dry stools, thirst with desire to sip water, dry mouth and throat especially in the evening, sore back and knees, dizziness, tinnitus, night sweating. Tongue: without coating, cracks; Red if there is Empty-Heat. Pulse: Floating-Empty. Tre atme nt principle
Nourish Yin, tonify the Kidneys and moisten the Intestines. Acupuncture
ST-36 Zusanli, KI-3 Taixi, KI-6 Zhaohai, BL-23 Shenshu, BL-25 Dachangshu. Reinforcing method, no moxa. He rbal tre atme nt
Prescriptions
• ZENG YE TANG Increasing Fluids Decoction
• TONG YOU TANG Penetrating the Deep Decoction
Liver-Qi stagnation
Clinical manifestations Constipation with stools shaped like pebbles but not dry, desire to open the bowels but difficulty in doing so, belching, abdominal distension, irritability. Tongue: may be of a normal colour or slightly Red on the sides. Pulse: Wiry; it may be Wiry only on the left side. Treatment principle Pacify the Liver, move Qi, eliminate stagnation. Acupuncture Ren-10 Xiawan, G.B.-34 Yanglingquan, LIV-3 Taichong. All with reducing or even method. Explanation
– Ren-10 stimulates the descending of Qi. This point can be used within the first 3 months of pregnancy but not after that. – G.B.-34 moves Liver-Qi in the lower abdomen. – LIV-3 moves Qi and pacifies the Liver. Herbal treatment
Prescription
– LIU MO TANG Variation – Six Ground-Herbs Decoction Variation Explanation
– Mu Xiang, Wu Yao and Chen Xiang regulate Qi, eliminate stagnation and make Qi descend. – Bing Lang and Zhi Ke move downwards and make Qi descend. Modifications
• If there are Heat signs, add Huang Qin Radix Scutellariae and Zhi Zi Fructus Gardeniae. Three Treasures remedy
– FREEING THE MOON This remedy is a variation of Xiao Yao San Free and Easy Wanderer Powder: it moves Qi, eliminates stagnation, nourishes Blood, tonifies Qi and resolves Dampness. The tongue presentation appropriate to this remedy is a normal-coloured body, perhaps with Pale sides if the deficiency of Blood is pronounced. Summary
Liver-Qi stagnation
Clinical manifestations Constipation with stools shaped like pebbles but not dry, desire to open the bowels but difficulty in doing so, belching, abdominal distension, irritability. Tongue: may be of a normal colour or slightly Red on the sides. Pulse: Wiry; it may be Wiry only on the left side. Treatment principle Pacify the Liver, move Qi, eliminate stagnation. Acupuncture Ren-10 Xiawan, G.B.-34 Yanglingquan, LIV-3 Taichong. All with reducing or even method. Herbal treatment
Prescription
• LIU MO TANG Variation Six Ground-Herbs Decoction Variation
Three Treasures remedy
• FREEING THE MOON
Prognosis and prevention Both acupuncture and herbs are excellent to treat this type of constipation and results should be obtained within a few weeks. The Chinese treatment based on nourishing Blood is much better than the Western treatment based on purgatives of the anthraquinone type, such as Cassia (Senakot, Dosalax, Senexone, etc.). Some exercise aimed at improving the tone of the abdominal muscles is essential, especially for the type from Liver-Qi stagnation. Apart from this, the woman should obviously pay attention to having plenty of fibre in her diet.
CHAPTER 43 Habitual Miscarriage
AETIOLOGY AND PATHOLOGY 545 IDENTIFICATION OF PATTERNS AND TREATMENT 546 Kidney-Yang deficiency 546 Kidney-Yin deficiency 548 Blood-Heat 549 Spleen-Qi deficiency 550 Blood deficiency 551 Blood stasis 552 PROGNOSIS AND PREVENTION 553 WESTERN VIEW 553 ‘Habitual miscarriage’ is usually defined as such after three occurrences. In Chinese medicine, miscarriage takes different names according to the time of pregnancy it occurs. If it occurs within 1 month of pregnancy, it is called
an chan ( labour’. Between 1
and
3
months,
), which means ‘hidden it is called duo tai (
), which means ‘falling fetus’. After
3 months it is called xiao chan (
) or
ban chan ( ), which mean ‘small labour’ or ‘half labour’ respectively. Habitual miscarriage is called hua tai (
) which means ‘slippery fetus’. It is important to remember that, according to the experience of Chinese medicine, a miscarriage is as draining to a woman’s energy as labour. Indeed, there is a saying that proclaims ‘a miscarriage is more serious than labour’ (xiao chan chong yu da chan
). This chapter will deal only with the treatment of habitual miscarriage, i.e. the treatment of the woman when she is not pregnant. The treatment for threatened miscarriage or an actual miscarriage was outlined in Chapter 31.
Aetiology and pathology The most common underlying cause is a deficiency of the Kidneys; other concurrent factors may be a deficiency of the Spleen, the Penetrating and Directing Vessels (Chong and Ren Mai) being not firm, and Qi sinking. The aetiological factors should be distinguished as due to the fetus or the mother: • From the fetus: it could be due to weak Original Qi which, in turn, may be due to the parents being too old or ill while conceiving. In such cases, the fetus cannot develop normally and miscarriage results. • From the mother: it could be due to weak body constitution, constitutionally weak Kidneys, excess sex, emotional problems, a Warm disease contracted during pregnancy, falls, accidents, emotional shocks, consumption of certain drugs or excessive lifting. Thus the main pathologies (of the mother) are as follows: • Kidney deficiency which can be constitutional or from overwork. This leads to the Penetrating and Directing Vessels not nourishing the fetus properly and also to Kidney-Qi not holding the fetus. • Blood deficiency from a diet lacking in nourishment, so that the fetus is not nourished properly. • Blood-Heat deriving from emotional problems or from a Warm disease affecting the mother. • Blood stasis deriving from emotional problems or abdominal surgery. In the first 3 months of pregnancy, miscarriage manifests with abdominal pain, sore back and vaginal bleeding which increases steadily with large clots. If miscarriage occurs after 3 months, the vaginal bleeding is heavier and the abdominal pain is severe.
Identification of patterns and treatment To treat the underlying cause of habitual miscarriage, it is best if the woman does not try to get pregnant for at least 6 months, and preferably for a year. Persuading the woman of this is important, and may sometimes be difficult as women who have been infertile for many years are, understandably, anxious to try to conceive as soon as possible. Another reason to dissuade a woman from trying to conceive during the course of treatment is that some of the herbal decoctions used might contain herbs that are contraindicated in pregnancy. It is important to have a clear idea in mind of the aim of our treatment for habitual miscarriage: we treat the woman when she is not pregnant by addressing the underlying condition which is causing her to miscarry. The approach is therefore quite different from that adopted in threatened miscarriage when the main emphasis of the treatment is on ‘calming the fetus’ and avoiding any herb that is contraindicated in pregnancy. It is important to stress this as some books, including Chinese ones, say that the approach to treatment of habitual miscarriage is the same as that for threatened miscarriage, a view with which I personally disagree. For example, the text Chinese Medicine Gynaecology says: “In treating a woman suffering from habitual miscarriage, one must protect the fetus and the treatment may be based on that for threatened miscarriage.”1 The most common underlying cause is a deficiency of the Kidneys. Other concurrent factors may be a deficiency of the Spleen, the Penetrating and Directing Vessels being not firm, and Qi sinking. Thus, apart from the conditions of Blood-Heat or Blood stasis, the main treatment principles in habitual miscarriage are to tonify the Kidneys, nourish Blood, tonify and raise Spleen-Qi and consolidate the Directing and Penetrating Vessels. The patterns discussed are: • Kidney-Yang deficiency
• Kidney-Yin deficiency • Blood-Heat • Spleen-Qi deficiency • Blood deficiency • Blood stasis.
Kidney-Yang deficiency
Clinical manifestations A history of miscarriages early in the pregnancy, lower backache, depression, feeling cold, cold feet, frequent, pale urination, a history of infertility. Tongue: Pale. Pulse: Deep, Weak. Treatment principle Tonify and warm the Kidneys, warm the Uterus, consolidate the Penetrating and Directing Vessels. Acupuncture BL-20 Pishu, BL-23 Shenshu, Du-20 Baihui, Ren-6 Qihai, Du-4 Mingmen, KI-3 Taixi, ST-36 Zusanli, Jinggong (half cun lateral to BL-52 Zhishi). All with reinforcing method and moxa. Explanation
– BL-20 tonifies the Spleen: it is nearly always necessary to do this in a chronic Kidney-Yang deficiency. – BL-23, with direct moxa cones, tonifies and warms Kidney-Yang. – Du-4 warms the Fire of the Gate of Life. – KI-3 tonifies the Kidneys.
– Du-20 and Ren-6 tonify and raise Qi to prevent the downwards movement of the fetus. – ST-36 tonifies Qi in general. – Jinggong tonifies the Kidneys and the Essence. Herbal treatment
a Prescription
– BU SHEN GU CHONG WAN – Tonifying the Kidneys and Consolidating the Penetrating Vessel Pill Explanation
– Tu Si Zi, Xu Duan, Ba Ji Tian, Du Zhong and Lu Jiao Shuang tonify and warm Kidney-Yang and strengthen the Governing Vessel. – Dang Gui, Shu Di Huang, Gou Qi Zi and E Jiao nourish Blood. – Dang Shen, Bai Zhu and Da Zao tonify and raise Qi. – Sha Ren resolves Dampness and counteracts the cloying nature of the tonics in the prescription. b. Prescription
– YOU GUI WAN Variation – Restoring the Right [Kidney] Pill Variation Explanation The formula You Gui Wan, already explained, tonifies and warms KidneyYang. Rou Gui has been removed to make it less hot and Dang Gui has been removed so as not to invigorate Blood. – Huang Qi tonifies and raises Qi to prevent the downward movement of the fetus when the woman does become pregnant. – Fu Pen Zi is astringent and tonifies Kidney-Yang. Being astringent, it prevents loss of the fetus. – Chi Shi Zhi is astringent and has been added for the same reason as above. c. Prescription
– YU SHEN JIAN PI AN TAI TANG2 – Generating the Kidneys, Strengthening the Spleen and Calming the Fetus Decoction Explanation
– Tu Si Zi, Du Zhong and Xu Duan tonify and warm Kidney-Yang, consolidate the Directing and Penetrating Vessels and calm the fetus.
– Sang Ji Sheng tonifies Liver and Kidneys and calms the fetus. – Dang Shen, Bai Zhu and Fu Ling tonify the Spleen to hold the fetus up. – Sheng Di Huang nourishes Yin and Blood and clears fetal Heat. – Su Geng subdues rebellious Qi, harmonizes the Centre and calms the fetus. – Zhu Ma Gen is astringent, it stops bleeding and calms the fetus. It is cold in energy and it clears fetal Heat. Three Treasures remedy
– STRENGTHEN THE ROOT This remedy is a variation of the formula You Gui Wan Restoring the Right [Kidney] Pill and it tonifies Kidney-Yang and strengthens the Governing, Directing and Penetrating Vessels. The tongue presentation appropriate to this remedy is a Pale and wet body. Case history A 40-year-old woman had had a child 6 years previously but she had suffered four miscarriages since then. These four miscarriages all occurred in the first trimester, at 3, 9 (twice) and 12 weeks of pregnancy. She also complained of lower backache, frequent urination, nocturia, a bearing-down feeling in the lower abdomen and tiredness. Her periods were regular, painless but heavier since her miscarriages. Her tongue was Pale and her pulse was Deep, Weak and especially so on both Rear positions. Diagnosis This is a very clear case of Spleen and Kidney-Yang deficiency. The
occurrence of the miscarriages in the first trimester often points to a Kidney deficiency and this is confirmed by the backache, the frequent urination, the nocturia, the Pale tongue and the Deep and Weak pulse on both Kidney positions. Besides this, there is also a deficiency and sinking of Spleen-Qi causing the tiredness, the bearing-down feeling and the heavy period. Treatment principle This patient was treated with both acupuncture and herbal medicine. The main points used were chosen from the following (all with reinforcing method): • ST-36 Zusanli and SP-6 Sanyinjiao tonify the Spleen. • BL-23 Shenshu and BL-20 Pishu tonify Kidney- and Spleen-Yang. • Ren-4 Guanyuan tonifies the Kidneys, strengthens the Uterus and consolidates the Directing and Penetrating Vessels.
The prescription used (as a decoction) was a variation of Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction: • Huang Qi Radix Astragali 9 g • Ren Shen Radix Ginseng 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Sheng Ma Rhizoma Cimicifugae 3 g • Chai Hu Radix Bupleuri 3 g • Tu Si Zi Semen Cuscutae 6 g • Du Zhong Cortex Eucommiae 4 g
• Xu Duan Radix Dipsaci 4 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g
Explanation The first seven herbs constitute the formula Bu Zhong Yi Qi Tang which tonifies and raises Spleen-Qi. • Tu Si Zi, Du Zhong and Xu Duan tonify Kidney-Yang and strengthen the Governing Vessel. • Zhi Gan Cao harmonizes.
After 5 months of fortnightly acupuncture sessions and continuous herbal treatment, she conceived again and carried the pregnancy to full term successfully. Summary Kidney-Yang deficiency
Clinical manifestations
A history of miscarriages early in the pregnancy, lower backache, depression, feeling cold, cold feet, frequent, pale urination, a history of infertility. Tongue: Pale. Pulse: Deep, Weak. Treatment principle
Tonify and warm the Kidneys, warm the Uterus, consolidate the Penetrating and Directing Vessels. Acupuncture
BL-20 Pishu, BL-23 Shenshu, Du-20 Baihui, Ren-6 Qihai, Du-4 Mingmen, KI-3 Taixi, ST-36 Zusanli, Jinggong (half cun lateral to BL-52 Zhishi). All with reinforcing method and moxa. Herbal treatment
Pre scriptions
• BU SHEN GU CHONG WAN Tonifying the Kidneys and Consolidating the Penetrating Vessel Pill • YOU GUI WAN Variation Restoring the Right [Kidney] Pill Variation • YU SHEN JIAN PI AN TAI TANG Generating the Kidneys, Strengthening the Spleen and Calming the Fetus Decoction Three Treasures remedy
• STRENGTHEN THE ROOT
Kidney-Yin deficiency
Clinical manifestations A history of repeated miscarriages (usually within the first 3 months) and infertility, dizziness, tinnitus, night sweating, backache, malar flush. Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty. Treatment principle Nourish Kidney-Yin, nourish Blood, consolidate the Penetrating and Directing Vessels. Acupuncture KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-7 Yinjiao, Ren-6 Qihai, Du-20 Baihui, ST-36 Zusanli, Du-4 Mingmen, BL-23 Shenshu. All with reinforcing method. No moxa. Explanation
– KI-3 nourishes the Kidneys. – LU-7 and KI-6 regulate the Directing Vessel and tonify the Uterus. – Ren-7 nourishes Yin. – Ren-6 and Du-20 tonify and raise Qi to prevent the downward movement of the fetus.
– ST-36 tonifies Qi in general. – Du-4 is used to consolidate the Directing and Governing Vessels. This point is used in combination with the Directing Vessel points as this vessel and the Governing Vessel form a continuous pathway, one Yin and one Yang. It is necessary to tonify the Governing Vessel in this case, even though there is a Yin deficiency, because the Yang-raising action of this vessel is needed to prevent miscarriage and strengthen the Uterus. In other words, it is not enough to tonify the Directing Vessel only: we should also tonify the Governing Vessel which influences the Uterus and gives it strength. – BL-23 tonifies the Kidneys. Herbal treatment
a. Prescription
– BAO YIN JIAN – Protecting Yin Decoction Explanation
– Sheng Di Huang, Shu Di Huang, Bai Shao and Shan Yao nourish Kidney-Yin. – Huang Qin and Huang Bo clear Empty-Heat. – Xu Duan tonifies Kidney-Yang and the Governing Vessel. The reason for its being in the prescription is the same as that for using the Governing Vessel
points in acupuncture (see above). – Gan Cao harmonizes. b. Prescription
– ZUO GUI WAN and ER ZHI WAN Variation – Restoring the Left [Kidney] Pill and Two Solstices Pill Variation Explanation The formula Zuo Gui Wan, already explained, nourishes Kidney-Yin and tonifies the Directing and Penetrating Vessels. Niu Xi has been removed because of its downward movement and its possible effect on the fetus, should the woman conceive during the course of treatment. – Nu Zhen Zi and Han Lian Cao constitute the formula Er Zhi Wan which nourishes Kidney-Yin and clears Empty-Heat. Three Treasures remedy
– NOURISH THE ROOT This remedy nourishes Kidney-Yin and strengthens the Directing and Penetrating Vessels. It is a variation of the formula Zuo Gui Wan Restoring the Left [Kidney] Pill. The tongue presentation appropriate to this remedy is a Red body without coating and possibly with cracks. Summary
Kidney-Yin deficiency
Clinical manifestations
A history of repeated miscarriages (usually within the first 3 months) and infertility, dizziness, tinnitus, night sweating, backache, malar flush. Tongue: without coating; Red, if there is Empty-Heat. Pulse: Floating-Empty. Treatment principle
Nourish Kidney-Yin, nourish Blood, consolidate the Penetrating and Directing Vessels. Acupuncture
KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-7 Yinjiao, Ren-6 Qihai, Du-20 Baihui, ST-36 Zusanli, Du-4 Mingmen, BL-23 Shenshu. All with reinforcing method. No moxa. Herbal treatment
Pre scription
• BAO YIN JIAN Protecting Yin Decoction • ZUO GUI WAN and ER ZHI WAN Variation Restoring the Left [Kidney] Pill and Two Solstices Pill Variation Three Treasures remedy
• NOURISH THE ROOT
Blood-Heat
Clinical manifestations A feeling of heat, thirst, mental restlessness, skin rashes, heavy periods. Tongue: Red with yellow coating. Pulse: Wiry, Overflowing, Rapid. This pattern is often related to Liver-Fire. Treatment principle Clear Heat, cool Blood, regulate periods. Acupuncture SP-10 Xuehai, L.I.-11 Quchi, P-3 Quze, BL-17 Geshu, KI-2 Rangu and LIV-3 Taichong, SP-6 Sanyinjiao, KI-6 Zhaohai, LIV-2 Xingjian. All with reducing or even method except for SP-6 and KI-6 which should be needled with reinforcing method. Explanation
– SP-10, BL-17 and L.I.-11 cool Blood. – P-3 cools Blood. – KI-2 and LIV-3, in combination, cool Blood from the Liver. – SP-6 and KI-6 nourish Yin. – LIV-2 drains Liver-Fire.
Herbal treatment
Prescription
– QING RE GU JING TANG Variation – Clearing Heat and Consolidating the Menses Decoction Variation Explanation The formula Qing Ren Gu Jing Tang, already explained, clears Heat and cools Blood from the Uterus. – Bei Sha Shen is added to nourish and protect the Yin from injury from Heat. Women’s Treasure remedy
– COOL THE MENSES This remedy cools Blood. Summary Blood-Heat
Clinical manifestations
A feeling of heat, thirst, mental restlessness, skin rashes, heavy periods. Tongue: Red with yellow coating. Pulse: Wiry, Overflowing, Rapid. Treatment principle
Clear Heat, cool Blood, regulate periods. Acupuncture
SP-10 Xuehai, L.I.-11 Quchi, P-3 Quze, BL-17 Geshu, KI-2 Rangu and LIV-3 Taichong, SP-6 Sanyinjiao, KI-6 Zhaohai, LIV-2 Xingjian. All with reducing or even method except for SP-6 and KI-6 which should be needled with reinforcing method. Herbal treatment
Pre scription
• QING RE GU JING TANG Variation Clearing Heat and Consolidating the Menses Decoction Variation Women’s Treasure remedy
• COOL THE MENSES
Spleen-Qi deficiency
Clinical manifestations A history of miscarriages after 3 months, tiredness, poor digestion, loose stools, depression, poor appetite. Tongue: Pale. Pulse: Weak. Treatment principle Tonify the Spleen, raise Qi, consolidate the Directing Vessel. Acupuncture Du-20 Baihui, Ren-6 Qihai, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, BL-23 Shenshu, BL-20 Pishu. All with reinforcing method. Moxa is applicable. Explanation
– Du-20 and Ren-6 tonify and raise Qi to prevent the downwards movement of the fetus. – Ren-12, ST-36, SP-6 and BL-20 tonify the Spleen. – KI-3 and BL-23 tonify the Kidneys and strengthen the Uterus. Herbal treatment
Prescription
– GU BEN ZHI BENG TANG Variation – Consolidating the Root and Stopping Flooding Decoction Variation Explanation
– Huang Qi, Ren Shen and Bai Zhu tonify and raise Qi to prevent the downward movement of the fetus when the woman does become pregnant. – Shu Di Huang tonifies the Kidneys and the Directing and Penetrating Vessels. – Pao Jiang tonifies and warms the Spleen. – Dang Gui was removed to eliminate its Blood-invigorating effect. – Sheng Ma, in combination with Huang Qi, raises Qi. – Shan Yao and Da Zao tonify the Spleen. – Wu Zei Gu is astringent and is added to ‘absorb’ the fetus and prevent miscarriage. Three Treasures remedy
– TONIFY QI AND EASE THE MUSCLES This remedy is a variation of the formula Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction which tonifies and
raises Qi: it can therefore prevent the downwards movement of the fetus. The tongue presentation appropriate to this remedy is a Pale body with a sticky coating. Summary Spleen-Qi deficiency
Clinical manifestations
A history of miscarriages after 3 months, tiredness, poor digestion, loose stools, depression, poor appetite. Tongue: Pale. Pulse: Weak. Treatment principle
Tonify the Spleen, raise Qi, consolidate the Directing Vessel. Acupuncture
Du-20 Baihui, Ren-6 Qihai, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, BL-23 Shenshu, BL-20 Pishu. All with reinforcing method. Moxa is applicable. Herbal treatment
Pre scription
• GU BEN ZHI BENG TANG Variation Consolidating the Root and Stopping Flooding Decoction Variation Three Treasures remedy
• TONIFY QI AND EASE THE MUSCLES
Blood deficiency
Clinical manifestations A history of miscarriages, dizziness, blurred vision, a history of scanty periods, insomnia, depression, dry hair and skin, tingling of limbs. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle Nourish Blood, nourish the Kidneys, consolidate the Directing Vessel. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), LIV-8 Ququan, BL-20 Pishu, BL-23 Shenshu, BL-17 Geshu, BL-18 Ganshu, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, Du-20 Baihui, Ren-6 Qihai. All with reinforcing method. Explanation
– LU-7 and KI-6 regulate the Directing Vessel and strengthen the Uterus. – LIV-8 and BL-18 nourish Liver-Blood. – BL-20 and BL-23 tonify Blood. – BL-17, with moxa cones, tonifies Blood. – Ren-4 nourishes Blood and strengthens the Uterus.
– ST-36 and SP-6 tonify Qi and Blood. – Du-20 and Ren-6 tonify and raise Qi to prevent the downward movement of the fetus when the woman becomes pregnant. Herbal treatment
Prescription
– SI WU TANG and SHI XIAO SAN – Four Substances Decoction and Breaking into a Smile Powder Explanation The formula Si Wu Tang nourishes Blood and the formula Shi Xiao San invigorates Blood. Women’s Treasure remedy
– PRECIOUS SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Blood deficiency
Clinical manifestations
A history of miscarriages, dizziness, blurred vision, a history of scanty periods, insomnia, depression, dry hair and skin, tingling of limbs. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle
Nourish Blood, nourish the Kidneys, consolidate the Directing Vessel. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), LIV-8 Ququan, BL-20 Pishu, BL-23 Shenshu, BL-17 Geshu, BL-18 Ganshu, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, Du-20 Baihui, Ren-6 Qihai. All with reinforcing method. Herbal treatment
Pre scription
• SI WU TANG and SHI XIAO SAN Four Substances Decoction and Breaking into a Smile Powder Women’s Treasure remedy
• PRECIOUS SEA
Blood stasis
Clinical manifestations A history of painful or irregular periods with dark, clotted blood, abdominal pain. Tongue: Purple. Pulse: Choppy or Wiry. In habitual miscarriage, this pattern is often associated with KidneyYang deficiency and the stasis of Blood arises from Cold in the Uterus: the tongue would therefore be Bluish-Purple. Treatment principle Warm the Uterus, invigorate Blood, eliminate stasis, tonify Kidney-Yang. Acupuncture Ren-4 Guanyuan, Zigong (extra point), KI-14 Siman, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), Ren-6 Qihai, SP-10 Xuehai, SP-6 Sanyinjiao, BL-17 Geshu, LIV-3 Taichong, BL-23 Shenshu. All with even method except for Ren-4 and BL-23 which should be needled with reinforcing method. Moxa must be used. Explanation
– Ren-4, and Zigong, with moxa cones, warm the Uterus. – KI-14, a point of the Penetrating Vessel, moves Qi and invigorates Blood in this vessel.
– SP-4 and P-6 regulate the Penetrating Vessel and invigorate Blood. – Ren-6 moves Qi in the lower abdomen, which helps to invigorate Blood. – SP-10, SP-6, BL-17 and LIV-3 invigorate Blood and eliminate stasis. – BL-23 tonifies Kidney-Yang. Herbal treatment
Prescription
– SHAO FU ZHU YU TANG Variation – Lower Abdomen Eliminating Stasis Decoction Variation Explanation This formula, already explained in Chapter 14 on painful periods, invigorates Blood and eliminates stasis in the Lower Burner, especially when Blood stasis is associated with Cold in the Uterus. – Qian Cao Gen was added to the root formula to combine invigoration of Blood with stopping bleeding so as to reduce the formula moving-Blood effect. For the same reason, Chuan Xiong and Chi Shao were removed. Three Treasures remedy
– INVIGORATE BLOOD AND STEM THE FLOW
This remedy is a variation of the formula Tao Hong Si Wu Tang Persica-Carthamus Four Substances Decoction which invigorates Blood in the Lower Burner and stops bleeding. The tongue presentation appropriate to this remedy is a Purple body. Summary Blood stasis
Clinical manifestations
A history of painful or irregular periods with dark, clotted blood, abdominal pain. Tongue: Purple. Pulse: Choppy or Wiry. Treatment principle
Warm the Uterus, invigorate Blood, eliminate stasis, tonify Kidney-Yang. Acupuncture
Ren-4 Guanyuan, Zigong (extra point), KI-14 Siman, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), Ren-6 Qihai, SP-10 Xuehai, SP-6 Sanyinjiao, BL-17 Geshu, LIV-3 Taichong, BL-23 Shenshu. All with even method except for Ren-4 and BL-23 which should be needled with reinforcing method. Moxa must be used. Herbal treatment
Pre scription
• SHAO FU ZHU YU TANG Variation Lower Abdomen Eliminating Stasis
Decoction Variation Three Treasures remedy
• INVIGORATE BLOOD AND STEM THE FLOW
Prognosis and prevention Chinese medicine is usually effective in treating habitual miscarriage. Of course, since the treatment is in this case essentially preventive, i.e. aimed at preventing the recurrence of a miscarriage, its success can never be ‘proved’; the woman might have carried the pregnancy to term spontaneously anyway. However, in this as in many other cases, the centuries-old experience of countless Chinese doctors indicates that Chinese medicine does indeed have a role to play in preventing habitual miscarriage. As mentioned before, it is essential that a woman seeking treatment for habitual miscarriage refrains from trying to conceive for at least 6 months, preferably a year. This time is necessary to give a fair chance to the treatment to effect a change in the woman’s condition. Furthermore, even if she does not suffer from habitual miscarriage, a woman should wait at least 3 months before trying to conceive again because a miscarriage has a very draining effect on a woman’s system. The popular view, often corroborated by medical opinion, is that a miscarriage is a trivial occurrence after which a woman can try to conceive again straight away.3 This is not so from the point of view of Chinese medicine which considers a miscarriage as draining to a woman’s system as childbirth, if not more so, especially if there is profuse loss of blood during the miscarriage. In fact, after a miscarriage, there is a sudden drop in hormone levels which has a very weakening effect on the mother. Furthermore, a miscarriage is more draining than childbirth from an emotional point of view as childbirth is at least followed by the joy and emotional fulfilment of motherhood, whereas a miscarriage is followed only by an intense sense of loss and, often, of failure, however unjustified.
Western view In Western medicine, as in Chinese medicine, the term habitual miscarriage (or the more usual term of ‘recurrent abortion’) refers to any case in which there have been at least three consecutive spontaneous abortions. The causes of spontaneous abortion may be classified into those due to the ovum and those due to the mother. Of embryos recovered from abortion, about half are abnormal either chromosomally or structurally. Causes due to the mother include high fever, congestive cardiac failure, severe Rh isoimmunization and chronic renal diseases. Causes due to the condition of the uterus include retroversion of the uterus, myomas (fibroids), cervical incompetence and congenital abnormality of the uterus. Clinical Note
Causes of recurrent abortion
• Embryo: chromosomal or structural abnormality • Mother: high fever, congestive cardiac failure, Rh iso-immunization, chronic renal disease • Uterus: retroversion, myoma, cervical incompetence, congenital abnormality
Early spontaneous abortions (within 3 months) have been attributed to a deficiency of progesterone but this view is not confirmed by controlled clinical trials which have shown no significant improvement from treatment with progestogens.4 An alternative treatment consists in supporting the corpus luteum with intramuscular injections of human chorionic gonadotropin twice weekly, but this treatment is not often given, not least because of its high cost. From a Chinese perspective, recurrent abortion in the first trimester is usually due to a Kidney deficiency and to weakness of the Directing and Penetrating Vessels. Recurrent abortions occurring in the second trimester of pregnancy are usually due to incompetence of the os of the cervix: this may be the result of previous obstetric trauma, previous dilatation and curettage, cone biopsy or cervical amputation. This problem is treated by a suture in the wall of the cervix inserted before the sixteenth week and removed shortly before term. From a Chinese perspective, recurrent abortion in the second trimester is often due to a deficiency and sinking of Spleen-Qi. End note 1. Cong Chun Yu 1989 Chinese Medicine Gynaecology (Zhong Yi Fu Ke Xue
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 60..
2. Zhou Cui Zhen 1996 Titbits from Dr Cai Xiao Sun’s Experience in Treating Difficult Gynaecological Diseases (Cai Xiao Sun Zhi Liao Fu Ke Yi Nan Bing Yan Fang Shi Ling), Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi
), Vol. 37, No. 2, p. 80..
3. For example, an obstetrics text recommends a rest of “a few days before resuming normal duties” after a miscarriage..
4. Lewis T L T, Chamberlain G V P 1994 Obstetrics by Ten Teachers, Edward Arnold, London, p. 146..
CHAPTER 44 Acupuncture and Herbal Treatment in Midwifery By, Sarah Budd, SRN, SCM, Dip.Ac., Sharon Yelland, RN, RM, C.Ac., (Nanjing), revised by Sarah Budd. Herbal treatment by Giovanni Maciocia
ACUPUNCTURE 555 INTRODUCTION 555 BREECH PRESENTATION 556 Exclusion criteria for moxibustion in breech presentation 557 THE USE OF ACUPUNCTURE IN LABOUR 557 IDENTIFICATION OF PATTERNS AND TREATMENT FOR DIFFICULT LABOUR 564 Deficiency of Qi and Blood 564 Stagnation of Qi and Blood 564 Ancient acupuncture prescriptions for difficult labour 565 IDENTIFICATION OF PATTERNS AND TREATMENT FOR RETAINED PLACENTA 565 Deficiency of Qi 565 Cold leading to stasis of Blood 566 IDENTIFICATION OF PATTERNS AND TREATMENT FOR RETENTION OF URINE AFTER DELIVERY 566 Deficiency of Qi 566
Deficiency of the Kidneys 567 CASE HISTORIES 568 TESTIMONIALS 569 CONCLUSION 571 HERBAL TREATMENT 571 HERBAL TREATMENT FOR INDUCTION OF LABOUR 571 HERBAL TREATMENT FOR DIFFICULT LABOUR 571 Deficiency of Qi and Blood 571 Stasis of Blood and stagnation of Qi 572 HERBAL TREATMENT FOR BREECH PRESENTATION 573 HERBAL TREATMENT FOR RETENTION OF PLACENTA 573 Qi and Blood deficiency 573 Stasis of Blood and Cold 574 DISEASES AFFECTING THE FETUS 574 CLINICAL TRIALS 575 Acupuncture and moxibustion for breech presentation 575 Acupuncture for labour 577 Herbal treatment in labour 583
The origin of the world is its mother; Understand the mother and you understand the child; Embrace the child, and you embrace the mother Who will not perish when you die. Lao Zi, Dao De Jing, Chapter 52.
Acupuncture
Introduction There are a limited number of midwives trained in Chinese medicine in the UK and using acupuncture in National Health Service (NHS) maternity units. Those that have been established for many years have found that there is a huge demand for acupuncture in pregnancy, labour and post-natally. The high success rate for treating conditions such as those discussed in previous chapters has contributed to the growth in the popularity of acupuncture in thousands of women who are searching for safe, non-pharmacological methods of treatment for their disorders in pregnancy. As well as treating many ante-natal conditions, these NHS maternity acupuncture services treat breech presentation, teach acupressure for pain relief in labour and, when available, use acupuncture in labour and postnatally. A survey of heads of midwifery throughout the UK in 2005 found that the majority would be keen to have a midwifery acupuncture service but constraints on finances for training and staff shortages made this unlikely. There may soon come a time in the UK when midwives are taught acupuncture specifically for use only in pregnancy, childbirth and for a few post-natal conditions. This is already wide practice in much of Europe, New Zealand and other countries. The experience of the established midwifery acupuncturists is that having acupuncture in pregnancy introduces this ancient treatment to vast numbers of women for the first time, who then go on to use it for themselves and their families at a later stage. Acupuncturists have set up groups to provide acupuncture in pregnancy and labour such as the Acupuncture for Childbirth Team (ACT) in Oxford and London. These groups have found that it is important to have a team approach when it comes to offering acupuncture for labour as it needs to be a 24-hour service.
Breech presentation Breech presentation occurs in 2–4% of pregnant women. There are three types of breech presentation: 1. ‘Flexed’ (with bent legs). 2. ‘Frank’ or ‘extended’ (with legs splinting the body). 3. ‘Footling’ (one or both feet above the cervix). The problem with these presentations is that the head may not fit through the maternal pelvis, and with breech delivery there is a possibility of umbilical cord prolapse or compression. The peri-natal mortality rate after breech delivery is three to four times higher than that associated with vertex delivery. Some obstetric units offer a technique called external cephalic version (ECV) where an experienced obstetrician will manually palpate the mother’s abdomen and try to turn the baby into cephalic or head-first presentation. The results are mixed and women who have had this technique often describe it as being quite uncomfortable. Most maternity units now tend to deliver babies in breech presentation by Caesarean section. Women hoping for a normal vaginal delivery are disappointed and frustrated by this. They are keen to try and do something for themselves and it may be for this reason that the use of acupuncture and moxibustion has attracted much attention. According to channel theory, breech presentation is thought to be due to a loss of equilibrium between the Kidney and Bladder channels. The technique to resolve this and turn the baby involves heating BL-67 Zhiyin with moxa on both feet for 15 minutes, once a day for 10 days in all. There are many reports from China about the efficacy of this treatment.1,2 It increases fetal activity, usually enough to turn the fetus from breech to cephalic presentation. Studies conducted in China and published in 1984 report varying success rates ranging from 89.9% to 90.3%.3 A study conducted in Italy in 1990 reports 60.6% success rate on a
group of 33 women of gestational ages ranging from 30 to 38 weeks.4 A second study by the same authors presents the results of 1 week’s treatment with moxibustion in 241 pregnant women of gestational ages ranging from 28 to 34 weeks, in comparison with 264 control subjects. In the group of women treated with moxa, there were 195 versions (81%) as against 130 (49%) in the control group; the difference is statistically significant (P < 0.05). Cardini’s trial confirmed findings in the Chinese trials that the success rate is higher in multigravidae, as would be expected, owing to the reduced tone of the abdominal muscles. A later study compared manual acupuncture to BL-67 with a control group on 67 women. The results were 76% version in the treatment group versus 45% in the control group.5 A larger randomized, controlled trial looked at 226 women with breech presentation and assigned them to either observation alone or acupuncture plus moxibustion to BL-67. The number of babies that had turned was 54% in the treatment group versus 37% in the controls.6 These results have significant effects on the number of deliveries by Caesarean section for breech presentation. Most research papers on moxibustion show that the 34th week of gestation is the optimum time to carry out the technique and gives a higher success rate. Much before this, the fetus is still very mobile and may change position freely and frequently. Later, there is little room left for turning. What are the mechanisms of the process? A trial carried out by the Cooperative Research Group of Moxibustion Version of Jiangxi Province postulates that the increase in adrenocortical secretion, through the resulting increase in placental oestrogens and changes in prostaglandin levels which they measured, raises basal tone and enhances uterine contractility, stimulating fetal motility, and thus making version more likely.7 This increase in fetal motility is one of the more striking features of moxibustion, perceived by almost all the women during the second half of the 15-minute treatment, and persisting even after the end of stimulation. Figure 44.1 shows the hypothetical mechanism of the effect of moxibustion on point BL-67 Zhiyin to turn the fetus.8 As moxibustion does
not involve the use of needles and needs daily applications for up to 10 days, the woman’s husband, partner or friend can be instructed in application and continue the treatment at home, with a handout covering the method and advice on safety issues regarding extinguishing of the moxa sticks.
Figure 44.1 Postulated mechanism of action of moxibustion for breech presentation.
Exclusion criteria for moxibustion in breech presentation Moxibustion for breech presentation is contraindicated in the following conditions: • Placenta previa where the placenta is lying on top of the cervix. • A history of antepartum haemorrhage or bleeding later in the pregnancy.
• Multiple pregnancy. • Known abnormality of the uterus or pelvis. • History of premature labour or premature rupture of the membranes. • Previous Caesarean section if more recent than than 2 years. • Oligohydramnios or too little amniotic fluid around the baby. • Known hydrocephalic baby with enlarged head. • Presence of Rhesus antibodies.
The use of acupuncture in labour
Physiology of labour
The end of pregnancy is characterized by the shift from a stage of Yin accumulation to a phase of Yang patterns, culminating in labour and delivery. Yang expels Yin, and the Yang force provides the movement that expels the fetus; Qi pushes Blood and ‘the uterine door opens’ in a significant downward movement. A correct balance of Qi and a sufficient supply of Blood are necessary for a harmonious delivery. Established labour is defined as the onset of regular uterine contractions with dilatation of the cervix. The first stage of labour continues until the cervix has dilated to roughly 10 cm. The second stage is from full dilatation of the cervix until expulsion of the fetus. The third stage is from the birth of the baby until expulsion of the placenta, and control of bleeding. Labour can start in different ways. Some women find that their membranes have ruptured and they are leaking amniotic fluid, which is known as ‘liquor’. The amount of leakage varies and the liquor should be either clear or slightly blood-stained. There may not be any contractions at this stage, but they will usually start and build up shortly afterwards. Clinical Note The three stages of labour: 1. From the beginning until the cervix has dilated to roughly 10 cm 2. From full dilatation of the cervix until expulsion of the fetus 3. From the birth of the baby until expulsion of the placenta and control of bleeding.
Because the membranes provide a protective barrier around the baby,
once they have ruptured there is a risk of infection unless the baby is delivered. There is much disagreement among obstetricians as to how long the interval between the rupture of the membranes and the delivery of the baby should be, and some advocate starting the contractions after 6 hours, whereas others will wait 24. The contractions are stimulated by administering Syntocinon, a synthetic form of oxytocin, the hormone from the hypothalamus, stored in the posterior pituitary. It must be given intravenously and the dosage carefully titrated. The intravenous infusion itself restricts the mobility of the mother and, in addition to this, there is a risk that the contractions may be too strong and that they will adversely affect the fetus. For this reason, a monitor called a ‘CTG’, or cardiotocograph, is used to record the fetal heart rate and the strength of the contractions. This further restricts the woman’s mobility, and she may start to feel that she is no longer in control. This is where acupuncture and acupressure have a lot to offer. They can be used to enhance the activity of the uterus and stimulate contractions, negating the need for the interventions normally used. Acupuncture for analgesia in labour
Many Chinese texts advocate the use of points L.I.-4 Hegu and SP-6 Sanyinjiao for analgesia in labour. However, it is our experience that these points are impractical once labour is well established and the contractions are coming every few minutes. Most women like to be mobile during labour. They take up different positions, some choosing to crouch on all fours, others wanting to walk around the room and ‘rock’ the pelvis during contractions, and others squatting. The choice varies, and most women will adopt several of these positions as the labour progresses. This is why we choose to use ear points for analgesia in labour, as they do not restrict the woman’s movements. Ear points
To find the exact point, one can ‘probe’ with a specially designed pressure palpator, or use the blunt end of an acupuncture needle. The points to use are: • Uterus • Shenmen • Endocrine. Use one ear, and change to the other if the first becomes sore or if the woman wishes to lie on the side in which the needles have been placed. Halfinch needles can be taped to the ear and electrodes attached to points Uterus and Endocrine, or to Shenmen and Endocrine. Tuck a small piece of cotton wool between the two needles to prevent them from touching or it will be uncomfortable for the patient should they short out. The electro-acupuncture apparatus provides stimulation to the needles and the woman can control it herself, increasing the intensity when a contraction takes place. Women tend to increase the intensity of stimulation gradually as labour progresses. There is much difference of opinion on the correct frequency to be used, but we have obtained the best results with dense-disperse frequency, set at 20–80 Hz. The auricular acupuncture can be started at any stage of the labour, according to individual needs. Some women will cope very well until the latter part of the first stage, when the cervix may be dilated by at least 6 or 7 cm; others may feel they need to start the acupuncture earlier; it is worth bearing in mind that, on average, it needs around 10–15 minutes to take effect. Many women like to spend their labour in a bath or birthing pool, and even give birth in water, and there is no reason why they should not have auricular acupuncture, but in these cases it will of course be necessary to disconnect the electro-acupuncture apparatus and use manual stimulation of the needles instead. The needles may be left for as long as necessary, usually until after the birth; they tend to be in the way once the baby has been born. There are a number of research trials looking at acupuncture analgesia in labour, with variable methodologies, point selections and results. One trial
looked at the effect of electro-acupuncture on 168 women, using the auricular points Shenmen bilaterally, and body point L.I.-4 Hegu bilaterally for either 20 or 30 minutes.9 They found that the analgesic effect began at a mean of 40 minutes after its application, and that its duration was a mean of 6 hours. It was not necessary to use analgesic drugs of any kind on any of those who delivered during this period of time. Origins of acupuncture treatment for delayed labour
Difficult or delayed labour was a very well-known and frequent cause of maternal and fetal mortality in ancient China. Stories about the use of acupuncture for the stimulation of contractions, or to ‘ease’ the ‘birth passage’, are well documented in Chinese history; this is probably because in cases of difficult labour acupuncture does indeed give good results. In her article, Legends about Acupuncture Treatment of Difficult Labour, Zheng Jin Sheng describes some of the legends that have been written down about this. One of the earliest legends dates from the Jin Dynasty (AD 265–420): It is said that Yu Fa Hai, an acupuncturist, came across a woman in labour when he put up for the night at an inn on his journey home. The woman happened to be the innkeeper’s wife. She had been in labour for several days, but the baby was still not born. ‘I can hasten the course of labour’, he said to her husband, and asked him to have a fat sheep slaughtered, and to make with the meat a delicious dish. Then he forced the woman to eat more than ten pieces of the mutton. Having finished eating, the woman was given acupuncture treatment. Soon the baby was born with a layer of sheep fat covering its body.10 Later, around the 5th century AD, a famous physician and acupuncturist, Xu Ben, was well known for his skill in using acupuncture on women as an oxytocic measure to expedite labour and promote a safe
delivery.11 During the Tang Dynasty (AD 618–907) under the rule of Emperor Tai Zang, it was recorded that a famous doctor, Li Tong Yuan, had saved the life of a baby born to Empress Changsun during a traumatic labour and birth. The Empress had been in a great deal of pain for several days and the baby had still not been born. Dr Li received an order to treat her as best he could. Having palpated the Empress’s pulse, he said ‘The baby’s hand has got hold of your heart, that’s why you can’t give birth to it easily.’ What should be done then? asked the Empress anxiously. Li Tong Yuan said, ‘The mother will die if the baby is saved, or the baby will die if the mother is saved.’ On hearing this, the Empress, showing the greatness of maternal love, said definitely: ‘Let the baby live, and may it bestow prosperity on the Empire in years to come.’ At her word, Dr Li Tong Yuan inserted the needle into her abdomen. The needle penetrated her heart and thrust directly toward the baby’s hand. In later life the baby became Emperor Gao Zong of the Tang Dynasty. It was said that the needle mark on the Emperor’s hand could still be seen, though faintly, on gloomy days.12 Many similar cases were reported from this time onwards, the most common form of treatment being to needle the fetus’s hand so that it drew back from the mother’s heart, and thus could be born easily. While these legends are obviously exaggerated and distorted, the names of the doctors, patients, dynasties, years and places are accurate. A final record written during the Song Dynasty (960–1279) records a delightful story which tells of the acupuncture treatment of a woman by an eminent doctor called Pang An Shi. During his medical practice at Tong County, Anshi Province, Pang An Shi received a patient who was in difficult labour for seven days. All treatment applied by other doctors had failed, but at the sight of the woman, Pang An Shi said with assurance, ‘Don’t worry, you’ll be all right.’ Immediately he had the woman’s abdomen and back warmed with hot, wet towels. Then he gently massaged her
abdomen. Gradually the woman became quiet. Just as she was feeling better she experienced a spasm of pain in the stomach and intestines which made her groan again. Before long, a boy was born to everyone’s joy and surprise. When asked what treatment method he applied, Pang An Shi said ‘As a matter of fact, the birth was not a difficult one. The problem was only that the baby’s hand had got hold of the mother’s intestines. I massaged the mother’s abdomen in order to find out the position of the baby’s hand. When I located it, I quickly inserted the needle at the point between the thumb and the index finger. As the hand shrank back with pain, the baby was born.’13 Acupuncture in labour: a short history
Acupuncture for the relief of pain in labour and delivery was rarely used in China because, in accordance with Chinese culture and oriental tradition, women were expected to experience the pain of childbirth. This was an accepted way of life and thus no acupuncture points were described just for pain relief in vaginal delivery. This may be very difficult for Westerners to understand, as Western practice often (and maybe incorrectly) emphasizes getting ‘rid’ of the ‘pain of labour’ and giving mother and child a comfortable birth experience. This tradition survived as late as 1970; the chapter on childbirth in the first Chinese–English edition of The Barefoot Doctor’s Manual, printed in that year, mentions nothing about labour pain and gives no advice on caring for the woman during the contractions; it does, however, refer to ‘sensations’ that a woman may have once contractions begin. The manual drew on the practical expertise of local country people in the various provinces (often self-taught health workers) who went from house to house administering medical care in the form of acupuncture or herbal medicine.14 It was during this same era in Europe that interest in acupuncture analgesia for childbirth became the focus of much research by some eminent
pioneers. In 1972, Christman Ehrstroem was reported to have performed the first acupuncture deliveries in Stockholm, Sweden. In 1974, Darras in France reported 20 electro-acupuncture deliveries of primiparae (first-born child) and multiparae (second or subsequent children).15 In China, Pei and Huang of the Nanjing Municipal Maternity hospital reported on a retrospective review of 200 women who had taken part in a study using acupuncture analgesia during childbirth in 1975.16 Parallel to these developments in this new field was the work on auricular acupuncture which over the past 40 years has been developed and refined by such pioneers as Nogier and Bardiol in France. Using the ear auricle with acupuncture needles inserted into the cartilage enables women in labour to move about freely and assume natural birth positions while benefiting from the potent analgesic effects. Acupuncture has rapidly become more popular for women in childbirth today, mainly because it is a natural pain reliever with no harmful side effects for mother or baby. Moreover, women like to feel in control during their labour and delivery, a feeling which they may be deprived of by some of the more potent conventional analgesia used in today’s maternity units. For example, the inducement or augmentation of labour with oxytocic drugs means the artificial forcing of a process which has not yet occurred within the woman’s body according to her own natural biological rhythm. It often involves rupturing the amniotic membranes artificially, using an intravenous infusion and Syntocinon (oxytocin) to stimulate uterine contractions. It is generally then necessary to use an epidural for anaesthesia, because of the increased pain that is frequently experienced in induced labour. Often these are the first steps down the ‘slippery slope’ that leads to surgical delivery and women feeling a loss of control in their own labour. Recently, there has been an enormous increase in the use of acupressure for labour for these very reasons, particularly when administered by birthing partners, thereby negating the need for needles and the availability of an acupuncturist. In the 1930s, Dr Grantly Dick-Read was the first doctor in England to advocate ‘natural childbirth’. In his famous book, Childbirth without Fear,
first published in 1942, he states: Anaesthesia for childbirth up until 1853 in England was unheard of. However, on the 7th April 1853, John Snow anaesthetized Queen Victoria when Prince Leopold was born. Simpson (a famous surgeon and obstetrician) was greatly criticised for using anaesthesia for this purpose. To prevent pain during childbirth, he was told, was contrary to religion and the express command of the scriptures. But anaesthesia had come to stay.17 Along with Ferdinand Lamaze of France, Dick-Read was a staunch advocate of the natural birth process, which had been lost sight of in preceding years. Today, women do not want to undergo the pain of childbirth, but they put a new emphasis on what they need in the birth process. To be ‘in control’; to be allowed to choose; to be encouraged to trust one’s own body to overcome the pain barrier through its own natural rhythm: this is what women are asking for. There are a number of ways of helping a woman to achieve the desired balance: yoga, massage, TENS (trans-cutaneous electrical nerve stimulation), Alexander technique, meditation, acupuncture and, more recently, a growing trend in the use of acupressure. Although Western doctors today are much more open to alternative ways, it remains very important for the medical profession to shake off its doubts and overcome its scepticism towards complementary medicine, so that women from the outset may be offered the choice. Recently, with much higher rates of epidurals and Caesarean sections, they are beginning to embrace other techniques which may help reduce some of the interventions responsible for these figures. Acupressure for labour
Acupressure, the application of pressure to acupuncture points. has become increasingly popular as a method of pain relief in labour. Acupuncturists and
midwives are teaching it to birthing partners as a way of becoming more involved in the labour and the results are very promising in terms of these women needing much less in the way of pharmaceutical pain relief. They are also having shorter labours and less intervention. Couples are taught that it originates in ancient traditional Chinese medicine, based on the concept of channels carrying Qi throughout the body, and that, in modern terms, the stimulation of certain points on these channels has an effect on blood flow to the uterus, cervical dilatation, movement of the baby, release of endorphins and helping the mother to relax. They are taught that, with acupressure, although the person applying the pressure may not be able to feel the Qi, the woman has the sensation of aching and tingling and they will see the changes in her body as she feels less pain, her contractions feel less intense, baby changes position and the cervix dilates. The majority of women really like it but it is obviously not for everyone. When it is working well for the woman, she does not want the partner to stop pressing and often asks for more pressure. The birthing partners may need a bit of persuasion, but they soon become good at it and really appreciate having something helpful to do instead of sitting, watching and not knowing what to do with themselves. Ideally, they will already have learnt about it at the end of the pregnancy, around 37 weeks, and be familiar and confident with it before labour starts. Those who do not find it useful tend to use it too late in labour, when the contractions are unmanageable, or in a short labour with intense contractions from the beginning. It is therefore most effective when the support person has time to use the points before labour goes into its most intense stage. It is important to teach and demonstrate the type of pressure needed, and when I am teaching I press on the birthing partners arm with a jab, explaining that this is not the type of pressure we are looking for, then press again as if sinking into butter slowly until there is a pleasant deep sensation which is the correct type of pressure. Specific actions of acupressure points used for labour are as follows: • To enhance contractions: L.I.-4.
• To dilate cervix: SP-6. • For cervical lip: BL-32 and SP-6. • To aid descent into the pelvis: G.B.-21 and BL-60. • For posterior position: SP-6, BL-60 and BL-67. • To help deal with fear: KI-1. • For nausea: P-6. • For efficient delivery of the placenta: G.B.-21, BL-60 and L.I.-4. The growing popularity of this technique is mainly due to the work by Debra Betts who, for years, has generously provided the acupressure booklet available for free download on her Web site.18 . This has made acupressure accessible for countless couples, midwives and acupuncturists in an easy, concise form. She started teaching it to women in 1992. They consistently reported a reduction in their pain, combined with an overall sense of calmness and a high level of satisfaction with their birth experience. Debra has also taught acupressure to many midwives and others in venues across the UK, Europe, Canada and, of course, her native New Zealand. It was an honour for me to help her teach it to a group of 20 Italian midwives in Milan in September 2009. I have been teaching it to couples for several years now and have been delighted with the results. We use Debra’s booklet, encouraging patients to download and print it for themselves, and I recommend her book for further details on the technique.19 Advantages There are many advantages to acupressure in labour: • Non-invasive technique.
• Accessible, effective, safe birthing tool. • Promotes birthing partner involvement. • Comfortable, not painful. • Can be started at home when labour begins. • Acupuncturists and midwives can use it for specific conditions pre, during and post labour. • Reduces need for intervention. Research Since 2003, research has been published in nursing journals and all say this is a safe technique. In 2005, Ingram et al published on acupressure for induction of labour. They taught acupressure to 66 women at 40 weeks’ gestation with a control group of 76 women. The women were taught by a midwife in a 15-minute session using points G.B.-21, L.I.-4 and SP-6 and were encouraged to use the points as often as it felt comfortable. There was no statistically significant difference between the groups for the usual parameters (e.g. parity, maternal age, etc).20 From the 66 women in the acupressure group, 30 completed the follow-up audit questionnaire: 87% used the acupressure, 80% found the points helpful and 63% used all three points. All went into spontaneous labour. They concluded that post-term women who used acupressure were significantly (P = 0.038) more likely to go into labour spontaneously than those who did not. A randomized controlled trial in 2004 by Lee et al looked at the effects of acupressure on labour pain and length of delivery time in 75 women using just the SP-6 point. They concluded that SP-6 acupressure was effective for decreasing labour pain and shortening the length of delivery time.21 In 2003, Chung looked at the effects of acupressure on the first stage of
labour. One hundred and twenty-seven women were randomly assigned to acupressure on points L.I.-4 and BL-67 or controls. Acupressure to these points was found to lessen labour pain during the active phase of the first stage of labour.22 A systematic review by Smith and Cochrane included three trials on acupuncture for pain management in labour, and concluded that evidence from the trials suggested women receiving acupuncture required less analgesia, including the need for epidurals. The results also suggested a reduced need for augmentation with oxytocin.23 The largest randomized controlled trial to date was conducted in Denmark with 607 women in labour at term who received acupuncture to individualized points, TENS or traditional analgesic drugs. The use of pharmaceutical and invasive methods was significantly lower in the acupuncture group (P < 0.001).24 There are not many studies published to date, mainly due to difficulties with obtaining funding for these types of study, but also due to acupressure for labour being a relatively new technique to research-minded practitioners in the West. However, as this is rapidly becoming a more popular choice for women in labour, it is likely that more research will follow. In any case, it is good practice for acupuncturists and midwives to at least record and audit their results. This will build and contribute to a growing body of evidence, such as some of the case studies and testimonials below. Acupuncture in the treatment of difficult labour
Difficult labour may result from abnormality of the uterine contractions, cephalo-pelvic disproportion (i.e. imbalance between the size of the maternal pelvis and the fetal head) or malposition of the baby. Acupuncture can be of help in the first of these, but not for the others. It is important to note that ‘malposition’ of the baby should not be confused with ‘malpresentation’, i.e. when the baby’s bottom (breech), face or brow presents first as opposed to head, as in normal cephalic presentation. ‘Malposition’ means incorrect
positioning of the head, which includes occipito-posterior position and deflection of the head (short of brow presentation). ‘Malpresentation’ occurs when various presenting parts other than the head show first, i.e. face, brow, breech (bottom) or shoulder (see Fig. 44.2).
Figure 44.2 Malposition and malpresentation. (Reproduced with kind permission from AWF Miller and R Callander 1994 Obstetrics Illustrated, Churchill Livingstone, Edinburgh, p. 296.)
The dangers of malposition and malpresentation are: the forewaters are not protected from the force of uterine contractions and are forced through an incompletely dilated cervix; the membranes rupture easily and the cord may prolapse; the contractions may be irregular and poorly sustained (if moulding occurs and the presenting part fits better, labour may progress more normally); labour may proceed too quickly in spite of the ill-fitting part; with brow or shoulder malpresentation there is a danger of obstructed labour and uterine rupture. Thus, acupuncture may not be effective in cephalo-pelvic disproportion and in malposition or malpresentation of the baby. Although certain acupuncture points (e.g. L.I.-4) can help to stimulate uterine contractions, when there is a cephalo-pelvic disproportion there is no way that acupuncture can ensure a safe delivery. The mechanics of the situation simply prevent vaginal delivery and make a Caesarian section inevitable. Malposition of the baby is also a common cause of difficult or delayed labour. In this case, the baby lies within the pelvic cavity in such a way that its head creates a larger presenting diameter so that it becomes obstructed at the outlet of the pelvis. This could happen when the baby is in an occipitoposterior position (baby is on its back instead of facing downwards) or in an occipito-transverse position (baby lies on its side). The malposition of the baby tends to slow down contractions and acupuncture here may be of some help in rotating the baby by increasing uterine contractions, but it is unlikely to produce good results. Acupuncture is not usually indicated in such cases which will be managed by artificial stimulation of contractions with Syntocinon or by mechanical delivery with forceps or Caesarian section. In all these situations it is very important that the acupuncturist works closely with the midwife or the obstetrician. Through vaginal examination, the midwife will be able to feel what the presentation and position of the baby are and advise accordingly. Our experience shows that in cases of difficult or delayed labour due to cephalo-pelvic disproportion or malposition, acupuncture is helpful only to stimulate or regulate contractions in cases when this stimulation or regulation is desirable. In certain situations, acupuncture would be the treatment of choice if contractions have weakened in strength,
rhythm or regularity or if they are totally absent. The ABC of Acupuncture (Jia Yi Jing, AD 282) states: “In prolonged labour and retained placenta use Kunlun [BL-60]”.25 Various research studies have explored acupuncture’s ability to initiate contractions prior to rupture of the membranes, and prior to the woman experiencing any labour pains.26 The acupuncture points which may be used vary according to the situation. In a straightforward case of ruptured membranes in a fit and healthy woman, with no contractions, such a treatment as the following may be used: – L.I.-4 Hegu, SP-6 Sanyinjiao, BL-31 Shangliao, BL-32 Ciliao. Explanation
– L.I.-4 is an empirical point to promote labour. – SP-6 regulates menstruation and labour. – BL-31 and BL-32 in our experience help to stimulate contractions. However, it is important to look for (and treat) any underlying pathology which may be present.
Identification of patterns and treatment for difficult labour There are two primary causes of delayed or difficult labour in Chinese medicine: • deficiency of Qi and Blood. • stagnation of Qi and Blood. Deficiency of Qi and Blood
Clinical manifestations
Labour is prolonged, contractions are weak or absent. There is delayed dilatation of the cervix. The woman feels tired and listless. There may be shortness of breath. Tongue: Pale, thin, white coating. Pulse: Deep, Fine, Weak. Treatment principle
Tonify Qi and Blood to induce labour. Acupuncture
ST-36 Zusanli, SP-6 Sanyinjiao, KI-7 Fuliu, BL-67 Zhiyin, followed by BL60 Kunlun, BL-20 Pishu, BL-21 Weishu. ST-36 and SP-6 with reinforcing method; KI-7, BL-20 and BL-21 with even method; BL-67 followed by BL-60 with reducing method. Explanation
– ST-36 and SP-6 tonify Qi. – KI-7 tonifies the Kidneys and strengthens the force of the delivery. – BL-67 with reducing method, is an empirical point to induce labour, and it promotes the downward movement of the head of the fetus, especially when followed 10 minutes later by needling BL-60.27 – BL-20 and BL-21 tonify the Stomach and Spleen. Summary De ficie ncy of Q i and Blood
Clinical manifestations
Labour is prolonged, contractions are weak or absent. There is delayed dilatation of the cervix. The woman feels tired and listless. There may be shortness of breath. Tongue: Pale, thin, white coating. Pulse: Deep, Fine, Weak. Treatment principle
Tonify Qi and Blood to induce labour. Acupuncture
ST-36 Zusanli, SP-6 Sanyinjiao, KI-7 Fuliu, BL-67 Zhiyin, followed by BL60 Kunlun, BL-20 Pishu, BL-21 Weishu. ST-36 and SP-6 with reinforcing method; KI-7, BL-20 and BL-21 with even method; BL-67 followed by BL-60 with reducing method. Stagnation of Qi and Blood
Clinical manifestations
Prolonged labour, severe pain in back and abdomen, a feeling of distension and oppression of the epigastrium, nausea, vomiting, nervousness. On internal examination, the cervix is tense and does not dilate with a contraction. Tongue: Dark Red. Pulse: Deep, Wiry or Firm. This is often seen when the woman has a lot of fear and tension before labour. Treatment principle
Promote the smooth circulation of Qi and Blood to induce labour. Acupuncture
L.I.-4 Hegu, SP-6 Sanyinjiao, LIV-3 Taichong, G.B.-34 Yanglingquan, BL67 Zhiyin. All with reducing method. Explanation
– L.I.-4 and SP-6 in combination promote the smooth circulation of Qi and Blood; often used by ancient doctors to induce labour. – G.B.-34 is the Gathering point for sinews and gives good results for dilating a tight or scarred cervix. – LIV-3 has an anti-spasmodic effect on the cervix; together they pacify the Liver and eliminate stagnation of Qi.
– BL-67 is an empirical point to induce labour. Summary Stagnation of Q i and Blood
Clinical manifestations
Prolonged labour, severe pain in back and abdomen, a feeling of distension and oppression of the epigastrium, nausea, vomiting, nervousness. On internal examination, the cervix is tense and does not dilate with a contraction. Tongue: Dark Red. Pulse: Deep, Wiry or Firm. Treatment principle
Promote the smooth circulation of Qi and Blood to induce labour. Acupuncture
L.I.-4 Hegu, SP-6 Sanyinjiao, LIV-3 Taichong, G.B.-34 Yanglingquan, BL67 Zhiyin. All with reducing method. Ancient acupuncture prescriptions for difficult labour28
1. SP-10 Xuehai, ST-36 Zusanli, SP-6 Sanyinjiao and Ren-6 Qihai (ABC of Acupuncture, Zhen Jiu Jia Yi Jing, AD 259). 2. Ren-6 Qihai, Ren-4 Guanyuan, L.I.-11 Quchi, SP-6 Sanyinjiao, L.I.-4 Hegu for postpartum abdominal pain and persistent lochial discharge (New Edition of Acupuncture and Moxibustion, Zhen Jiu Xue Xin Bian). 3. G.B.-21 Jianjing for difficult labour with reducing method (Thousand Golden Ducat Prescriptions, Qian Jin Yao Fang, AD 652).
4. SP-6 Sanyinjiao with 50 moxa cones for uterine bleeding after childbirth (Thousand Golden Ducat Prescriptions). 5. SP-6 Sanyinjiao for difficult labour, persistent uterine bleeding after childbirth, transverse position of the fetus and restlessness of the fetus (Thousand Golden Ducat Prescriptions). 6. Duyin (extra point under the pad of the second toe), L.I.-4 Hegu, SP-6 Sanyinjiao for difficult labour (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601). 7. L.I.-4 Hegu (reinforced), SP-6 Sanyinjiao (reduced), LIV-3 Taichong for difficult labour if the previous formula does not give results (Great Compendium of Acupuncture). 8. SP-12 Chongmen, LIV-4 Zhongfeng, ST-30 Qichong, L.I.-4 Hegu, SP-6 Sanyinjiao and G.B.-21 Jianjing for difficult labour (Universal Prescriptions, Pu Ji Fang, early 15th century).
Identification of patterns and treatment for retained placenta The placenta and membranes are usually delivered within a few minutes of the baby. This, the third stage of labour, is considered prolonged if it exceeds 20 minutes. In some cases, acupuncture can be extremely helpful in speeding up this process, but there are others where the placenta is actually adhering to the uterine wall; known as ‘placenta accretia’, this needs medical attention as there is a greater risk of severe haemorrhage. Sometimes a full bladder can inhibit the separation of the placenta by preventing strong contraction of the uterus. The woman can be encouraged to try to pass urine, but if she is unsuccessful a catheter may be used to empty the bladder. Retention of the placenta may be due to either maternal exhaustion leading to Qi deficiency or invasion of Cold during labour leading to stagnation of Blood in the Uterus and general weakness of Qi. There may be a combination of both causative factors. Deficiency of Qi
Clinical manifestations
Fatigue, pallor, fear of cold, dizziness, shortness of breath. Tongue: Pale with thin coating. Pulse: Hollow and Weak. Treatment principle
Tonify Qi and nourish Blood. Acupuncture
SP-6 Sanyinjiao, L.I.-4 Hegu, Ren-6 Qihai, Ren-4 Guanyuan, G.B.-21 Jianjing. All with reinforcing method. Explanation
– SP-6 and L.I.-4 promote the smooth circulation of Qi and Blood. – Ren-6 moves and tonifies Qi. – Ren-4 moves and nourishes Blood. – G.B.-21 is an empirical point for retained placenta. Summary De ficie ncy of Q i
Clinical manifestations
Fatigue, pallor, fear of cold, dizziness, shortness of breath. Tongue: Pale with thin coating. Pulse: Hollow and Weak. Treatment principle
Tonify Qi and nourish Blood. Acupuncture
SP-6 Sanyinjiao, L.I.-4 Hegu, Ren-6 Qihai, Ren-4 Guanyuan, G.B.-21 Jianjing. All with reinforcing method. Cold leading to stasis of Blood
Clinical manifestations
Dark blue complexion, pain in the lower abdomen, possibly vomiting. Tongue: Pale body. Pulse: Deep, Wiry and Slow. Treatment principle
Expel Cold and promote flow of Qi Acupuncture
G.B.-21 Jianjing, BL-60 Kunlun, SP-8 Diji, Ren-4 Guanyuan. All with reducing method. Explanation
– G.B.-21 (empirical point for retained placenta) with BL-60 to make Qi descend. – SP-8 regulates the Uterus, eliminates stasis of Blood and stops pain. – Ren-4 regulates the Uterus and invigorates Blood. Summary Cold le ading to stasis of Blood
Clinical manifestations
Dark blue complexion, pain in the lower abdomen, possibly vomiting.
Tongue: Pale body. Pulse: Deep, Wiry and Slow. Treatment principle
Expel Cold and promote flow of Qi Acupuncture
G.B.-21 Jianjing, BL-60 Kunlun, SP-8 Diji, Ren-4 Guanyuan. All with reducing method.
Identification of patterns and treatment for retention of urine after delivery Retention of urine after delivery may be caused by bruising or prolonged overstretching of the urethra, or overdistension of the bladder during labour. A lax abdominal wall and sore perineum may also cause difficulty with micturition after delivery. There may be as much as 1 litre of urine in the bladder which eventually overflows: this is called ‘retention with overflow’. The principal problems associated with retention of urine are that the full bladder may prevent the uterus from contracting, thus leading to haemorrhage which can be severe, and it may predispose to infection. The treatment is to insert a catheter and empty the distended bladder. If the woman is still unable to pass urine, the catheter is reinserted and left in situ for several days to restore the tone of the bladder. It is well worth offering acupuncture in the early stages, to prevent days of discomfort, embarrassment and having to stay in hospital because of an inability to pass urine. We have been very pleased with the results from acupuncture treatment for this condition. It can occur immediately after delivery. Deficiency of Qi
Clinical manifestations
Retention of urine with lower abdominal distension, in severe cases there may be retention with overflow, lassitude, weakness of the limbs, pale complexion. Tongue: Pale. Pulse: Weak. Treatment principle
Tonify Qi and the Kidney to promote function of the bladder.
Acupuncture
Ren-6 Qihai, Ren-3 Zhongji, SP-6 Sanyinjiao, BL-28 Pangguangshu, BL-32 Ciliao. All with reinforcing method. Explanation
– Ren-3 and BL-28, a combination of Back-Transporting and FrontCollecting points, regulate the urinary bladder to benefit urination. – Ren-6 tonifies the Original Qi to strengthen the urinary bladder. – SP-6 promotes diuresis, invigorates Qi, strengthens the Spleen and tonifies the Kidneys. – BL-32 tonifies the Kidneys and Essence. Summary De ficie ncy of Q i
Clinical manifestations
Retention of urine with lower abdominal distension, in severe cases there may be retention with overflow, lassitude, weakness of the limbs, pale complexion. Tongue: Pale. Pulse: Weak. Treatment principle
Tonify Qi and the Kidney to promote function of the bladder. Acupuncture
Ren-6 Qihai, Ren-3 Zhongji, SP-6 Sanyinjiao, BL-28 Pangguangshu, BL-32
Ciliao. All with reinforcing method. Deficiency of the Kidneys
Clinical manifestations
Retention of urine with lower abdominal distension and pain. In severe cases there may be overflow. Pale complexion, soreness and weakness in the lumbar region. Tongue: Pale with wet coating. Pulse: Deep, Fine and Slow. Treatment principle
Tonify Qi, strengthen the Kidney and regulate the urinary bladder. Acupuncture
Ren-6 Qihai, Ren-3 Zhongji, SP-6 Sanyinjiao, BL-28 Pangguangshu, BL-32 Ciliao. All with reinforcing method. Explanation
– Ren-3 and BL-28, a combination of Back-Transporting and FrontCollecting points, regulate the urinary bladder to benefit urination. – Ren-6 tonifies the Original Qi to strengthen the urinary bladder. – SP-6 promotes diuresis, invigorates Qi, strengthens the Spleen and tonifies the Kidneys.
– BL-32 tonifies the Kidneys and Essence. Ear acupuncture Points: Urethra, Urinary Bladder, Sympathetic Nerve, Kidney. Treatment is given with moderate stimulation, needles retained for 20–30 minutes. Intradermal needles or seeds can also be applied to the same points and left in place for 3 days. Summary Deficiency of the Kidneys
Clinical manife stations
Retention of urine with lower abdominal distension and pain. In severe cases there may be overflow. Pale complexion, soreness and weakness in the lumbar region. Tongue: Pale with wet coating. Pulse: Deep, Fine and Slow. Tre atme nt principle
Tonify Qi, strengthen the Kidney and regulate the urinary bladder. Acupuncture
Ren-6 Qihai, Ren-3 Zhongji, SP-6 Sanyinjiao, BL-28 Pangguangshu, BL-32 Ciliao. All with reinforcing method. Ear acupuncture
Points: Urethra, Urinary Bladder, Sympathetic Nerve, Kidney. Treatment is given with moderate stimulation, needles retained for 20–30 minutes. Intradermal needles or seeds can also be applied to the same points and left in place for 3 days.
Case histories
Acupuncture for induction of labour Jane, 29. Occupation: interior designer. Background
• Second baby • Term +7 days • Frightened of impending threat of artificial induction of labour with prostaglandin/Syntocinon drugs • Husband in the Royal Navy and going to sea for 6 months in a week’s time
Jane was desperate to incur a natural labour and delivery. As the threat of intervention loomed nearer, she contacted the acupuncture clinic at the hospital in tears, asking if we could induce her labour with acupuncture. She had had a ‘show’ a few days previously and some irregular tightening of the uterus but no painful contractions. (Over the past few days she had spent all her time trying out old wives’ tales, including wearing her husband’s dirty socks!) Treatment The points L.I.-4 Hegu, SP-6 Sanyinjiao, BL-31 Shangliao, BL-32 Ciliao and LIV-3 Taichong were used. Strong needle stimulation was given to all the points and they were retained in-situ for 45 minutes. L.I.-4 and SP-6 were attached to an electro-acupuncture stimulator set at 35–40 kHz on ‘continuous dispersion’. During the treatment, approximately 30 minutes later, Jane felt a
‘wetness’ and on closer inspection it seemed that there was a small continual leakage of amniotic fluid. She also felt much fetal activity and became very relaxed. Jane went into spontaneous labour 8 hours after the treatment, and had an uncomplicated birth of a baby girl. Acupuncture for labour: home birth Kate, 36. Occupation: mother Background
• Three girls at home, the youngest aged 2 • Dissatisfaction with previous labours in hospital • Adamant that she wanted to stay at home this time • Frightened of ‘not coping’ well and having to go into hospital • Keen to try acupuncture analgesia
Kate approached me as her midwife, as she had recently joined my GP practice and had heard that I was keen on home birthing. She was 36 weeks pregnant with a past history of what she described as ‘terrible’ birth experiences. We discussed a home birth; she was keen, I was happy, and we decided to see how things went. She wanted to try acupuncture analgesia if needed. Kate was a very anxious person normally and I felt that this was not going to help her once labour began. When I was called to her home at 02.00 a.m. on a cold November morning I quickly realized that she was not doing well, as she was already terribly anxious. She said the contractions were coming every 5 minutes, but I found she felt moderate to palpate and her cervical dilation was still only 2 cm. I decided to give her auricular acupuncture treatment both to help relax her and to stimulate the contractions at the same time – giving her body time to restore its pool of Qi while also encouraging
descent of the fetus. Treatment The ear points used were: • Shenmen for relaxation • Uterus point to strengthen and regulate the contractions • Endocrine to stimulate the hormones • Stomach for nausea
I used 2-inch stainless steel needles and gave stimulation manually every 15 minutes for the first hour and every 30 minutes thereafter. At this time I encouraged Kate to take a bath and then we all sat in the bathroom while her husband Mike massaged her back during the contractions, which were now regular and much stronger. Kate was by now totally relaxed. She had settled into herself and seemed quite euphoric after the acupuncture needles were sited. She was also coping very well with the pain. After 3 hours of mobilizing, singing, chanting and needle stimulation I reexamined Kate to assess progress of labour. She was now 8 cm dilated and was still coping well. One hour later, Kate had an urge to push and delivered a beautiful baby girl weighing 9 lb 7 oz. Both Kate and Mike told me that it had been the best birth of the four. Kate was so proud because she felt she had been in control this time. Acupuncture for Labour: Hospital Birth Maeve, 28. Occupation: civil servant. Background
• First baby • Request for acupuncture analgesia during childbirth
I had first met Maeve at the acupuncture clinic when she was 28 weeks pregnant. We discussed acupuncture analgesia and how it worked; and I performed a demonstration using ‘Ear Shenmen’ so she would be aware of the sensation before labour began. The next time I saw her was 11 weeks later. The labour ward contacted me at midday and I found Maeve 39 weeks pregnant in strong, spontaneous labour. Cervical dilatation was 5 cm and she was requesting pain relief. On my arrival, her face was white and she was breathing very fast. She was complaining of a lot of back pain, with the contractions mainly dominating pain in that area. She had been in labour for most of the night but nothing was established until the morning and therefore she was by now very tired. Treatment I gave her acupuncture analgesia to help move stagnation, to relieve her back pain, to relax her and to encourage the smooth flow of Qi. The points used were: • BL-32 Ciliao, leant flat on the skin and taped down after strong stimulation • Ear Shenmen to relax her • Ear Uterine to strengthen and regulate the contractions • Ear Stomach for nausea
Maeve immediately felt a lot of warmth and tingling in her back instead of the earlier intense dull ache. Her facial colour was now much brighter. With the pain lessened, Maeve was able to rest between contractions on her side in a lateral position and breathe some Entonox (gas and air) to help her with the ‘big ones’.
I attached Shenmen and Uterus ear points to the electro-acupuncture stimulator set at ‘dense-dispersion’ at 20–80 kW; as the contractions became more intense I showed Maeve how to use the ‘intensity’ button to render them bearable. Although she could still feel the pain of the contractions, she was visibly more relaxed and comfortable. A few hours later Maeve delivered a baby boy (it was a relatively short labour for a primigravida) and felt exhausted, but blissfully happy.
Testimonials
Jess: first baby I first had acupuncture with Sarah when I had really bad morning sickness from my pregnancy, I had got to a point that I couldn’t go to work. It was recommended to me to try acupuncture and it really helped me to cope with the morning sickness, I had treatments every week for about 4 weeks. In the treatments I had needles that were left in just under my collar bone and on my ankle which helped when I felt a wave of sickness come over me; I would just press them for a minute and the sickness would fade away. I would recommend this treatment to anyone who has really bad morning sickness as it worked very well. My mum and I used some of the acupressure points Sarah taught us to bring my labour forward which worked amazingly. The techniques that Sarah taught us were very easy to use and easy to remember. We used the techniques in labour as well which helped me through it. I had 2 days of period pains getting worse at night and not really coming to anything so my mum used some of the techniques on me to bring the labour on. The points were on my ankle and hand. It worked that evening and I woke up at midnight with regular contractions and a show. The contractions went from 7 minutes apart to 3 minutes apart in an hour. We got to Exeter hospital and just went on with 3 minute contractions which were quite intense. We tried some acupressure techniques that Sarah gave us and it worked really well; the points were on my lower back just around my coccyx. If my mum or Tom took their hands away from these points, I felt like I was losing control. It relieved the pain for me and helped me to work with the contractions and helped me to stay focused. It was amazing. I had a good labour and had very little pain relief; just a bit of gas and air towards the end as I got tired from being on all fours for hours. He got a little stuck as he kept crowning for an hour so I stopped with the gas and air and focused on my breathing, which I learnt from my natural breathing class, and
he was born soon after I stopped the gas and air. I have been seeing Sarah for a few months after having my baby to help me with low energy levels and low moods as I had been doing too much with a small baby. I feel so good and back to my normal self, I really feel without acupuncture it could have got worse. My experience of the treatment is that it worked very well for my labour and my sickness, I would use it again and recommend it to anyone specially for the labour points. Noah and Naoko: a testimonial from both partners They were taught acupressure by my colleague Khim Ang prior to labour. Noah My wife Naoko had her homebirth on December 29th in the early hours of the morning, and as soon as midwife had arrived it progressed very quickly. Naoko began having huge contractions, and me, as her husband, wanted to help in anyway that I could. I held her hand and tried to help her through her breathing, and whenever it became really intense again I applied pressure on her lower back on the acupressure point. This seemed to really help her, and sometimes if I was pushing on slightly the wrong point, she even managed to guide me, and told me when to apply more or less pressure onto this point to relieve the pain. Naoko I felt srong contractions from early evening. Whenever I felt pain, my husband applied acupressure on my back. It worked very well, and the pain became noticeably less intense, which made me able to cope with the pain a lot better.
During the labour I did not take any drugs or gas and air for the pain relief; I managed to cope with just my husband doing the acupressure. It was a great relief! Jessica: second baby When I was pregnant with my second child and having acupuncture for pregnancy-related ailments, Khim Ang taught me some simple acupressure for use in labour. Having been through labour with my first child, I was a little skeptical as to whether this might give much pain relief. I am, however, completely convinced that the acupressure points were very effective in relieving the intense pain during contractions and keeping me focused and calm. My labour was rapid (a little over 3 hours), and initially I used a TENS machine. The TENS machine worked more as a distraction, but as the contractions quickly became closer together and more intense, I urged my husband to try the acupressure points. I distinctly remember the first moment he did because I almost couldn’t believe that I was in the middle of the contraction. The acupressure was amazingly effective and it meant that I had energy and a clear state of mind to talk and function in between contractions. We tried to use it throughout, although largely stopped by the time I got to the hospital (and delivered our daughter about 20 minutes later). I feel very grateful to Khim Ang for teaching me acupressure. In my experience, acupressure during labour is very effective and there is no doubt that I would use it again. I would recommend it to anyone having a baby.
Conclusion Acupuncture for analgesia in labour is becoming very sought after by today’s childbearing women. The use of auricular acupuncture, as mentioned previously, often seems more practical, as it allows the woman greater freedom of movement without the restriction of body points. There is a great and urgent need for acupuncturists specializing in this field to meet the demands of women who request acupuncture for labour. There are still very few midwife/acupuncturists working in Britain today, especially within a hospital environment. There is a considerable advantage if they are familiar with the situation of the woman in labour and thus can enable her to work autonomously and holistically without interruption. Pressures on the acupuncturist coming to give a pregnant woman acupuncture in the labour ward or going to her home for the birth are often due to the following factors: • Time commitment (bearing in mind that a primipara can take 12–24 hours on average, and a multipara about half that time). • The cost involved to the practitioner, i.e. tiredness or the need to cancel clinics/clients; often further complicated as labour can begin as early as the 37th week or as late as the 42nd, and at any time of day or (usually) the night. • Prejudice and scepticism on the part of staff involved with the woman’s obstetric/midwifery care on the delivery suite; the practitioner may be made to feel in the way. Maybe solutions to some of these negative but very real points are as follows: • To work in some kind of established rota within a group of practitioners, so that there is cover for your other clients and clinics should you need to spend time with a woman in labour.
• To arrange for one of your fellow practitioners to meet the woman beforehand, so that if you need to call on relief for a while, there is some continuity of care. • To be prepared to give lectures at your local hospital to promote trust and acceptance of acupuncture.
Herbal treatment
Herbal treatment for induction of labour
– EMPIRICAL PRESCRIPTION by Dr J H F Shen29 Explanation
– Sheng Di Huang and Bai Shao nourish Blood and moisten the Uterus to facilitate the movement of the baby. – Dang Gui, Chuan Xiong, Hong Hua and Yi Mu Cao invigorate Blood, eliminate stasis and move the baby. – Hou Po and Qiang Huo remove obstructions from the Connecting channels to facilitate the birth. – Gan Jiang and Ai Ye warm the Uterus. – Huang Qin balances the warming action of the previous two herbs and calms the fetus. – Bai Zhu tonifies Qi to give the mother the force to expel the baby. – Tu Si Zi tonifies the Kidneys.
Herbal treatment for difficult labour
Deficiency of Qi and Blood
Clinical manifestations
Mild labour pains, duration of uterine contractions is short, the stages of labour develop slowly, heavy bleeding, pale complexion, lassitude, palpitations. Tongue: Pale. Pulse: Weak. Treatment principle
Tonify Qi, nourish Blood. Prescription
– NAN CHANG FANG – Difficult Labour Formula Explanation
– Huang Qi, Dang Shen and Fu Shen tonify Qi. – Dang Gui, Bai Shao and Gou Qi Zi nourish Blood. – Gui Ban tonifies the Kidneys and consolidates the Directing and
Penetrating Vessels. – Chuan Xiong invigorates Blood and eliminates stasis. Summary De ficie ncy of Q i and Blood
Clinical manifestations
Mild labour pains, duration of uterine contractions is short, the stages of labour develop slowly, heavy bleeding, pale complexion, lassitude, palpitations. Tongue: Pale. Pulse: Weak. Treatment principle
Tonify Qi, nourish Blood Herbal treatment
Prescription • NAN CHANG FANGDifficult Labour Formula
Stasis of Blood and stagnation of Qi
Clinical manifestations
Severe abdominal pain, back pain, irregular uterine contractions, stages of labour develop slowly, scanty bleeding with dark blood, dark complexion, nausea. Tongue: Purple. Pulse: Wiry or Choppy. Treatment principle
Invigorate Blood, move Qi. a Prescription
– CUI SHENG YIN Variation – Hastening Labour Decoction Variation Explanation
– Dang Gui, Chuan Xiong and Yi Mu Cao invigorate Blood and eliminate stasis. – Zhi Ke and Da Fu Pi move Qi to invigorate Blood. – Bai Zhi fragrantly opens the orifices of the genital system to facilitate labour. b Prescription
– SHEN GUI YIN CHAN FANG30 – Codonopsis-Angelica Labour-Inducing Formula Explanation
– Dang Shen tonifies Qi. – Dang Gui nourishes Blood.
– Chuan Xiong, Hong Hua, Chuan Niu Xi, Yi Mu Cao and Ji Xue Teng invigorate Blood and eliminate stasis. c Prescription
– YI MU XIONG GUI TANG31 – Leonorus-Ligusticum-Angelica Decoction Explanation
– Dang Gui nourishes Blood. – Chuan Xiong, Dan Shen, Yi Mu Cao, Hong Hua and Tao Ren invigorate Blood and eliminate stasis. – Hou Po moves Qi. – Huai Niu Xi attracts the formula downwards to the Lower Burner. d Prescription
– FU FANG HUANG QI JIAN32 – Revised Astragalus Decoction Explanation
– Huang Qi tonifies Qi.
– Dang Gui nourishes Blood. – Chuan Xiong, Chuan Niu Xi, Hong Hua and Tao Ren invigorate Blood and eliminate stasis. – Rou Gui warms the Lower Burner and warms the Minister Fire. – Sheng Jiang harmonizes and warms the channels, which helps to invigorate Blood. – Mang Xiao facilitates labour by moving downward. e Prescription
– EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan33 Explanation
– Chen Pi, Xiang Fu, Wu Yao and Zhi Ke move Qi and eliminate stagnation. – Yi Mu Cao, Dang Gui, Hong Hua, San Leng, E Zhu, Wu Ling Zhi and Chuan Niu Xi invigorate Blood and eliminate stasis. – Bai Zhi opens the orifices in the genital tract. – Gan Jiang and Rou Gui warm the Uterus. – Mu Tong removes obstructions from the Connecting channels. Summary
Stasis of Blood and stagnation of Q i
Clinical manifestations
Severe abdominal pain, back pain, irregular uterine contractions, stages of labour develop slowly, scanty bleeding with dark blood, dark complexion, nausea. Tongue: Purple. Pulse: Wiry or Choppy. Treatment principle
Invigorate Blood, move Qi. Herbal treatment
Prescriptions • CUI SHENG YIN Variation Hastening Labour Decoction Variation • SHEN GUI YIN CHAN FANGCodonopsis-Angelica Labour-Inducing Formula • YI MU XIONG GUI TANGLeonorus-Ligusticum-Angelica Decoction • FU FANG HUANG QI JIANRevised Astragalus Decoction • EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan
Herbal treatment for breech presentation The following formula can be used from 30 weeks of pregnancy onwards. The formula is from Fu Qing Zhu’s Gynaecology.34 Please refer to the discussion above to identify cases where acupuncture or herbal medicine cannot help. Prescription
– BAO CHAN WU YOU SAN – Protecting Labour Worry-Free Powder
Herbal treatment for retention of placenta
Qi and Blood deficiency
Clinical manifestations
Profuse bleeding after labour, retention of placenta, no abdominal pain or distension, dizziness, palpitations, sweating, feeling faint, unwilling to speak, cold limbs, pale complexion, pale lips. Tongue: Pale. Pulse: Weak. Treatment principle
Benefit Qi, nourish Blood, eliminate stasis. a Prescription
– BAO SHENG WU YOU SAN – No-Worry Protecting Birth Powder Explanation
– Dang Gui, Chuan Xiong and Ru Xiang nourish and invigorate Blood and eliminate stasis. – Zhi Ke, and Mu Xiang move Qi which helps to invigorate Blood.
– Bai Shao nourishes Blood. – Xian He Cao stops bleeding. – Gan Cao harmonizes. b Prescription
– SONG BAO TANG – Despatching the Uterus Decoction Explanation
– Dang Gui nourishes and invigorates Blood. – Chuan Xiong, Yi Mu Cao, Ru Xiang and Mo Yao invigorate Blood and eliminate stasis. – Jing Jie enters the Blood portion and directs the formula to the Blood. – She Xiang opens the orifices and facilitates the elimination of stasis. However, this substance can be omitted as, apart from its use being illegal, it would also be prohibitively expensive. It can be replaced by Shi Chang Pu Rhizoma Acori graminei 6 g or Bai Zhi Radix Angelicae dahuricae 3 g. This prescription is from Fu Qing Zhu’s Gynaecology and is specific for retention of placenta from Blood deficiency. Fu Qing Zhu says: After delivery, some women’s placenta may remain within the abdomen for two or three days … Some people think this is due to the pedicle of the placenta not breaking off; who would know that it is due to the Blood being deficient and dry so that the placenta sticks to the abdomen? … The appropriate treatment is to strongly tonify
Qi and Blood; when Blood is generated to despatch the placenta, this will be naturally moistened and, once moistened, it descends easily … the formula to use is Song Bao Tang.35 Summary Q i and Blood de ficie ncy
Clinical manifestations
Profuse bleeding after labour, retention of placenta, no abdominal pain or distension, dizziness, palpitations, sweating, feeling faint, unwilling to speak, cold limbs, pale complexion, pale lips. Tongue: Pale. Pulse: Weak. Treatment principle
Benefit Qi, nourish Blood, eliminate stasis. Herbal treatment
Prescriptions • BAO SHENG WU YOU SANNo-Worry Protecting Birth Powder • SONG BAO TANGDespatching the Uterus Decoction
Stasis of Blood and Cold
Clinical manifestations
Retention of placenta, scanty and dark lochia, dark complexion, abdominal pain that is worse with pressure, mental restlessness, agitation, dizziness,
purple lips. Tongue: Purple. Pulse: Firm. Treatment principle
Warm the channels, invigorate Blood, eliminate stasis. Prescription
– DUO MING WAN – Seizing Life Pill Explanation
– Mu Dan Pi, Tao Ren, Chi Shao and Pu Huang invigorate Blood and eliminate stasis. Pu Huang also stops bleeding. – Fu Ling and Gui Zhi, in combination, warm the channels and invigorate Blood. Summary Stasis of Blood and Cold
Clinical manifestations
Retention of placenta, scanty and dark lochia, dark complexion, abdominal pain that is worse with pressure, mental restlessness, agitation, dizziness, purple lips. Tongue: Purple. Pulse: Firm. Treatment principle
Warm the channels, invigorate Blood, eliminate stasis. Herbal treatment
Prescription • DUO MING WANSeizing Life Pill
Diseases affecting the fetus The Collection of Medical Prescriptions by Category (Yi Fang Lei Ju, 1443) mentions several conditions affecting the fetus during pregnancy. The main ones are listed below. Possession
Although possession may occur in the fetus, this is due to the father’s Essence being deficient and the mother’s Qi declining: these [father’s Essence and mother’s Qi] cannot nourish the fetus which therefore cannot ‘swim’. This happens in the seventh or eighth month of pregnancy and causes delivery to be late because Qi and Blood are deficient and there is not enough force to make Qi descend. This causes the fetus and resulting baby to be weak. Close-succession pregnancy
If the mother falls pregnant again a few weeks after the birth of a child, her Qi and Blood stagnate, ‘the two ends meet’, the new fetus is gradually weakened, the milk is poisoned, there is both a deficiency of the body’s Qi and a pathogenic factor, the newly born baby cries, the stagnation injures the Mind and Corporeal Soul, the baby may develop Nutritional Impairment Disease [Gan], he is weak, withering, skinny and irritable, he vomits and cannot sleep. To treat this, the mother must obtain someone else’s milk [by employing a wet nurse], one must warm and balance Stomach-Qi, and harmonize Blood: by so doing the baby will get better quickly.
Fetus Heat
If during pregnancy the mother has a shock or eats too much hot food, the baby will suffer from Deficiency and Phlegm, his eyes will be runny and sticky, he will cry and suffer from hiccup and constipation, his fists will be tightened and his legs twitching, he might have a squint and suffer from blood in the urine: this indicates Fetus Heat. Use Xiao Feng San. Fetus’s accumulated Heat
If during pregnancy the mother gets angry frequently affecting her chest and causing stagnation and a feeling of oppression, this makes the fetus restless. The birth will be difficult, the mother is under shock, the milk will not flow, the baby screams, vomits, has no set pattern, the Spirit is restless and on hearing sounds his hands twitch and contract. Fetus Wind-Heat
If during pregnancy the mother likes to eat Wind-producing foods, Toxic Heat enters the fetus, settles in the channels, its hands and feet contract, Toxic Heat enters the Blood and causes the muscles to wither, its eyes want to close, Blood does not nourish the Heart, the Mind has no residence and the baby is fearful. If this is not treated early the baby is like in a trance and although the body grows, from the affective point of view he is dull. Wind-producing foods are mushrooms, spinach, shellfish, eel and
rooster’s head. Fetus’s shock and Heat
If during pregnancy the mother has a shock and palpitations, this affects the fetus; after birth the baby’s Spirit is not gathered, his complexion is white and his cheeks red and he has palpitations on hearing noises. Fetus’s Wind-Phlegm
If during pregnancy the mother eats too much hot food, Heat leads to Wind, the Spleen and Lungs are not harmonized and Wind and Phlegm develop. One must clear the Heart and Lungs and cool the diaphragm.
Clinical trials
Acupuncture and moxibustion for breech presentation
Moxibustion and other acupuncture point stimulation methods to treat breech presentation: a systematic review of clinical trials
– Chinese Medicine 2009 27(4): 4. – Li X, Hu J, Wang X, Zhang H, Liu J. – Centre for Evidence-Based Chinese Medicine and University of Chinese Medicine, Beijing, China. Objective To evaluate the efficacy and safety of moxibustion and other acupuncture point stimulations to treat breech presentation. Methods A search was conducted for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) involving moxibustion, acupuncture or any other acupuncture point-stimulating methods for breech presentation in pregnant women. The following databases were searched up until July 2008: PubMed, the Cochrane Library (2008 Issue 2), China National Knowledge Information (CNKI), Chinese Scientific Journal Database (VIP) and the WanFang Database. Two authors extracted and analysed the data
independently. Results Ten RCTs involving 2090 participants and 7 CCTs involving 1409 participants were included in the study. A meta-analysis showed significant differences between using moxibustion and having no treatment (RR 1.35, 95% CI 1.20–1.51; 3 RCTs). A comparison between using moxibustion and assuming the knee-chest position (hands and knees on the floor with the bottom raised) did not show significant differences (RR 1.30, 95% CI 0.95– 1.79; three RCTs). Moxibustion plus other therapeutic methods showed significant beneficial effects (RR 1.36, 95% CI 1.21–1.54; two RCTs). Laser stimulation was more effective than assuming the knee–chest position plus pelvis rotation. Moxibustion was more effective than no treatment (RR 1.29, 95% CI 1.17–1.42; two CCTs) but was not more effective than the knee–chest position treatment (RR 1.22, 95% CI 1.11–1.34; two CCTs). Laser stimulation at BL-67 Zhiyin was more effective than the knee–chest position treatment (RR 1.30, 95% CI 1.10–1.54; two CCTs). Conclusion Moxibustion, acupuncture and laser acupuncture point stimulation tend to be effective in the correction of breech presentation. The effectiveness of acupuncture-type interventions versus expectant management to correct breech presentation: a systematic review
– Complementary Therapies in Medicine 2008 16(2): 92–100. – van den Berg I, Bosch J L, Jacobs B, Bouman I, Duvekot J J, Hunink
M G. – Department of Epidemiology and Biostatistics, Erasmus University Medical Centre Rotterdam, The Netherlands. Objective To assess the effectiveness of acupuncture-type interventions (moxibustion, acupuncture or electro-acupuncture) at BL-67 Zhiyin to correct breech presentation compared to expectant management, based on controlled trials. Methods Articles published from 1980 to May 2007 in the databases of Medline, EMBASE, the Cochrane Central Register of Controlled Trials, AMED, NCCAM, Midirs and in reference lists were analysed. Original articles, RCTs or controlled cohort studies were included that looked at acupuncturetype intervention at BL-67 Zhiyin compared with expectant management with ultrasound-confirmed breech presentation and post-treatment position of the fetus, position at delivery and/or incidence of Caesarean section. Three reviewers independently extracted data. Of 65 retrieved citations, 6 RCTs and 3 cohort studies fulfilled the inclusion criteria. Data were pooled using random-effects models. Results In the RCTs, the pooled proportion of breech presentations was 34% following treatment versus 66% in the control groups (OR 0.25, 95% CI 0.11–0.58). The pooled proportion in the cohort studies was 15% after treatment versus 36% in the control groups (OR 0.29, 95% CI 0.19–0.43). The pooled proportion in all the studies combined was 28% versus 56% (OR 0.27, 95% CI 0.15–0.46).
Conclusion The results suggest that acupuncture-type interventions at BL-67 Zhiyin are effective in correcting breech presentation compared to expectant management. Some studies were of inferior quality to others and further RCTs of improved quality are necessary to adequately answer the research question. Acupuncture plus moxibustion to resolve breech presentation: a randomized controlled study
– Journal of Maternal, Fetal and Neonatal Medicine 2004 15(4): 247– 252. – Neri I, Airola G, Contu G, Allais G, Facchinetti F, Benedetto C. – Department of Obstetrics and Gynaecology, University of ModenaReggio Emilia, Modena, Italy. Objective To ascertain the effectiveness of acupuncture plus moxibustion at BL-67 Zhiyin in correcting breech presentations. Methods Two-hundred and twenty-six women at 33–35 weeks of gestation carrying a fetus in breech presentation were randomized to receive acupuncture plus moxibustion (treatment group, n = 112) or to receive no treatment (observation group, n = 114). Bilateral acupuncture plus moxibustion was applied to BL-67 Zhiyin. The primary outcome of the study was fetal
presentation at delivery. Results At delivery, the proportion of cephalic presentations in the observation group was 36.7% versus 53.6% in the treatment group (P = 0.01). Therefore, the proportion of Caesarean sections indicated for breech presentation was significantly lower in the treatment group than in the observation group (52.3% vs. 66.7%, P = 0.03). Conclusion Acupuncture plus moxibustion is more effective than observation in correcting breech presentation fetuses. The treatment appears to be a valid option for women hoping to experience a natural birth. Acupuncture conversion of fetal breech presentation
– Fetal Diagnosis and Therapy 2003 18(6): 418–421. – Habek D, Cerkez Habek J, Jagust M. – Clinical Department of Obstetrics and Gynaecology, Clinical Hospital Osijek, Osijek, Croatia. Objective To assess the effectiveness of acupuncture in turning breech presentations. Methods
A randomized prospective controlled clinical study included 67 pregnant women with singleton breech presentations. The treatment group participants received acupuncture at BL-67 Zhiyin (n = 34) and the control group did not receive any treatment (n = 33). Acupuncture was administered daily for 30 minutes from 34 weeks of pregnancy with simultaneous cardiotocography. Results The breech position was corrected in 76.4% (26 women) in the acupuncture group and 45.4% (15 women) in the control group (P < 0.001). Conclusion Acupuncture was a relatively simple, efficacious and inexpensive method of correcting breech presentation, and was associated with a lower percentage of assisted deliveries or Caesarean sections, which reflects in improved parameters of vital and peri-natal statistics. Acupuncture for labour
The effect of acupuncture on labour induction
– Journal of Alternative and Complementary Medicine 2009 15(11): 1209–1214. – Lim C E, Wilkinson J M, Wong W S, Cheng N C. – Division of Chinese Medicine, Royal Melbourne Institute of Technology University, Bundoora Campus, Victoria, Australia.
Objective The objective of this study was to review the existing scientific evidence on the potential role of acupuncture on the induction of labour. Methods The following databases were searched to identify relevant monographs from 1970 to 2008: Medline, EMBASE, Cochrane Central Register of Controlled Trials, AMED and NCCAM. The inclusion criteria were all available human acupuncture studies written in English on pregnant women carrying a viable fetus due for third trimester induction of labour. Results Ten studies on labour induction by acupuncture were identified. The duration of labour ranged from 10 hours 20 minutes to 29 hours 10 minutes. However, because two randomized controlled trials reported that there was no statistically significant effect of acupuncture, these results are more suggestive than definitive. Furthermore, although the relationship between cervical ripening and interleukin-8 (IL-8), prostaglandin F2α (PGF2α), and beta-endorphin is well documented in the literature, there is no evidence to suggest that acupuncture alters these mediators. Serum levels of IL-8, betaendorphin, and PGF2α were not found to be significantly influenced by acupuncture. Conclusion Although the definitive role of acupuncture in inducing labour is still to be established, the existing studies suggest that acupuncture may be beneficial. Further randomized clinical trials are needed to investigate this further.
The effects of acupuncture during labour and delivery in a US hospital setting: a case-control pilot study
– Journal of Alternative and Complementary Medicine 2009 15(5): 501– 505. – Citkovitz C, Klimenko E, Bolyai M, Applewhite L, Julliard K, Weiner Z. – Lutheran Medical Centre, Brooklyn, New York, USA. Objective The objective of this study was to assess the clinical effects and logistical feasibility of acupuncture given during labour and delivery in a US hospital setting. Methods A case-control pilot study was conducted whereby 45 participants received acupuncture during labour and delivery alongside standard care. The participants were compared to 127 historical controls matched for maternal age, gestational age, parity and use of oxytocin (augmentation and induction were matched separately). The primary outcome measures were: incidence of Caesarean section, amount of parenteral opioids used, use of epidural anaesthesia and duration of labour. Secondary outcome measures included patient satisfaction and nursing staff acceptance as assessed by a postpartum questionnaire, maximum flow rate of oxytocin, incidence of instrumental delivery, Apgar score and the incidence of adverse events. Results
The acupuncture patients underwent significantly fewer Caesareans (7% versus 20%, P = 0.004). No significant differences were noted in other clinical outcome measures. Seventy-eight per cent of nurses reported a subjective perception of improvement in patients’ comfort as a result of the acupuncture, while 83% reported that the acupuncturist’s presence never interfered with their work. Eighty-seven per cent of patients reported that acupuncture had helped them. Conclusion Acupuncture during labour and delivery is well tolerated by patients and medical staff. It should be further evaluated for its promise in potentially reducing the incidence of Caesareans. Acupuncture as pain relief during delivery: a randomized controlled trial
– Birth 2009 36(1): 5–12. – Borup L, Wurlitzer W, Hedegaard M, Kesmodel U S, Hvidman L. – Department of Obstetrics and Gynaecology, Aarhus University Hospital, Skejby, Brendstrupgaardsvej, Aarhus N, Denmark. Objective The objective of this study was to compare the effect of acupuncture with transcutaneous electric nerve stimulation (TENS) and traditional analgesics for pain relief and relaxation during delivery with respect to pain intensity, birth experience and obstetric outcome. Methods
An RCT was conducted with 607 healthy women in labour at term who received acupuncture, TENS or traditional analgesics. Primary outcomes were the need for pharmacological and invasive interventions, level of pain assessed by a visual analogue scale, birth experience and satisfaction with delivery, and pain relief evaluated at 2 months postpartum. Secondary obstetric outcomes were duration of labour, use of oxytocin, mode of delivery, postpartum haemorrhage, Apgar score and umbilical cord pH value. Results The use of pharmacological and invasive interventions was significantly lower in the acupuncture group (acupuncture vs. traditional, P < 0.001; acupuncture vs. TENS, P = 0.031). Pain scores were comparable. Acupuncture did not influence the duration of labour or the use of oxytocin. The mean Apgar score at 5 minutes and umbilical cord pH value were significantly higher among infants in the acupuncture group compared with infants in the other groups. Conclusion Acupuncture reduced the need for pharmacological and invasive interventions during delivery. Acupuncture is a good supplement to existing pain relief methods. The safety of electro-acupuncture at L.I.-4 Hegu plus oxytocin for hastening uterine contractions of women in labour – a randomized controlled clinical observation
– Journal of Traditional Chinese Medicine 2008 28(3): 163–167.
– Liu J, Han Y, Zhang N, Wang B, Zhou Y, Yang D et al. – Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China. Objective To investigate the safety of electro-acupuncture plus oxytocin for uterine contractions of women in labour. Methods Two-hundred and seventy-six women undergoing difficulties in labour were randomly divided into a medication group which was treated with intravenous dripping of oxytocin, and an acupuncture plus medication group which received electro-acupuncture bilaterally at L.I.-4 Hegu in addition to the oxytocin. The heart rate, respiratory frequency and blood pressure of the women were observed, along with the fetal heart rate and the birth process. Results During labour the heart rate, respiratory frequency, blood pressure, fetal heart rate and the birth process were all within normal ranges for all 276 cases. Better effects in the acupuncture plus medication group were observed compared with the medication alone group. No side effects on either the women or the newborns were apparent. Conclusion Electro-acupuncture at bilateral L.I.-4 Hegu plus intravenous dripping of oxytocin can intensify uterine contractions, and shorten the birth process to avoid probable systemic exhaustion.
Electro-acupuncture for relieving labour pain
– Evidence-Based Complementary and Alternative Medicine 2007 4(1): 125–130. – Qu F, Zhou J. – Heilongjiang University of Chinese Medicine, Harbin, China. Objective To study the efficacy of electro-acupuncture for the relief of labour pain, and to further understand the influence of electro-acupuncture upon the neuroendocrine system. Methods Thirty-six primiparas were randomly divided into an electro-acupuncture group and a control group. Assessments of pain intensity and the degree of relaxation during labour were analysed. The differences between the electroacupuncture group and the control group on the concentration of betaendorphin (beta-EP) and 5-hydroxytryptamine (5-HT) in the peripheral blood were compared. Results The electro-acupuncture group was found to exhibit a lower pain intensity and a better degree of relaxation than the control group (P = 0.018; P = 0.031). There existed a significant difference in the concentration of beta-EP and 5-HT in the peripheral blood between the groups at the end of the first stage (P = 0.037; P = 0.030).
Conclusion Electro-acupuncture provided effective pain relief during labour. The benefit of electro-acupuncture for relieving labour pain may be based on the mechanism of producing a synergism of the central nervous system with a direct impact on the uterus through increasing the release of beta-EP and 5HT into the peripheral blood. The effects of acupuncture during labour on nulliparous women: a randomised controlled trial
– Australian and New Zealand Journal of Obstetrics and Gynaecology 2007 47(1): 26–30. – Hantoushzadeh S, Alhusseini N, Lebaschi A H. – Department of Obstetrics and Gynaecology, Vali Asr Research Centre for Reproductive Health, Imam Medical Complex, Tehran, Iran. Objective To assess the effects of acupuncture on nulliparous women during labour with respect to pain, labour duration and maternal acceptability. Methods One-hundred and forty-four healthy nulliparous women in the active phase of labour were randomized into the study and control group, receiving real and minimal acupuncture, respectively. The visual analogue scale was used to assess pain. The objectives were to evaluate the effect of acupuncture upon pain and labour duration and patients’ willingness to receive acupuncture for
subsequent pregnancies. Results The visual analogue scale pain score in the study group was lower after 2 hours. The active phase duration and the amount of oxytocin administered were lower in the study group. Study group patients had greater willingness to receive acupuncture again. No adverse effects were detected. Conclusion Acupuncture reduced pain, active phase duration and the amount of oxytocin used. Patients were satisfied and no adverse effects were noted. Acupuncture administered after spontaneous rupture of the membranes at term significantly reduces the length of birth and use of oxytocin. A randomized controlled trial
– Acta Obstetricia et Gynecologica Scandinavica 2006 85(11): 1348– 1353. – Gaudernack L C, Forbord S, Hole E. – Kvinneklinikken, Rikshospitalet University Hospital, Oslo, Norway. Objective To investigate whether acupuncture could be a reasonable option for augmentation in labour after spontaneous rupture of the membranes at term and to look for possible effects on the progress of labour. Methods
In a randomized controlled trial, 100 healthy patients with spontaneous rupture of the membranes at term were assigned to receive either acupuncture or no acupuncture. The primary outcome measures were the duration of active labour, the amount of oxytocin given and number of inductions. Results The duration of labour was significantly reduced (mean difference 1.7 hours, P = 0.03) and there was significant reduction in the need for oxytocin infusion to augment labour in the study group compared to the control group (P = 0.018). The participants in the acupuncture group who needed labour induction had a significantly shorter duration of the active phase than the patients induced in the control group (mean difference 3.6 hours, P = 0.002). Conclusion Acupuncture may be a good alternative, or complement, to pharmacological methods in the effort to facilitate birth and provide normal delivery for women with pre-labour rupture of the membranes. A randomized controlled trial of acupuncture for the initiation of labour in nulliparous women
– Journal of Maternal, Fetal and Neonatal Medicine 2006 19(8): 465– 470. – Harper T C, Coeytaux R R, Chen W, Campbell K, Kaufman J S, Moise K J, Thorp J M. – Department of Obstetrics and Gynaecology, University of North
Carolina, NC, USA. Objective To evaluate the use of outpatient acupuncture for labour stimulation. Methods Nulliparous women at 39 weeks or greater with a singleton gestation and a Bishop score of less than 7 were randomized to usual care and three outpatient acupuncture treatments (acupuncture group) versus solely usual medical care (control group). Each treatment consisted of bilateral needling of L.I.-4 Hegu, SP-6 Sanyinjiao, BL-31 Shangliao and BL-32 Ciliao. The primary outcome measure was time elapsed from the time of randomization to delivery. Secondary outcome measures included rates of Caesarean sections and inductions. Medical records were abstracted for maternal demographic, medical and delivery outcome data. Fifty-six women were randomized and completed the study procedures. Race, age, gestational age and cervical Bishop score were similar in both groups. Results The mean time to delivery occurred 21 hours sooner in the acupuncture group, but this difference did not reach statistical significance (P = 0.36). Compared to controls, women in the acupuncture group tended to be more likely to labour spontaneously (70% vs. 50%, P = 0.12) and less likely to deliver by Caesarean section (39% vs. 17%, P = 0.07). Of women who were not induced, those in the acupuncture group were more likely to be delivered than the controls at any point after enrolment (P = 0.05). Conclusion
Acupuncture is well tolerated among term nulliparous women and holds promise in reducing interventions that occur in post-term pregnancies. Acupuncture during labour can reduce the use of meperidine: a controlled clinical study
– Clinical Journal of Pain 2003 19(3): 187–191. – Nesheim B I, Kinge R, Berg B, Alfredsson B, Allgot E, Hove G, et al. – Department of Obstetrics and Gynaecology, Ulleval University Hospital, Oslo, Norway. Objective To evaluate the effectiveness of acupuncture as an analgesic during labour. Methods A randomized, unblinded, controlled study took place at a labour ward in a university hospital involving women at term. Group A received acupuncture (n = 106) and Group B did not receive any acupuncture (n = 92). A second control group (Group C, n = 92) consisted of patients from the labour ward who met the eligibility criteria for the study and were matched to the Group B by parity, but who had not been offered the opportunity to take part. The outcome measure, which was the effectiveness of the acupuncture, was measured by the requirement for meperidine. Results Meperidine was given to 11% of Group A and 37% of Group B which was a
significant difference (P < 0.0001), and 29% of Group C. The use of other analgesics was also lower in the acupuncture group. Patient satisfaction was high as 89 out of 103 patients consulted said they would choose acupuncture during another labour. Conclusion Acupuncture during labour reduced the requirement for other painkillers and had high patient satisfaction in this randomized, unblinded, controlled study. Acupuncture during labour – a randomised controlled trial
– BJOG: An International Journal of Obstetrics and Gynaecology 2002 109(6): 637–644. – Ramnerö A, Hanson U, Kihlgren M. – Department of Obstetrics and Gynaecology, Orebro University Hospital, Sweden. Objective To investigate the efficacy of acupuncture during labour with regard to pain intensity, degree of relaxation and the delivery outcome. Methods This was an RCT which took place at a delivery ward at a tertiary care centre hospital in Sweden involving 90 parturients who delivered between 12 April 1999 and 4 June 2000. Forty-six women were randomized to receive acupuncture during labour as a complement, or an alternative, to
conventional analgesia. The main outcome measures were pain intensity, degree of relaxation during labour and the delivery outcome. Results Acupuncture significantly reduced the need of epidural analgesia (12% vs. 22%). Patients receiving acupuncture also felt significantly more relaxed than those in the control group. There were no negative effects of acupuncture given during labour in relation to the delivery outcome. Conclusion The results suggest that acupuncture could be a good alternative, or complement, to patients who seek an alternative to pharmacological analgesia in childbirth. However, further trials with larger numbers of patients are required to clarify if the main effect is analgesic or relaxing. Acupuncture for cervical ripening and induction of labour at term – a randomized controlled trial
– Wiener Klinische Wochenschrift 2001 17(113): 942–946. – Rabl M, Ahner R, Bitschnau M, Zeisler H, Husslein P. – Department of Obstetrics and Gynaecology, University of Vienna, Austria. Objective The aim of this study was to evaluate whether acupuncture at term can influence cervical ripening, induce labour and thus reduce the need for post-
dates induction. Methods On the estimated date of confinement (EDC), women were prospectively randomized to an acupuncture group (AG, n = 25) or a control group (CG, n = 20). Inclusion criteria were: confirmed EDC, uncomplicated course of pregnancy and singleton pregnancy in cephalic presentation. Exclusion criteria were: cervical dilation >3 cm, active labour, premature rupture of the membranes, previous Caesarean section and pathologies in the mother or fetus. Women were examined at 2-day intervals. The cervical length was measured with vaginal ultrasonography, cervical mucus was obtained for a fetal fibronectin test and the cervical status was assessed according to the Bishop score. In the AG, L.I.-4 Hegu and SP-6 Sanyinjiao were needled bilaterally every second day. If women were not delivered 10 days after EDC, labour was induced by administering vaginal prostaglandin tablets. Results The cervical length in the AG was shorter than that in the CG on day 6 and day 8 after EDC (P = 0.04 for both days). In the AG, the time period from the first positive fibronectin test to delivery was 2.3 days, while that in the CG was 4.2 days (P = 0.08). The time period from EDC to delivery was on average 5.0 days in the AG and 7.9 days in the CG (P = 0.03). Labour was induced in 20% of women in the AG (n = 5) and in 35% in the CG (n = 7; P = 0.3). Overall duration of labour, and first and second stage of labour, were not different in the two groups. In 56% of women who received acupuncture and in 65% of controls, oxytocin was used to augment labour (P = 0.54). Conclusion Acupuncture at L.I.-4 Hegu and SP-6 Sanyinjiao supports cervical ripening
at term and can shorten the time interval between the EDC and the actual time of delivery. The influence of acupuncture on the duration of labour
– Gynaecologic and Obstetric Investigation 1998 46(1): 22–25. – Zeisler H, Tempfer C, Mayerhofer K, Barrada M, Husslein P. – Department of Obstetrics and Gynaecology, University of Vienna, Austria. Objective The aim of this case control study was to evaluate the influence of acupuncture on the duration of labour. Methods Fifty-seven women who received acupuncture (group A) were included in the study after spontaneous vaginal full-term delivery. Sixty-three women comprised the control group (group B). Results The median duration of the first stage of labour was 196 minutes in group A and 321 minutes in group B (P < 0.0001). The median duration of the second stage of labour was 57 minutes in group A and 57 minutes in group B (P = 0.82). Premature rupturing of the membranes occurred in 66.7% of Group A and 33.3% in Group B (P = 0.02). Women in group B received significantly more oxytocin during the first stage of labour compared with
group A (85% and 15% respectively, P = 0.01), as well as during the second stage of labour (72% and 28% respectively, P = 0.03). Conclusion The study suggests that acupuncture is a recommendable form of childbirth preparation due to its positive effect on the duration of labour, namely by shortening the first stage of labour. Acupuncture for pain relief during childbirth
– Acupuncture and Electrotherapeutics Research 1998 23(1): 19–26. – Ternov K, Nilsson M, Löfberg L, Algotsson L, Akeson J. – Department of Anaesthesia and Intensive Care, University Hospitals, Malmö, Sweden. Objective To evaluate the efficacy of acupuncture as an analgesic during labour. Methods Ninety women were given acupuncture (AG) and 90 women who did not receive acupuncture comprised the control group (CG). The analgesic effect of acupuncture during childbirth was assessed by comparing the need for other forms of pain relief. These were: epidural analgesia using bupivacaine, pudendal nerve block, intramuscular meperidine, nitrous oxide/oxygen and intracutaneous sterile water injections. Results
Fifty-two women (58%) in the acupuncture group and 13 (14%) in the control group managed their deliveries without further pain relief (P < 0.001). The groups were similar with respect to age, pariety, duration of delivery, use of oxytocin and incidence of Caesareans. Acupuncture was found to have no major side effects, and 85 women (94%) given acupuncture reported that they would reconsider acupuncture for future deliveries. Conclusion Acupuncture reduces the need for other methods of analgesia in childbirth. Herbal treatment in labour
A clinical study on the efficacy of Chan Li Bao Labour Regulating Infusion in accelerating the second stage of labour
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 1998 18(4): 214–216. – Qiu H, Zhu H, Ouyang W. – Department of Obstetrics and Gynaecology, Xiehe Hospital, Tongji Medical University, Wuhan, China. Objective To observe the clinical effects and the mechanism of Chan Li Bao (CLB) in accelerating the second stage of labour. Methods
Primiparae were randomly divided into a CLB group (n = 80), an oxytocin group (OTC, n = 52) and a control group (n = 29). The control group consisted of women experiencing natural labour and to whom no drug was given. The duration of the second stage of labour and the prognosis of both mother and newborn in each group were observed and compared. Intrauterine pressure and fetal heart rate were electronically monitored. Isolated uterine muscular tissue was used to observe the reactivity to CLB. Results The results showed that the duration of the second stage of labour and postpartum haemorrhage in the CLB group were less than those in the control group. The average intra-uterine pressure and the contraction strength of isolated uterine muscle in the CLB group was higher than in the control group. There was no significant difference between the results in the CLB or OTC group. There were no side effects in the CLB group. Conclusion CLB strengthened uterine contractions and accelerated the second stage of labour. It is inexpensive, convenient and does not cause any side effects. It can, therefore, be used as a new, safe and effective alternative for improving the prognosis of mother and newborn, especially in cases where oxytocin or profuse infusion is contraindicated. End note 1. Tian Cong Huo 1985 Collection of Acupuncture Experiences (Zhen Jiu Yi Xue Yan Ji
), Science and Literature Publishing House, Chongqing, p. 229..
2. Chen You Bang 1990 Chinese Acupuncture Therapy (Zhong Guo Zhen Jiu Zhi Liao Xue
), China Scientific Publishing House, Beijing, p. 910..
3. Co-operative Research Group of Moxibustion Version 1984 Clinical Observation on the Effects of Version by Moxibustion, Abstracts from the Second National Symposium on Acupuncture and Moxibustion and Acupuncture Anaesthesia, All-China Society of Acupuncture and Moxibustion, Beijing, p. 150. ‘Version’ here refers to the turning of the fetus in the uterus..
4. Cardini F, Marcolongo A 1993 Moxibustion for Correction of Breech Presentation: a Clinical Study with Retrospective Controls, American Journal of Chinese Medicine 21(2): 133– 138..
5. Habek D, Habek J, Jagust M 2003 Acupuncture Conversion of Fetal Breech Presentation, Fetal Diagnosis and Therapy 18(6): 418–421..
6. Neri I, Airoli G, Contu G et al 2004 Acupuncture plus Moxibustion to Resolve Breech Presentation: a Randomized Controlled Study, Journal of Maternal, Fetal and Neonatal Medicine 15(4): 247–252..
7. Cooperative Research Group of Moxibustion Version of Jangxi Province 1980 Studies of Version by Moxibustion on Zhiyin Points, in: Xiangtong Z (ed.) Research on Acupuncture, Moxibustion and Acupuncture Anesthesia, Beijing, China, Science Press, pp 810–819..
8. Ibid., pp 810–819..
9. Martoudis S, Christofides K 1990 Electro-Acupuncture for Pain Relief in Labour, Acupuncture in Medicine 8(2): 51..
10. Zheng J 1990 Legends about Acupuncture Treatment of Difficult Labour, International Journal of Clinical Acupuncture 1(3): 309–310..
11. Ma K 1992 The Roots and Development of Chinese Acupuncture: from Prehistory to early Twentieth Century, Acupuncture in Medicine 10: 96..
12. Legends about Acupuncture Treatment of Difficult Labour, pp 309–310..
13. Ibid., pp 309–310..
14. Revolutionary Health Committee of Hunan Province 1978 A Barefoot Doctor’s Manual, Routledge & Kegan, London, p. 62..
15. Budd S 1995 Complementary Therapies for Pregnancy and Childbirth, Bailliere Tindall, London, p. 234..
16. Pei D, Huang Y 1985 Use of Acupuncture during Childbirth, Journal of Traditional Chinese Medicine 5(4): 253–255..
17. Dick-Read G 1945 Childbirth without Fear, Heinemann Medical Books, London, p. 3..
18. The free booklet is available to download at The Debra Betts Web site: http://acupuncture.rhizome.net.nz/.
19. Betts D 2006 The Essential Guide to Acupuncture in Pregnancy and Childbirth, Journal of Chinese Medicine, Brighton..
20. Ingram J, Domagala C, Yates S 2005 The Effects of Shiatsu on Post-term Pregnancy, Complementary Therapies in Medicine 13: 11–15..
21.
Lee M K, Chang S B, Kang D H 2004 Effects of SP-6 Acupressure on Labour Pain and Length of Delivery Time in Women During Labour, Journal of Alternative and Complementary Medicine 10(6): 956–965..
22. Chung U L J 2003 Effects of L.I.-4 and BL-67 Acupressure on Labour Pain and Uterine Contractions in the First Stage of Labour, Journal of Nursing Research 11(4): 251– 260..
23. Smith C A, Cochrane S 2009 Does Acupuncture Have a Place as an Adjunct Treatment During Pregnancy? A Review of Randomized Controlled Trials and Systematic Reviews, Birth 36(3): 246–253..
24. Borup L, Wurlitzer W, Hedegaard M, Kesmodel U S, Hvidman L 2009 Acupuncture as Pain Relief During Delivery: a Randomized Controlled Trial, Birth 36(1): 5–12..
25. Shandong College of Traditional Chinese Medicine 1980 An Explanation of the ABC of Acupuncture (Zhen Jiu Jia Yi Jing Jiao Shi
), People’s Health Publishing House, Beijing, p. 1484. The ABC of Acupuncture was written by Huang Fu Mi and published in AD 282..
26. Kubista E, Kucera H, Müller-Tyl E 1975 Initiating Contractions of the Gravid Uterus through Electro-Acupuncture, American Journal of Chinese Medicine 3(4): 343; Ying Y K, Lin J T, Robins J 1985 Acupuncture for the Induction of Cervical Dilatation in Preparation for First-Trimester Abortion and its Influence on HCG, Journal of Reproductive Medicine 30(7): 530–534; Dunn P A, Rogers D, Halford K 1989 Transcutaneous Electrical Nerve Stimulation at Acupuncture Points in the Induction of Uterine Contractions, Obstetrics and Gynaecology 73(2): 286–290..
27. Rempp C, Bigler A 1991 Pregnancy and Acupuncture from Conception to Postpartum, American Journal of Acupuncture 19(4): 305–313..
28. Wang Xue Tai 1995 Great Treatise of Chinese Acupuncture (Zhong Guo Zhen Jiu Da Quan
), Henan Science and Technology Publishing House, p. 483..
29. Personal communication, London, September 1996..
30. Hu Xi Ming 1990 Great Treatise of Secret Formulae in Chinese Medicine (Zhong Guo Zhong Yi Mi Fang Da Quan
), Culture Publishing House, Shanghai, Vol. 2, p. 247..
31. Ibid., p. 247..
32. Ibid., p. 248..
33. Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 20. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang) and published in 1729..
34. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p. 76. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
35. Ibid., p. 52..
SECTION 7 Diseases after Childbirth
Introduction 45. POST-NATAL DEPRESSION 593 46. ABDOMINAL PAIN AFTER CHILDBIRTH 601 47. PERSISTENT LOCHIAL DISCHARGE (AND RETENTION OF LOCHIA) 607 48. URINARY DIFFICULTY AFTER CHILDBIRTH 615 49. SWEATING AFTER CHILDBIRTH 625 50. CONSTIPATION AND HAEMORRHOIDS AFTER CHILDBIRTH 629 51. FEVER AFTER CHILDBIRTH 639 52. JOINT PAIN AFTER CHILDBIRTH 651 53. BREAST MILK NOT FLOWING (AND ACUTE MASTITIS) 657 54. SPONTANEOUS FLOW OF MILK 669 55. COLLAPSE AFTER CHILDBIRTH 673 56. CONVULSIONS AFTER CHILDBIRTH 679
The period considered here is the first few weeks after delivery, called the puerperium in Western medicine. In Chinese medicine, this period was
called chan ru (
): chan
means ‘childbirth’ and ru means ‘cotton mattress’. This name gives an immediate indication about Chinese recommendations regarding the length of bed rest required after childbirth. The old doctors placed the emphasis on different aspects of the period after delivery: some said that the three main conditions at this time are convulsions (now rare), invasions of external pathogenic factors and constipation. These three conditions were called san bing (
), i.e. the ‘three diseases’. Others considered the three main problems as being vomiting, sweating and diarrhoea: these were called san ji (
Yet
other
doctors
emphasized
), i.e. the ‘three emergencies’. the san chong (
), meaning ‘three upward rebellions’, i.e. depleted Blood rebelling upwards in the Penetrating Vessel (Chong Mai) towards the Heart, Lungs or Stomach. Clinical Note
Three diseases after childbirth are: • convulsions • invasion of external pathogenic factors • constipation
Three emergencies after childbirth are: • vomiting • sweating • diarrhoea
Three upwards rebellions after childbirth are: • depleted Blood rebelling upwards in the Penetrating Vessel • towards the Heart • towards the Lungs • towards the Stomach
Zhang Zhong Jing says in his Synopsis of Prescriptions from the Golden Cabinet: After childbirth the three main diseases are convulsions, collapse and constipation. After delivery, Blood is exhausted, the woman has perspired profusely, so that internal Wind develops and leads to convulsions. Exhaustion of Blood and profuse sweating may also allow Cold to invade leading to collapse. The exhaustion of body fluids leads to dryness of the Stomach and therefore constipation.1 Whatever the problems after childbirth, the puerperium is characterized by two major possible conditions: a deficiency of Qi, Blood or Yin, or Blood stasis. The force required for delivery taxes the woman’s Qi, the loss of blood during childbirth injures Blood and Yin, the sudden expulsion of the placenta injures the Original Qi, the Directing and Penetrating Vessels are depleted and the blood vessels and channels are Empty and prone to
invasions by Exterior pathogenic factors. All these factors mean that a deficiency (of Qi, Blood, Yin) is the overriding pathological condition of women after childbirth. However, this is not to say that there are no Full conditions after delivery. Zhang Jing Yue says in the Complete Works of Jing Yue (1624): After childbirth Blood is lost and there is often a Deficiency. However, there are conditions of Deficiency, conditions without Deficiency, and Excess conditions. In these three cases, one must consider the woman and the pattern to differentiate between Deficiency and Excess. In treatment, one must not stick to one’s views complacently and when one tonifies one must also pay attention to eliminating pathogenic factors.2 Dr Chen Jia Yuan also places the emphasis on deficiency of Blood as the main condition after birth but he does not overlook pathogenic factors either: After birth Blood is deficient and one must therefore tonify Blood. However, there may also be other patterns which must be treated and one should drive out the stale and generate the new.3 As a general decoction to be used after childbirth, Dr Chen recommends Dang Gui Radix Angelicae sinensis, Chuan Xiong Rhizoma Chuanxiong, Shu Di Huang Radix Rehmanniae preparata, Rou Gui Cortex Cinnamomi, Bai Zhi Radix Angelicae dahuricae, Shan Zha Fructus Crataegi, Wu Yao Radix Linderae, Chen Pi Pericarpium Citri reticulatae, Jie Geng Radix Platycodi, Gan Jiang Rhizoma Zingiberis, Gan Cao Radix Glycyrrhizae, Chuan Niu Xi Radix Cyathulae and Wu Ling Zhi Faeces Trogopteri. From an analysis of this formula’s ingredients, we can see that Dr Chen nourishes Blood but also invigorates Blood and eliminates stasis after childbirth. Apart from the above deficiencies, a stasis of Blood is the other common pathological condition after childbirth. Stasis of Blood after delivery may be due to retention of old blood in the uterus or retention of lochiae.
Deficiency of Blood or stasis of Blood after childbirth are, in fact, the two underlying conditions for mental changes in the puerperium: deficiency of Blood may cause post-natal depression while stasis of Blood may cause psychosis. Apart from a deficiency and stasis of Blood, another consequence of the strain of childbirth is the propensity to invasions of external pathogenic factors. As mentioned above, after childbirth when the blood vessels and channels are Empty due to the loss of blood during delivery, they are prone to invasion of Wind. As for diagnosis, apart from the usual diagnostic tools, three questions, called san shen (
), are often referred to as crucial after delivery. The first question is whether or not there is abdominal pain: this tells the doctor whether there is retention of lochiae or not. The second question concerns whether or not there is constipation: this indicates the extent of exhaustion in the body fluids, Blood or Yin, i.e. the more constipation there is, the greater the exhaustion. The third question is whether or not the mother’s breast milk is flowing: this tells us how much Stomach-Qi has been weakened, i.e. the less milk there is, the more Stomach-Qi has been weakened. Clinical Note The three questions after childbirth are: • pain? tells us whether there is stasis or not • constipation? tells us whether the fluids are exhausted or not • breast milk? tells us whether Stomach-Qi has been injured (scanty milk)
The treatment principle in treating women during the puerperium is to assess the relative importance of deficiency and excess, i.e. deficiency of Blood and/or Yin versus stasis of Blood. In any case, one must not adhere rigidly to the accepted, conventional ideas about the pathology after childbirth discarding any manifestation that might not fit into the accepted patterns. The Chinese explain this in a succinct saying that, translated, states: “Do not adhere rigidly to ideas about the post-partum conditions, but, on the other hand, do not forget the post-partum pathology.” Thus, the treatment principle should be based on a clear differentiation between deficiency or excess (in the form of stasis of Blood): if a deficiency predominates, one must nourish Blood, tonify Qi or nourish Yin, and if there is stasis of Blood, one must invigorate Blood and eliminate stasis. However, it is of course possible for these two conditions to occur simultaneously and, indeed, one would probably never nourish only or eliminate only to the exclusion of the other. For example, if we believe that a deficiency of Blood predominates and prescribe a Blood-nourishing prescription, it would be a good idea to include one or two herbs to invigorate Blood: the closer in time to delivery, the more important it would be to invigorate Blood also. Vice versa, if one were using a formula to invigorate Blood and eliminate stasis, it would be a good idea to add one or two Blood tonics. The problem of preventing stagnation when tonifying does not really exist with acupuncture as practically any acupuncture point moves Qi and Blood. For example, if we use ST-36 Zusanli and SP-6 Sanyinjiao to tonify Qi and Blood, there will be no danger of creating some stagnation, a risk we would run with Bloodtonic herbs due to their cloying effect. Zhang Jing Yue says that three treatment methods should not be used after childbirth, i.e. sweating, moving downwards and promoting urination. He says that using sweating may damage Qi, moving downwards will damage the Spleen and cause the pulse to become scattered, and promoting urination will damage the Body Fluids and cause Stomach dryness.4 Clinical Note
Three treatment methods not to be used after childbirth are: • sweating: it damages Qi • moving downwards: it damages the Spleen • promoting urination: it damages the Body Fluids and causes Stomach dryness
Dr Chen Jia Yuan differentiates between treatment methods to be adopted according to a time scale. He says: The treatment principle must be adapted according to timing: within 20 days from the birth Qi and Blood are still unsettled, the lochiae are being discharged and the main treatment principle is to ‘break Blood’ [i.e. strongly invigorate Blood]. After 20 days from the birth, Qi and Blood are settled and they have returned to the channels, even if there is still a lochial discharge, one should not move, but tonify Qi and Blood as well as simultaneously invigorate Blood.5 Clinical Note Dr Chen Jia Yuan’s differentiation of treatment methods according to time scale is: • within 20 days from childbirth: ‘break Blood’ • after 20 days from childbirth: tonify Qi and Blood as well as simultaneously invigorating Blood
Fu Qing Zhu emphasizes that the central pathology of post-partum conditions is deficiency of Qi and Blood and of Stomach and Spleen. He advises against using too many Qi-moving herbs, or cold herbs such as Huang Qin Radix Scutellariae or Huang Lian Rhizoma Coptidis, or too hot herbs such as Fu Zi Radix Aconiti lateralis preparata. He also advises against applying a diaphoretic treatment with Ma Huang Tang Ephedra Decoction, or a purgative one with Cheng Qi Tang Conducting Qi
Decoction, or a harmonizing one with Xiao Chai Hu Tang Small Bupleurum Decoction.6 Fu Qing Zhu also lists ten common mistakes made in the treatment of post-partum conditions: 1. Even though Qi may be stagnant, it is a mistake to use herbs that disperse Qi: this will only aggravate the feeling of oppression in the chest. Zhi Ke Fructus Aurantii and Hou Po Cortex Magnoliae officinalis should not be used at all and Chen Pi Pericarpium Citri reticulatae only in a dosage of 1.5 g. 2. Even though there is injury of Qi, one should not use herbs that dissolve (Food accumulation) or move downward. Do not use Da Huang Radix et Rhizoma Rhei, Zhi Ke Fructus Aurantii, San Leng Rhizoma Sparganii, Shen Qu Massa medicata fermentata or Hou Po Cortex Magnoliae officinalis. 3. Even if there is Heat, do not use cold herbs. Do not use Huang Qin Radix Scutellariae, Huang Lian Rhizoma Coptidis, Shan Zhi Zi Fructus Gardeniae, Huang Bo Cortex Phellodendri, Sheng Ma Rhizoma Cimicifugae or Chai Hu Radix Bupleuri. 4. Even if one has administered Sheng Hua Tang Generating and Transforming Decoction (which is specific to invigorate Blood after childbirth), do not use Ren Shen Radix Ginseng, Huang Qi Radix Astragali or Bai Zhu Rhizoma Atractylodis macrocephalae as long as there is a pain from an abdominal mass. 5. Do not use Sheng Di Huang Radix Rehmanniae or Shu Di Huang Radix Rehmanniae preparata because they may lead to stagnation of lochia. 6. Do not use Zhi Ke Fructus Aurantii, Niu Xi Radix Achyranthis bidentatae seu Cyathulae or Zhi Shi Fructus Aurantii immaturus. 7. If there is constipation, do not use Da Huang Radix et Rhizoma Rhei or Mang Xiao Sulfas Natrii. 8. Do not use Su Mu Lignum Sappan, San Leng Rhizoma Sparganii or E Zhu Rhizoma Curcumae to dissolve Blood masses. 9. Do not use Shan Zha Tang Crataegus Decoction to dissolve Blood masses with
a fixed pain: it will injure new Blood. 10. Do not use Ji Kun Dan Rescuing Female Pill over-readily to induce birth or promote the expulsion of the placenta. 7
Although the above rules provide an interesting insight into Fu Qing Zhu’s thinking regarding treatment strategies after childbirth, they should not be accepted without question. In fact, some of them contradict what Fu Qing Zhu himself says earlier. For example, he considers a deficiency of Qi and Blood and of Stomach and Spleen as central to post-partum pathology, but in rules 4 and 5 above he cautions against using Huang Qi Radix Astragali or Shu Di Huang Radix Rehmanniae preparata; on the other hand, he uses the formula Sheng Hua Tang Generating and Transforming Decoction (which invigorates Blood and eliminates stasis) for very many post-partum conditions. When using herbal medicine in the weeks immediately after childbirth, one must exercise caution, especially when expelling pathogenic factors. Thus, when moving Qi, one should not use too many scattering herbs; when dissolving masses, one should support the Spleen; when expelling Cold, one should not use too hot herbs, which may dry up Yin; when cooling, one should not use too many cold herbs, which may damage the Stomach. Clinical Note When using herbal medicine in the weeks immediately after childbirth: • When moving Qi, do not use too many scattering herbs • When dissolving masses, support the Spleen • When expelling Cold, do not use too hot herbs, which may dry up Yin • When cooling, do not use too many cold herbs, which may damage the Stomach
Also crucial in the period after childbirth is paying proper attention to nursing, achieving a good balance between rest and activity, eating a
nourishing but light diet, not being exposed to extremes of cold or heat and avoiding emotional stress. In particular, the ancient Chinese placed great stress on avoiding exposure to cold after childbirth, which they considered one of the major aetiological factors of post-partum problems. Dr Chen Jia Yuan says: Of the post-partum problems, most are due to Wind-Cold or improper diet … In summer, post-partum diseases are mostly due to Wind, while in Winter mostly to Cold; diseases due to improper diet occur independently of seasons. Post-partum diseases occurring after an easy childbirth are easy to treat, while those occurring after a difficult labour are difficult to treat.8 Of particular importance to Western patients is the stress on the need for rest after childbirth which runs counter to modern post-partum practice. It is of the utmost importance for women to have plenty of rest for at least a month after childbirth. By ‘rest’ is meant alternating periods of activity with frequent periods of bed rest as lying down benefits Liver-Blood. The modern tendency is, of course, for women to try and resume a ‘normal’ lifestyle a few days after childbirth: this is definitely wrong from the Chinese point of view and the importance of rest after childbirth cannot be overemphasized. This is all the more important if the childbirth was long, difficult or if there was a larger than normal loss of blood. However, it is also necessary for women to do some gentle exercise after childbirth to prevent the development of stagnation of Qi and Blood. A woman after childbirth should avoid exposure to cold as the channels and blood vessels are vulnerable and in an ‘open’ state after childbirth and are therefore prone to invasions of external pathogenic factors. However, she should also avoid excessive exposure to heat as sweating is particularly weakening after childbirth (as loss of fluids at this time may easily lead to Yin deficiency). For the same reason, a woman should not sunbathe in the summer. As for diet after childbirth, this should consist of nourishing but easilydigestible foods. A woman should avoid eating greasy, fried foods which may
cause Phlegm and cold, raw foods which may cause Cold in the Uterus. Particularly beneficial foods are beef, free-range chicken, carp, pig’s trotter, carrots and Day Lily (Hemerocallis fulva) vegetables.
Western view The time after childbirth is called the puerperium and is defined as the time during which the pelvic organs return to their normal condition: by convention, the puerperium is said to last about 6 weeks. One of the main priorities after delivery is prevention of infection from implantation of pathogenic organisms in the birth canal. On this subject, ancient Chinese doctors knew the danger of infection from exogenous pathogenic factors and attributed propensity to infection to the exhausted state of Blood. For this reason, the vulva and perineum should be kept as clean and as dry as possible. From the Western point of view, the main danger of infection is from streptococci or staphylococci organisms and therefore visitors or hospital staff who have septic foci should be excluded from visiting the woman. Western ideas about exercise after childbirth differ from Chinese ones and women are usually encouraged to return home (if they have delivered in a hospital) within 5 days or less. However, moderate exercise is important to restore the tone of the pelvic muscles, improve circulation in the legs and reduce the incidence of venous thrombosis. The temperature usually rises to 37.9°C (100°F) in the first 24 hours but, under normal circumstances, it soon falls to normal. If the temperature is raised for longer than a few hours and is accompanied by a rise in the pulse rate, an infection of the genital tract should be suspected. The pulse rate also rises shortly after childbirth but it returns to normal the second day. A persistent rise in the pulse rate may indicate severe anaemia, venous thrombosis or infection of the birth canal. Breastfeeding soon after delivery stimulates the release of oxytocin and the contraction of the uterus. The uterus takes about 8 weeks to return to its normal size. Immediately after delivery the border of the uterus is about 4 cm below the umbilicus and, by the tenth day, it cannot be felt above the pubis. End notes
1. He Ren 1981 A New Explanation of the Synopsis of Prescriptions from the Golden Cabinet
(Jin Kui Yao Lue Xin Jie ), Zhejiang Science Publishing House, p. 177. The Synopsis of Prescriptions from the Golden Cabinet was written by Zhang Zhong Jing c. AD 200..
2. Zhang Jing Yue 1986 The Complete Works of Jing Yue (Jing Yue Quan Shu
), Shanghai Science and Technology Press, Shanghai, p. 669. First published in 1624..
3. Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 23. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang) and published in 1729..
4. The Complete Works of Jing Yue, p. 670..
5. Eight Secret Books on Gynaecology, p. 65..
6. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, pp 70–71. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
7. Ibid., pp 70–71..
8. Eight Secret Books on Gynaecology, p. 65..
CHAPTER 45 Post-Natal Depression
AETIOLOGY 594 PATHOLOGY 594 IDENTIFICATION OF PATTERNS AND TREATMENT 595 Heart-Blood deficiency 595 Heart-Yin deficiency 597 Heart-Blood stasis 598 PROGNOSIS AND PREVENTION 600 WESTERN VIEW 600 Surprisingly, the condition of post-natal depression is not mentioned in modern Chinese books and the discussion of it in this chapter draws primarily on old gynecology and obstetrics books. The pathology of post-natal depression in Chinese medicine revolves around Blood: the exertion and loss of blood occurring at childbirth induce a state of Blood deficiency; since the Heart houses the Mind and governs Blood, Heart-Blood becomes deficient, the Mind has no residence and it becomes depressed and anxious. This causes a state of depression, mild anxiety, insomnia and fatigue: on a mental level the mother feels unable to cope, she is tearful, she loses any libido and she may feel angry or guilty. From Blood deficiency, other conditions may develop: after some time, and in women who have a predisposition to Yin deficiency, Blood deficiency may give rise to Yin deficiency and Empty-Heat. This would cause a more
severe condition of depression with more intense anxiety, insomnia, mental restlessness and agitation. Conditions of neurotic, obsessive, phobic or psychotic behaviour after childbirth are usually due to stagnant Blood harassing the Mind (rather than the more common Phlegm-Heat). In such cases, the woman is not only depressed but also confused, she may display obsessive behaviour or phobias and, in extreme cases, she may manifest psychotic behaviour. She may be aggressive and offensive, she may have hallucinations and delusions and she may display suicidal tendencies and even harbour destructive thoughts against her baby. Of course, every woman suffering from post-natal depression will present with pre-existing disharmonies which will play a role in the pathology of this condition. For example, Phlegm is an important contributory factor as it obstructs the Mind. In old China, there were various conditions describing the above situations. Chan Hou Wang Yan Wang Jian (
) means ‘absurd speaking and absurd seeing after childbirth’: this indicates a delusional state with incoherent speech and hallucinations. Chan Hou Wang Yan Jian Gui Fa Kuang (
) means ‘absurd speaking, seeing ghosts and manic behaviour after childbirth’ and it indicates incoherent speech, visual and acoustic hallucination and hypomania. It was described by Wu Qian in his Golden Mirror of Medicine
(1742).1 Chan
Hou
Xu
Fan
(
) means ‘mental restlessness after childbirth’ and it indicates a state of mental restlessness, insomnia and a feeling of heat in the evening, normally associated with Yin deficiency. Chan Hou Jing Ji (
) means ‘palpitations and anxiety after childbirth’ and it indicates palpitations, anxiety and a flustered and confused state after childbirth, normally associated with Blood deficiency. Chan Hou San Chong (
) means ‘three rebellions after childbirth’ and it indicates three conditions all resulting from retention of lochia and stasis of Blood in the Penetrating Vessel (Chong Mai), affecting the Heart (causing mental confusion, manic behaviour or depression, a feeling of oppression of the chest, mental restlessness and hysteria), the Lungs (breathlessness, cough, feeling of oppression of the chest) or the Stomach (a feeling of oppression of the epigastrium, nausea, vomiting, abdominal pain and fullness). It is worth noting that the Chinese
word for ‘rebellious’ (chong) is the same as in Chong Mai (Penetrating Vessel).
Aetiology
Severe loss of blood during childbirth Severe loss of blood during childbirth causes Blood deficiency; since the Heart houses the Mind and governs Blood, deficient Heart-Blood fails to house the Mind which becomes depressed and anxious. In women with a pre-existing deficiency of Blood, this situation may arise even if the blood loss during childbirth is not particularly heavy. Deficiency of Blood will cause depression, resulting in a case of Mind Weakened; if the deficiency of Blood gives rise also to anxiety and insomnia, it may result in Mind Weakened and Unsettled.2 Blood stasis after childbirth Blood stasis after childbirth may occur in women who have a pre-existing state of stasis of Blood. Stagnant Blood rebels upwards in the Penetrating Vessel and harasses the Heart (though which the Penetrating Vessel flows): as the Heart governs Blood and houses the Mind, stagnant Blood harasses and obstructs the Mind. This is a case of Mind Unsettled and Obstructed. Constitutional tendency to mental–emotional problems A constitutional tendency to mental–emotional problems is often the basis for the development of mental problems after childbirth. The signs that may indicate such a tendency are: • tongue with a deep Heart crack • tongue that is ‘hammer-shaped’
• very Swollen tongue with a very sticky coating • eyes lacking any lustre (i.e. eyes without shen). Figure 45.1 illustrates the first and second types of tongue, i.e. one with a deep Heart crack and one that is hammer-shaped.
Figure 45.1 Tongue with deep Heart crack and hammer-shaped tongue.
Pathology The pathology of post-natal depression is centred around Blood: it is due either to a Blood deficiency, or to a Blood deficiency turning into Yin deficiency, or to Blood stasis. The principal organ involved is always the Heart: Heart-Blood deficiency, Heart-Yin deficiency or Heart-Blood stasis respectively. However, other organs are involved too: a state of Heart-Blood deficiency after childbirth nearly always involves Liver-Blood deficiency; a state of Heart-Yin deficiency is frequently associated with Liver- and/or Kidney-Yin deficiency; and a state of Heart-Blood stasis is nearly always associated with Liver-Blood stasis within the Penetrating Vessel. Moreover, Blood deficiency and Blood stasis affect not only the Heart (and therefore the Mind) but also the Liver and therefore the Ethereal Soul (Hun). A deficiency of Blood may induce a state of rootlessness and excessive movement of the Ethereal Soul which causes anxiety. On the other hand, if the Blood deficiency is associated with a Qi deficiency, the movement of the Ethereal Soul is impaired and this results in depression. The main treatment principles adopted in post-natal depression from deficiency of Blood or Yin are therefore to nourish Blood or Yin and calm the Mind and the Ethereal Soul, and, in post-natal psychosis, to calm the Mind and the Ethereal Soul, invigorate Blood, eliminate stasis and open the Mind’s orifices. Psychotic and manic behaviours are manifestations of obstruction of the Mind and one must therefore open the Mind’s orifices with herbs such as Shi Chang Pu Rhizoma Acori tatarinowii, Hu Po Succinum, Yu Jin Radix Curcumae, He Huan Pi Cortex Albiziae and Yuan Zhi Radix Polygalae. Acupuncture points that open the Mind’s orifices include: P-5 Jianshi, Du-20 Baihui, Du-26 Renzhong, ST-40 Fenglong, ST-25 Tianshu, all the Well points, G.B.-17 Zhengying, G.B.-18 Chengling, Du-19 Houding, G.B.-13 Benshen, SP-1 Yinbai and Du-18 Qiangjian.
Identification of patterns and treatment The patterns discussed are : • Heart-Blood deficiency • Heart-Yin deficiency • Heart-Blood stasis.
Heart-Blood deficiency
Clinical manifestations Post-natal depression, fatigue, mild anxiety, insomnia, tearfulness, a feeling of guilt, loss of libido, poor memory, palpitations. Tongue: Pale and Thin. Pulse: Choppy and Weak on the left side, especially on the Middle and Front positions. Treatment principle Nourish Blood, strengthen the Heart, lift mood. Acupuncture HE-5 Tongli, HE-7 Shenmen, Ren-14 Juque, Ren-15 Jiuwei, BL-15 Xinshu, LIV-8 Ququan, Du-20 Baihui, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, Du-19 Houding, P-6 Neiguan. All with reinforcing method, except Du-19 which should be needled with even method. Moxa is applicable. Explanation
– HE-5 and BL-15 tonify Heart-Qi. – HE-7, Ren-14 and Ren-15 nourish the Heart and calm the Mind. – Du-20 lifts mood and relieves depression. – LIV-8 nourishes Liver-Blood.
– Ren-4, with moxa cones, nourishes Blood and strengthens the Uterus. – ST-36 and SP-6 nourish Blood. They are particularly effective with warming needle. – Du-19 calms the Mind: it is particularly effective combined with Ren-15. – P-6 calms the Mind and lifts mood. Herbal treatment
a Prescription
– FU SHEN SAN – Poria Powder Explanation
– Wu Qian in his Golden Mirror of Medicine (1742) recommends this formula for palpitations, anxiety and confused behaviour after childbirth.3 The term I have translated as ‘confused behaviour’ is huang hu, which means ‘absent-minded’ or ‘as if in a trance’. – Ren Shen and Huang Qi tonify Qi and strengthen the Original Qi. – Shu Di Huang, Bai Shao, Dang Gui and Huai Niu Xi nourish Blood. – Rou Gui warms the Interior. It also enters the Heart and encourages the generation of Qi and Blood.
– Fu Shen, Hu Po and Long Chi calm the Mind. b Prescription
– GUI PI TANG Variation – Tonifying the Spleen Decoction Variation Explanation The formula Gui Pi Tang, already explained, tonifies Spleen-Qi and HeartBlood and calms the Mind: it is ideally suited to treat post-natal depression and insomnia. This formula is also recommended by Wu Qian in his Golden Mirror of Medicine for post-natal depression from worry, pensiveness and sadness.4 – Long Chi has been added to calm the Mind and settle the Ethereal Soul. Three Treasures remedy
– CALM THE SHEN This remedy is a variation of the formula Gui Pi Tang Tonifying the Spleen Decoction which tonifies Heart- and Spleen-Qi and Heart- and Spleen-Blood. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Heart-Blood deficiency
Clinical manifestations
Post-natal depression, fatigue, mild anxiety, insomnia, tearfulness, a feeling of guilt, loss of libido, poor memory, palpitations. Tongue: Pale and Thin. Pulse: Choppy and Weak on the left side, especially on the Middle and Front positions. Treatment principle
Nourish Blood, strengthen the Heart, lift mood. Acupuncture
HE-5 Tongli, HE-7 Shenmen, Ren-14 Juque, Ren-15 Jiuwei, BL-15 Xinshu, LIV-8 Ququan, Du-20 Baihui, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, Du-19 Houding, P-6 Neiguan. All with reinforcing method, except Du-19 which should be needled with even method. Moxa is applicable. Herbal treatment
Pre scriptions
• FU SHEN SAN Poria Powder • GUI PI TANG Variation Tonifying the Spleen Decoction Variation Three Treasures remedy
• CALM THE SHEN
Case history A 35-year-old woman had been suffering from depression and insomnia since the birth of her first child 2 years previously. She felt very depressed, had negative thoughts and found everything an effort. In addition, she slept badly, with nightmares, and woke up frequently during the night; she also experienced a floating sensation just as she was about to fall asleep. On interrogation, it transpired that she also suffered from poor memory, tingling of the limbs, palpitations, a feeling of heat at night, night sweating, dry eyes and a dry mouth and throat at night. Her periods were regular but rather scanty, lasting only 3 days. Her tongue was Thin, with a shallow Heart crack, and had generally a normal colour except for being Red on the tip. Her pulse was Fine. Diagnosis This is a clear case of Liver- and Heart-Blood and Liver-Yin deficiency. The symptoms of Liver-Blood deficiency are: depression, insomnia, tingling of limbs, poor memory, scanty periods, Thin tongue and Fine pulse. The symptoms of Liver-Yin deficiency are: feeling of heat at night, night sweating, dry mouth and throat at night, a floating feeling just before falling asleep, nightmares and dry eyes. Although the tongue does not show any Yin deficiency, this simply means that the Yin deficiency is of recent date and not yet severe enough to show on the tongue. The deficient Liver-Blood and Liver-Yin fail to root the Ethereal Soul at night, hence the insomnia and nightmares; the floating sensation just before falling asleep indicates Liver-Yin deficiency. The wandering of the Ethereal Soul which results from the deficiency of Liver-Blood and Liver-Yin also induces a state of aimlessness, depression and despair. Apart from the patterns of Liver-Blood and LiverYin deficiency, there is also some Heart-Blood deficiency evidenced by the palpitations. The tip of the tongue is Red from some Empty-Heat arising from the Yin deficiency and affecting the Heart. The midline Heart crack indicates a constitutional tendency to Heart patterns and emotional problems.
However, this Heart pathology is secondary to that of the Liver. Treatment principle The treatment principle adopted was to nourish Liver-Blood and Liver-Yin, nourish Heart-Blood, calm the Mind and settle the Ethereal Soul. This patient was treated with both acupuncture and herbs. Acupuncture
The main points used were selected from the following: • Ren-4 Guanyuan to nourish Blood and Yin. • Ren-15 Jiuwei to calm the Mind. • ST-36 Zusanli, SP-6 Sanyinjiao and LIV-8 Ququan to nourish Liver-Blood. Herbal treatment
The herbal formula used was a variation of Yi Guan Jian One Linking Decoction which nourishes Liver-Yin: • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 9 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Wu Wei Zi Fructus Schisandrae 3 g • Shan Zhu Yu Fructus Corni 4 g • Ye Jiao Teng Caulis Polygoni multiflori 6 g • Shou Wu Radix Polygoni multiflori preparata 6 g
• Long Yan Rou Arillus Longan 6 g • Bai Zi Ren Semen Platycladi 6 g • Gou Qi Zi Fructus Lycii 6 g • Han Lian Cao Herba Ecliptae 4 g • Chuan Lian Zi Fructus Toosendan 3 g
Explanation
• Dang Gui, Bai Shao, Shu Di Huang, Shou Wu and Gou Qi Zi nourish LiverBlood. Bai Shao is astringent and roots the Ethereal Soul in the Liver. Gou Qi Zi also nourishes Liver-Yin. • Mai Men Dong, Shan Zhu Yu and Wu Wei Zi nourish Yin. Wu Wei Zi and Shan Zhu Yu are also astringent and therefore help to root the Ethereal Soul in the Liver. Wu Wei Zi also calms the Mind. • Long Yang Rou, Ye Jiao Teng and Bai Zi Ren nourish Blood, calm the Mind, promote sleep and settle the Ethereal Soul. • Han Lian Cao clears Empty-Heat arising from Liver-Yin deficiency. • Chuan Lian Zi moves Liver-Qi and counterbalances the cloying effect of the Blood and Yin tonics: it is also one of the few herbs that move Liver-Qi without injuring Yin.
After 6 months of treatment along the above lines, this patient’s mood returned to normal, her depression lifted and her sleep became much deeper.
Heart-Yin deficiency
Clinical manifestations Post-natal depression, insomnia (waking up frequently during the night), mental restlessness, a feeling of guilt, exhaustion, scanty breast milk, palpitations, loss of libido, a feeling of heat in the evening, night sweating. Tongue: without coating, with a Heart crack; Red, if there is Empty-Heat. Pulse: Floating-Empty. Treatment principle Nourish Yin, tonify the Heart, calm the Mind. Acupuncture HE-7 Shenmen, HE-5 Tongli, P-7 Daling, Ren-14 Juque, Ren-15 Jiuwei, Du-19 Houding, Du-24 Shenting, Ren-4 Guanyuan, LIV-8 Ququan, SP-6 Sanyinjiao. All with reinforcing method, except for the point on the head which should be needled with even method. No moxa. Explanation
– HE-7, P-7, Ren-14 and Ren-15 calm the Mind and nourish the Heart. – HE-5 tonifies the Heart. – Ren-4, LIV-8 and SP-6 nourish Yin. – Du-19 and Du-24 calm the Mind.
Herbal treatment
a Prescription
– REN SHEN DANG GUI TANG – Ginseng-Angelica Decoction Explanation This formula is also recommended by Wu Qian in his Golden Mirror of Medicine.5 – Ren Shen tonifies the original Qi. – Dang Gui, Bai Shao and Shu Di Huang nourish Blood. – Mai Men Dong nourishes Yin. – Rou Gui promotes the generation of Qi and Blood. Although it is hot and therefore contraindicated in Yin deficiency, a small dose appears in the formula to act as a ‘spark’ to promote the generation of Blood and Yin. Modifications
• If Yin deficiency is pronounced, reduce the dosage of Rou Gui further and add Tian Men Dong Radix Asparagi, Tian Hua Fen Radix Trichosanthis and Sheng Di Huang Radix Rehmanniae. • If there is Empty-Heat, add Di Gu Pi Cortex Lycii and Zhi Mu Rhizoma
Anemarrhenae. b Prescription
– TIAN WANG BU XIN DAN – Heavenly Emperor Tonifying the Heart Pill Explanation This formula, already explained, is used if, in addition to Heart-Yin deficiency, there is also Kidney-Yin deficiency. It nourishes Blood and Heartand Kidney-Yin, calms the Mind and clears Empty-Heat. c Prescription
– AN XIN TANG – Calming the Heart Decoction Explanation This formula from Fu Qing Zhu’s Gynaecology is for depression and psychotic behaviours after childbirth caused by Blood deficiency with Empty-Heat harassing the Heart.6 – Dang Gui and Chuan Xiong nourish and invigorate Blood. – Sheng Di Huang and Mu Dan Pi cool Blood and clear Empty-Heat.
– Pu Huang invigorates Blood and eliminates stasis to expel any residual lochia. – He Ye acts as a messenger to direct the formula to the Heart. Women’s Treasure remedy
– HEAVENLY EMPRESS This remedy is a variation of the formula Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill which nourishes Heart- and Kidney-Yin, clears Heart Empty-Heat and calms the Mind. Summary Heart-Yin deficiency
Clinical manifestations
Post-natal depression, insomnia (waking up frequently during the night), mental restlessness, a feeling of guilt, exhaustion, scanty breast milk, palpitations, loss of libido, a feeling of heat in the evening, night sweating. Tongue: without coating, with a Heart crack; Red, if there is Empty-Heat. Pulse: Floating-Empty. Treatment principle
Nourish Yin, tonify the Heart, calm the Mind. Acupuncture
HE-7 Shenmen, HE-5 Tongli, P-7 Daling, Ren-14 Juque, Ren-15 Jiuwei, Du-19 Houding, Du-24 Shenting, Ren-4 Guanyuan, LIV-8 Ququan, SP-6 Sanyinjiao. All with reinforcing method, except for the point on the head which should be needled with even method. No moxa. Herbal treatment
Pre scriptions
• REN SHEN DANG GUI TANG Ginseng-Angelica Decoction • TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill • AN XIN TANG Calming the Heart Decoction Women’s Treasure remedy
• HEAVENLY EMPRESS
Heart-Blood stasis
Clinical manifestations Post-natal depression, manic behaviour, scolding people, aggressive behaviour, delusions, hallucinations, suicidal, destructive thoughts, lack of bonding with the baby. Tongue: Purple. Pulse: Wiry, Rapid. Treatment principle Invigorate Blood, eliminate stasis, subdue rebellious Qi in the Penetrating Vessel, calm the Mind, open the Mind’s orifices. Acupuncture P-7 Daling, G.B.-17 Zhengying, G.B.-18 Chengling, Du-24 Shenting, Ren14 Juque, BL-15 Xinshu, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), KI-1 Yongquan, LIV-3 Taichong, BL-17 Geshu, SP-10 Xuehai. All with reducing method. Explanation
– P-7 and Ren-14 calm the Mind, open the Mind’s orifices and nourish the Heart. – G.B.-17 and G.B.-18 open the Mind’s orifices in cases of Mind Obstructed. – Du-24 calms the Mind.
– BL-15 clears the Heart and calms the Mind. – SP-4 and P-6 regulate the Penetrating Vessel, invigorate Blood and subdue rebellious Qi. – LIV-3 invigorates Blood and subdues rebellious Qi and Blood in the Penetrating Vessel. – KI-1 calms the Mind and subdues rebellious Qi. – BL-17 and SP-10 invigorate Blood and eliminate stasis. Herbal treatment
a Prescription
– XIAO TIAO JING TANG – Small Regulating the Menses Decoction Explanation This formula from the Golden Mirror of Medicine is for Blood which is both deficient and rebelling upwards to harass the Heart causing post-natal psychosis. – Bai Shao and Dang Gui nourish Blood. – Mo Yao and Hu Po invigorate Blood and eliminate stasis. Hu Po also calms the Mind.
– Rou Gui is added to promote the generation of Qi and Blood. – Xi Xin helps to open the Mind’s orifices through its pungent nature. – She Xiang opens the Mind’s orifices. This substance is now forbidden and it should therefore be replaced with Shi Chang Pu Rhizoma Acori tatarinowii 9 g. b Prescription
– SHA XIANG SAN – Cinnabaris-Musk Powder Explanation This formula is also from the Golden Mirror of Medicine and is specific for post-natal psychosis. What we now call psychosis was described as “seeing ghosts and incoherent speech” in the original text.7 – Ren Shen, Huang Qi, Shan Yao and Fu Ling tonify Qi and the Original Qi. – Yuan Zhi, Zhu Sha and Fu Shen calm the Mind. The use of Zhu Sha is now illegal and we should therefore replace it with Long Chi Fossilia Dentis mastodi 12 g. – Gan Cao harmonizes. – Jie Geng directs the formula to the Upper Burner and therefore the Mind. – Mu Xiang moves Qi and helps the digestion of the other ingredients.
– She Xiang opens the Mind’s orifices. Use of this substance is now banned and we should replace it with Shi Chang Pu Rhizoma Acori tatarinowii 6 g and Yu Jin Radix Curcumae 6 g. Three Treasures remedy
– RED STIRRING This remedy is a variation of the formula Xue Fu Zhu Yu Tang BloodMansion Eliminating Stasis Decoction which invigorates Blood and eliminates stasis in the Upper Burner. The remedy has been modified from the original formula with the addition of herbs that calm the Mind and open the Mind’s orifices. The tongue presentation appropriate to this remedy is a Purple body. Summary Heart-Blood stasis
Clinical manifestations
Post-natal depression, manic behaviour, scolding people, aggressive behaviour, delusions, hallucinations, suicidal, destructive thoughts, lack of bonding with the baby. Tongue: Purple. Pulse: Wiry, Rapid. Treatment principle
Invigorate Blood, eliminate stasis, subdue rebellious Qi in the Penetrating Vessel, calm the Mind, open the Mind’s orifices. Acupuncture
P-7 Daling, G.B.-17 Zhengying, G.B.-18 Chengling, Du-24 Shenting, Ren14 Juque, BL-15 Xinshu, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), KI-1 Yongquan, LIV-3 Taichong, BL-17 Geshu, SP-10 Xuehai. All with reducing method. Herbal treatment
Pre scriptions
• XIAO TIAO JING TANG Small Regulating the Menses Decoction • SHA XIANG SAN Cinnabaris-Musk Powder Three Treasures remedy
• RED STIRRING
Prognosis and prevention Post-natal depression usually responds well to treatment with acupuncture and Chinese herbs and the overwhelming majority of cases can be helped in a relatively short period of time, perhaps a few months. The pattern from Blood deficiency is easier to treat than that from Yin deficiency. Post-natal psychosis is much more difficult to treat and, in severe cases, Chinese treatment may have to be combined with Western medication, especially if the mother is suicidal or destructive towards the baby. In any case, the signs that point to a poor prognosis are: • red tongue with a redder tip and a very deep Heart crack • extremely Swollen tongue with sticky coating • tongue that has a very marked hammer shape (see Fig. 45.1) • eyes that lack any shen (lustre, shine) and therefore look extremely dull • uncontrolled look of the eyes, meaning that the eyes are staring, or fixed, or moving too much, or with the white of the eye showing all round.
Western view A mild state of depression a few days after delivery is very common and can be considered ‘normal’: about 60–70% of women suffer from it. This is not surprising given the tiredness from childbirth, probably the perineal pain, the feeding difficulties and the sense of anticlimax. This mild depressed state typically starts between the third and fifth day after delivery and is characterized by tearfulness, insomnia, fatigue, despondency and anxiety. Seen from a Chinese perspective, it is obvious that the depleted state of Qi and Blood after childbirth may have its correspondence on the mental level with some depression. In most cases, this lifts a few days after its occurrence. In about 10% of cases from this group, the depressive symptoms persist, manifesting with a depressed mood, irritability, insomnia, a feeling of being unable to cope with the baby and a disinterest in sex. It may take a whole year before the woman returns to normal and a few women do not, going on to develop more serious symptoms. From a Western point of view, mental symptoms after childbirth may be classified under the three broad categories of depression, depressive neurosis and psychotic depression. Depression is characterized by a severely depressed mood, insomnia, irritability and inability to cope. Anger is often present and this may be vented against her partner or even her baby; insomnia is a major problem as it is compounded by the night-feeding of the baby. Her energy is very low and she has no interest in herself, her baby or her family; loss of libido is often present. Depressive neurosis is characterized by obsessional neurosis or hysteria: the woman feels miserable, tearful and unable to cope with motherhood; she may develop obsessive behaviour or phobias. Psychotic depression is characterized by psychotic behaviour such as delusions, confusion, disorientation and an aversion to the baby; the woman may become aggressive and may shout and swear at people or laugh uncontrollably. Her behaviour may oscillate between mania and depression
or it may even manifest with schizophrenic symptoms such as paranoia, hallucinations and delusions. She may also be suicidal. Chlorpromazine is usually used, often in combination with antidepressants. From a Chinese perspective, this would be a case of Mind Obstructed. Usually, the more severe forms of depression, depressive neurosis and, even more so, psychotic depression occur in women who have a pre-existing or a latent form of mental illness. From a Western point of view, factors which make post-natal mental illness more likely are a history of previous post-natal psychiatric illness, a history of depression, lack of support by the woman’s partner, marital stress, cultural isolation (as that occurring in immigrants) and the recent loss of a parent. End note 1. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian
), People’s Health Publishing House, Beijing, Vol. 3, p. 88. First published in 1742..
2. For a description of the concepts of Mind Weakened, Mind Obstructed and Mind Unsettled, see Maciocia G 2008 The Practice of Chinese Medicine, 2nd edn, Elsevier, London, Chapter 9..
3. Golden Mirror of Medicine, p. 88..
4. Ibid., p. 88..
5. Ibid., p. 89..
6. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology, (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p. 56..
7. Golden Mirror of Medicine, p. 88..
CHAPTER 46 Abdominal Pain after Childbirth
AETIOLOGY 601 PATHOLOGY 601 IDENTIFICATION OF PATTERNS AND TREATMENT 602 Blood deficiency 602 Blood stasis 603 Retention of food 604 Ancient acupuncture prescriptions for post-partum abdominal pain 605 PROGNOSIS AND PREVENTION 605 Abdominal Pain after Childbirth includes abdominal or epigastric pain occurring soon after delivery.
Aetiology
Severe blood loss during childbirth A profuse blood loss during delivery leads to Blood deficiency and to the Directing and Penetrating Vessels being Empty: the Uterus Vessel loses nourishment and lower abdominal pain develops. On the other hand, Blood deficiency leads to Qi deficiency; when Qi is deficient, it fails to move Blood properly, and this, in turn, leads to some Blood stasis. Exposure to cold, irregular diet Exposure to cold or excessive consumption of cold foods may create internal Cold which, in turn, leads to Blood stasis. Stagnant Blood leads to abdominal pain. Emotional stress Emotional stress after childbirth or an exacerbation of pre-existing emotional problems from the stress of delivery and puerperium leads to stagnation of Qi. In itself this may cause abdominal pain; in addition, it may lead to Blood stasis, which causes more, and worse, abdominal pain. Stagnation of Qi and Blood after delivery also leads to a total or partial retention of lochia which, in itself, is a further cause of abdominal pain. Irregular diet Excessive consumption of greasy and sweet foods after childbirth may lead to retention of food and abdominal pain.
Pathology The pathology of Abdominal Pain after Childbirth is, as always, characterized by either a deficiency or an excess condition. The Golden Mirror of Medicine says: Post-partum abdominal pain is caused by deficiency of Blood if there is heavy loss of blood; by stasis of Blood if lochiae are retained; by retention of Food if there is poor appetite, distension and fullness; and by invasion of Cold if pain is accompanied by a cold feeling.1 Deficient Blood and Qi may cause abdominal pain of a deficient nature, i.e. quite mild, better with pressure and better after eating. Causes which are excess in nature include stagnation of Qi, stasis of Blood and retention of food: these cause a Full type of pain which is more intense, with a feeling of distension in the case of Qi stagnation and fixed, stabbing in the case of Blood stasis. Full-type pain is worse with pressure and worse after eating. It is also possible to have a mixed deficiency/excess condition since when Qi and Blood are deficient, they fail to move Blood properly and hence some stasis of Blood ensues. The Complete Works of Jing Yue says: Deficiency and Excess should be differentiated in the treatment of post-partum abdominal pain. Pain from stasis of Blood is of the Excess type, while that due to deficiency of Blood is of the Deficient type. Pain accompanied by a feeling of distension or a sensation as if a stream of air was rushing upwards to the chest and hypochondrium, aggravated by pressure, is of the Excess type. To treat it, one must move Qi and disperse. Pain without distension or fullness and alleviated by pressure, warmth or eating, is of the Deficient type. One should not use herbs that expel pathogenic factors.2 When a woman has abdominal pain after childbirth, any question of
infection must first be excluded. From a Chinese perspective, abdominal pain from infection would be accompanied by shivering, fever that rises continuously and discharge of lochia with a smell like rancid soya sauce.
Identification of patterns and treatment The treatment principle must be based on a clear differentiation between Empty and Full types of pain: in case of deficiency, one needs to tonify Qi and nourish Blood and in case of Fullness one needs to invigorate Blood and eliminate stasis or dissolve accumulation of food. Bearing in mind what was discussed at the beginning of this section, one should not underestimate the possibility of stasis of Blood after delivery: often it is necessary to invigorate Blood to some extent even when the main treatment principle adopted is to nourish Blood. The patterns discussed are : • Blood deficiency • Blood stasis • retention of food.
Blood deficiency
Clinical manifestations Dull abdominal pain after childbirth which is relieved by pressure and after eating, scanty, but continuous uterine bleeding which is pale in colour, dizziness, tiredness, blurred vision, constipation. Tongue: Pale and Thin. Pulse: Choppy. Treatment principle Tonify Qi, nourish Blood, stop pain. Acupuncture Ren-6 Qihai, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan. All with reinforcing method, moxa is applicable. Explanation
– Ren-6 tonifies Qi in general and moves Qi in the abdomen. – Ren-4 nourishes Blood and strengthens the Uterus. – ST-36 and SP-6 tonify Qi and Blood. – LIV-8 nourishes Liver-Blood. Herbal treatment
a Prescription
– CHANG NING TANG – Intestines Tranquillity Decoction Explanation
– Dang Gui, E Jiao and Shu Di Huang nourish Blood. – Ren Shen and Shan Yao tonify Qi and strengthen the Original Qi. – Mai Men Dong nourishes Yin which helps to nourish Blood. – Xu Duan tonifies Kidney-Yang and consolidates the Directing and Penetrating Vessels. – Rou Gui promotes the generation of Qi and Blood. – Gan Cao harmonizes. Modifications
• If there is constipation, remove Rou Gui and add Rou Cong Rong Herba Cistanchis. • If there is Cold and the patient has a strong preference for warm foods, add Xiao Hui Xiang Fructus Foeniculi and Pao Jiang Rhizoma Zingiberis preparatum (toasted).
• If there is retention of lochia, add Tao Ren Semen Persicae and Yi Mu Cao Herba Leonuri. b Prescription
– DANG GUI SHENG JIANG YANG ROU TANG – Angelica-Zingiber-Ovis Decoction Explanation This formula is used if the complexion is very pale and there are pronounced symptoms of Qi deficiency. – Dang Gui nourishes Blood. – Sheng Jiang warms and harmonizes. – Lamb meat tonifies Kidney-Yang and nourishes the Directing and Penetrating Vessels. c Prescription
– DANG GUI JIAN ZHONG TANG – Angelica Strengthening the Centre Decoction Explanation This is a variation of Xiao Jian Zhong Tang Small Strengthening the Centre
Decoction (with the addition of Dang Gui) which is for epigastric and abdominal pain of an Empty and Cold nature. – Dang Gui nourishes Blood. – Gui Zhi warms the channels and stops pain from Cold. – Yi Tang tonifies Qi. – Bai Shao and Zhi Gan Cao stop pain and ‘moderate urgency’. – Sheng Jiang warms the channels. – Da Zao tonifies Qi and harmonizes. Women’s Treasure remedy
– PRECIOUS SEA This remedy is a variation of the formula Yi Mu Ba Zhen Tang Leonorus Eight Precious Decoction which nourishes Blood. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Blood deficiency
Clinical manifestations
Dull abdominal pain after childbirth which is relieved by pressure and after eating, scanty, but continuous uterine bleeding which is pale in colour, dizziness, tiredness, blurred vision, constipation. Tongue: Pale and Thin.
Pulse: Choppy. Treatment principle
Tonify Qi, nourish Blood, stop pain. Acupuncture
Ren-6 Qihai, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan. All with reinforcing method, moxa is applicable. Herbal treatment
Pre scriptions
• CHANG NING TANG Intestines Tranquillity Decoction • DANG GUI SHENG JIANG YANG ROU TANG Angelica-Zingiber-Mutton Decoction • DANG GUI JIAN ZHONG TANG Angelica Strengthening the Centre Decoction Women’s Treasure remedy
• PRECIOUS SEA
Blood stasis
Clinical manifestations Abdominal pain after childbirth that is worse with pressure and worse after eating, discharge of dark lochia, dark complexion, cold limbs. Tongue: Purple. Pulse: Deep and Wiry. Treatment principle Invigorate Blood, eliminate stasis, scatter Cold, stop pain. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), ST-30 Qichong, KI-14 Siman, SP-10 Xuehai, BL-17 Geshu, SP-6 Sanyinjiao, LIV-3 Taichong, ST-29 Guilai. All with reducing or even method. Moxa can be used if there are symptoms of Cold. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel, subdue rebellious Qi and eliminate stasis in the abdomen. – ST-30, an important point of the Penetrating Vessel, regulates Qi and Blood in this vessel and treats abdominal pain. – KI-14, a point of the Penetrating Vessel, moves Qi and Blood in this vessel and stops abdominal pain.
– SP-10 and BL-17 invigorate Blood and eliminate stasis. – SP-6 stops abdominal pain and invigorates Blood. – LIV-3, a point also acting on the Penetrating Vessel, moves Qi and Blood and stops pain. – ST-29 stops abdominal pain and invigorates Blood. Herbal treatment
Prescription
– SHENG HUA TANG Variation – Generating and Resolving Decoction Variation Explanation The first five herbs constitute the formula Sheng Hua Tang which is specific for stasis of Blood with retention of lochia after childbirth. – Dang Gui nourishes and invigorates Blood. – Chuan Xiong and Tao Ren invigorate Blood and eliminate stasis. – Pao Jiang warms the channels and blood vessels and helps to invigorate Blood. – Zhi Gan Cao harmonizes.
– Yi Mu Cao is added to invigorate Blood and eliminate stasis. Modifications
• If stasis of Blood is pronounced and there is scanty lochia with dark clots, add Wu Ling Zhi Faeces Trogopterori and Pu Huang Pollen Typhae. • If there is vomiting and cold limbs, add Wu Zhu Yu Fructus Evodiae and Ban Xia Rhizoma Pinelliae preparatum. • If there is abdominal distension, add Zhi Ke Fructus Aurantii and Xiang Fu Rhizoma Cyperi. • If there is hypochondrial pain and distension, add He Huan Pi Cortex Albiziae, Yu Jin Radix Curcumae and Chai Hu Radix Bupleuri. • If there is breathlessness, tiredness and depression, add Ren Shen Radix Ginseng and Huang Qi Radix Astragali. Three Treasures remedy
– STIR FIELD OF ELIXIR This remedy is a variation of the formula Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction which invigorates Blood and eliminates stasis in the Lower Burner and treats abdominal pain from stasis of Blood. The tongue presentation appropriate to this remedy is a Purple body. Summary Blood stasis
Clinical manifestations
Abdominal pain after childbirth that is worse with pressure and worse after eating, discharge of dark lochia, dark complexion, cold limbs. Tongue: Purple. Pulse: Deep and Wiry. Treatment principle
Invigorate Blood, eliminate stasis, scatter Cold, stop pain. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), ST-30 Qichong, KI-14 Siman, SP-10 Xuehai, BL-17 Geshu, SP-6 Sanyinjiao, LIV-3 Taichong, ST-29 Guilai. All with reducing or even method. Moxa can be used if there are symptoms of Cold. Herbal treatment
Pre scription
• SHENG HUA TANG Variation Generating and Resolving Decoction Variation Three Treasures remedy
• STIR FIELD OF ELIXIR
Retention of food
Clinical manifestations Abdominal and epigastric pain after childbirth, a feeling of fullness in the abdomen and epigastrium, foul breath, belching. Tongue: thick coating. Pulse: Slippery. Treatment principle Dissolve food accumulation, harmonize the Centre. Acupuncture Ren-11 Jianli, ST-22 Guanmen, ST-19 Burong, Ren-10 Xiawan, Ren-13 Shangwan, P-6 Neiguan, ST-34 Liangqiu, SP-6 Sanyinjiao. All with even or reducing method. Explanation
– Ren-11 and ST-22 dissolve food accumulation and stop pain. – ST-19 dissolves food accumulation in the Upper Burner. – Ren-10 promotes the descending of Stomach-Qi. – Ren-13 subdues rebellious Stomach-Qi and stops nausea and belching. – P-6 harmonizes the Stomach and promotes the descending of its Qi.
– ST-34, Accumulation point, stops epigastric pain. – SP-6 stops abdominal pain. Herbal treatment
Prescription
– DAO GONG TANG Variation – Conducting and Attacking Decoction Variation Explanation The first five herbs constitute the formula Dao Gong Tang. – Dang Shen and Bai Zhu tonify the Spleen and Stomach. – Fu Ling and Chen Pi resolve Dampness and move Qi in the Centre. – Zhi Gan Cao harmonizes and stops pain. – Shan Zha dissolves food accumulation. – Zhi Shi moves Qi and conducts Stomach-Qi downwards. Summary Retention of food
Clinical manife stations
Abdominal and epigastric pain after childbirth, a feeling of fullness in the abdomen and epigastrium, foul breath, belching. Tongue: thick coating. Pulse: Slippery. Tre atme nt principle
Dissolve food accumulation, harmonize the Centre. Acupuncture
Ren-11 Jianli, ST-22 Guanmen, ST-19 Burong, Ren-10 Xiawan, Ren-13 Shangwan, P-6 Neiguan, ST-34 Liangqiu, SP-6 Sanyinjiao. All with even or reducing method. He rbal tre atme nt
Prescription
• DAO GONG TANG Variation Conducting and Attacking Decoction Variation
Ancient acupuncture prescriptions for post-partum abdominal pain3
1. Ren-6 Qihai, Ren-4 Guanyuan, L.I.-11 Quchi, SP-6 Sanyinjiao and L.I.-4 Hegu (new edition of Acupuncture and Moxibustion, Zhen Jiu Xue Xin Bian). 2. SP-6 Sanyinjiao for abdominal pain with persistent lochial discharge and a feeling of cold in the umbilical region (Experience of Acupuncture and Moxibustion Therapy, 1220). 3. SP-6 Sanyinjiao and Ren-6 Qihai for post-partum abdominal pain with Blood masses (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601). 4. Ren-6 Qihai with 100 moxa cones for post-partum abdominal pain (Collection of Acupuncture and Moxibustion, Zhen Jiu Ji Cheng, 1874). 5. KI-6 Zhaohai, Ren-9 Shuifen, Ren-4 Guanyuan, BL-43 Gaohuangshu and SP-6 Sanyinjiao for post-partum umbilical pain with persistent lochial discharge (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601).
Prognosis and prevention Both acupuncture and herbs are very effective to treat Abdominal Pain after Childbirth. In fact, provided that infection as a cause of the pain can be excluded, Chinese medicine probably offers the best chance of curing this problem as Western medicine would have very little to offer. The pattern from stasis of Blood is the most difficult to treat and the one from Blood deficiency the easiest. In most cases, an improvement can be expected even after a few days. In my experience, it is important to include some Bloodinvigorating herbs even in the pattern of Blood deficiency. There is no Western view of post-partum abdominal pain that does not assign it an infective nature. End note 1. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian
), People’s Health Publishing House, Beijing, Vol. 3, p. 77. First published in 1742..
2. Zhang Jing Yue 1986 The Complete Works of Jing Yue (Jing Yue Quan Shu
), Shanghai Science and Technology Press, Shanghai, p. 670. First published in 1624..
3. Wang Xue Tai 1995 Great Treatise of Chinese Acupuncture (Zhong Guo Zhen Jiu Da Quan
), Henan Science and Technology Publishing House, p. 493..
CHAPTER 47 Persistent Lochial Discharge (and Retention of Lochia)
AETIOLOGY 607 PATHOLOGY 607 IDENTIFICATION OF PATTERNS AND TREATMENT 608 Qi deficiency 608 Blood stasis 609 Blood-Heat 610 Ancient acupuncture prescriptions for Persistent Lochial Discharge 612 PROGNOSIS AND PREVENTION 612 WESTERN VIEW 612 APPENDIX: RETENTION OF LOCHIA 612 AETIOLOGY AND PATHOLOGY 612 IDENTIFICATION OF PATTERNS AND TREATMENT 612 Qi and Blood stagnation 612 Stagnation of Cold and stasis of Blood 613 Ancient acupuncture prescriptions for retention of lochia 614 Persistent Lochial Discharge consists in a lochial discharge that goes on
for longer than normal and continues to be red in colour rather than changing to a yellowish, serous discharge. Lochia refers to the bloody discharge coming from the placental site. The normal time of lochial discharge is about 3 weeks. As for the nature of lochia, see Western View towards the end of this chapter.
Aetiology
Excessive strain during delivery, long labour A long labour severely depletes Qi. When Qi is deficient, it fails to gather Blood which may leak out causing lochial bleeding with pale blood. Invasion of cold Invasion of Cold during or after delivery affects the blood vessels and the Uterus: Cold slows down the circulation of Blood and may cause stasis of Blood. Stagnant Blood obstructs the blood vessels and the Uterus so that newly generated Blood has nowhere to go and bleeding results. Severe loss of blood during childbirth Severe loss of blood during childbirth injures Blood and Yin: in women with a pre-existing condition of Yin deficiency, this leads to severe Yin deficiency with Empty-Heat. Heat enters the Blood portion and makes the Blood reckless causing it to spill out of the blood vessels.
Pathology The pathology of Persistent Lochial Discharge consists in three possible conditions: Qi deficiency, Blood stasis or Blood-Heat. When Qi is deficient, it fails to hold Blood and bleeding results: in this case, the blood discharged will be pale. When Blood stagnates, the blood vessels and the uterus are obstructed by stagnant Blood; as newly generated Blood has nowhere to go, it leaks out. In this case, the lochial discharge is dark and with clots. When Heat invades the Blood portion, it makes Blood reckless so that it pushes out of the blood vessels, causing bleeding: in this case, the lochial discharge will be bright red or dark red. The condition of Persistent Lochial Discharge should be differentiated from that of Fever after Childbirth. If the lochial discharge has an offensive odour (which the Chinese describe as that of rancid soya sauce) and the woman runs a temperature, this indicates an infection and, in Chinese medicine, falls under the category of Fever after Childbirth (see Chapter 51). Thus, Persistent Lochial Discharge assumes that there is no infection and the lochia does not have an offensive odour. However, please note that absence of odour does not necessarily mean that there is no infection, as virulent infection with haemolytic streptococci is not accompanied by an offensive smell. Thus, the most important distinguishing sign of a post-partum infection is fever.
Identification of patterns and treatment The amount, colour, density and smell of the lochia should be analysed carefully to distinguish deficiency from excess and Heat from Cold. Thus, red, profuse, dilute, non-smelling lochia indicates Qi deficiency. Dark, dense lochia with a foul smell indicates Blood-Heat. Purplish lochia with clots denotes Blood stasis. The treatment principles are therefore to tonify Qi, invigorate Blood or cool Blood. When tonifying with herbs, one must be careful not to overtonify as this may create stagnation. When invigorating Blood, do not use strong herbs that ‘break’ Blood as these may deplete Blood. One should try to use herbs that simultaneously gather Blood and stop bleeding, or herbs that cool Blood and stop bleeding. Also, when invigorating Blood, one should usually use one or two tonic herbs so that the Upright Qi is not damaged and the Directing and Penetrating Vessels may be tonified to carry out their normal function of expelling lochia. The patterns discussed are: • Qi deficiency • Blood stasis • Blood-Heat.
Qi deficiency
Clinical manifestations Persistent lochial discharge that is red, profuse, dilute and without odour, dizziness, exhaustion, breathlessness, sweating, a dislike of speaking, a feeling of bearing-down in the abdomen. Tongue: Pale. Pulse: Weak. Treatment principle Tonify Qi, gather Blood. Acupuncture Ren-12 Zhongwan, Ren-6 Qihai, Du-20 Baihui, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, BL-20 Pishu, BL-23 Shenshu, SP-1 Yinbai. All with reinforcing method; moxa is applicable. Explanation
– Ren-12, Ren-6, ST-36, SP-6 and BL-20 tonify Spleen-Qi. – Du-20 raises Qi to stop bleeding. – Ren-4 nourishes Blood, strengthens the Uterus and tonifies the Directing and Penetrating Vessels. – BL-23 strengthens the Directing and Penetrating Vessels. – SP-1, with moxa cones, stops uterine bleeding.
Herbal treatment
a. Prescription
– BU ZHONG YI QI TANG Variation – Tonifying the Centre and Benefiting Qi Decoction Variation Explanation This formula, already explained, tonifies and raises Qi and stops bleeding from Qi deficiency. – Lu Jiao Jiao was added to tonify the Governing, Directing and Penetrating Vessels and stop bleeding. – Ai Ye was added to warm the Uterus and stop bleeding. Modifications
• If there are cold limbs and abdominal pain, add Gui Zhi Ramulus Cinnamomi, Pao Jiang Rhizoma Zingiberis preparatum (toasted) and Bu Gu Zhi Fructus Psoraleae. • If there are clots in the lochia and abdominal pain, add Wu Zei Gu Endoconcha Sepiae and Yi Mu Cao Herba Leonuri. • If there is dizziness, blurred vision and palpitation, add Bai Shao Radix Paeoniae alba and Long Yan Rou Arillus Longan.
• If there is backache and the limbs are weak, add Xu Duan Radix Dipsaci and Du Zhong Cortex Eucommiae. • If there is a dry mouth and the tongue has no coating, add Mai Men Dong Radix Ophiopogonis, Shi Hu Herba Dendrobii and Yu Zhu Rhizoma Polygonati odorati. b. Prescription
– SHI QUAN DA BU TANG Variation – Ten Complete Great Tonification Decoction Variation Explanation The first 10 herbs constitute the formula Shi Quan Da Bu Tang which tonifies Qi, warms Yang and nourishes Blood. – E Jiao nourishes Blood and stops bleeding. – Xu Duan consolidates the Governing and Directing Vessels and stops bleeding. Three Treasures remedies
– TONIFY QI AND EASE THE MUSCLES This remedy is a variation of the formula Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction which tonifies and raises Qi. The tongue presentation appropriate to this remedy is a Pale body with a sticky coating.
– CALM THE SHEN This remedy is a variation of the formula Gui Pi Tang Tonifying the Spleen Decoction which tonifies Heart- and Spleen-Qi, nourishes Heartand Spleen-Blood and calms the Mind. One of its uses is to stop bleeding from Qi deficiency. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Qi deficiency
Clinical manifestations
Persistent lochial discharge that is red, profuse, dilute and without odour, dizziness, exhaustion, breathlessness, sweating, a dislike of speaking, a feeling of bearing-down in the abdomen. Tongue: Pale. Pulse: Weak. Treatment principle
Tonify Qi, gather Blood. Acupuncture
Ren-12 Zhongwan, Ren-6 Qihai, Du-20 Baihui, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, BL-20 Pishu, BL-23 Shenshu, SP-1 Yinbai. All with reinforcing method; moxa is applicable. Herbal treatment
Pre scriptions
• BU ZHONG YI QI TANG Variation Tonifying the Centre and Benefiting Qi Decoction Variation • SHI QUAN DA BU TANG Variation Ten Complete Great Tonification Decoction Variation Three Treasures remedies
• TONIFY QI AND EASE THE MUSCLES • CALM THE SHEN
Blood stasis
Clinical manifestations Persistent lochial discharge that is dark, scanty and with clots, abdominal pain that is relieved by the passing of clots. Tongue: Purple. Pulse: Wiry. Treatment principle Invigorate Blood, eliminate stasis, stop bleeding. Acupuncture SP-10 Xuehai, LIV-6 Zhongdu, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), BL-17 Geshu, Ren-4 Guanyuan, SP-1 Yinbai. All with even method. Moxa may be used if there are Cold symptoms. Explanation
– SP-10 and LIV-6, in combination, invigorate Liver-Blood. – SP-4 and P-6 regulate the Penetrating Vessel and invigorate Blood. – BL-17 invigorates Blood. – Ren-4 strengthens the Uterus and regulates the Directing and Penetrating Vessels. – SP-1, with moxa cones, stops uterine bleeding.
Herbal treatment
Prescription
– SHENG HUA TANG and SHI XIAO SAN – Generating and Resolving Decoction and Breaking into a Smile Powder Explanation The first five herbs constitute the formula Sheng Hua Tang which invigorates Blood and eliminates stasis, especially when Blood stasis derives from Cold. The last two herbs constitute the formula Shi Xiao San which invigorates Blood and stops bleeding. Modifications
• If there is abdominal pain from Cold, add Wu Zhu Yu Fructus Evodiae and Ai Ye Folium Artemisiae argyi. • If there is exhaustion and breathlessness, add Dang Shen Radix Codonopsis and Huang Qi Radix Astragali. • If there is depression and hypochondrial pain, add Chai Hu Radix Bupleuri, Yu Jin Radix Curcumae and Xiang Fu Rhizoma Cyperi. • If the lochia has an offensive smell and there is thirst, fever, a Red tongue and a Rapid pulse, add Jin Yin Hua Flos Lonicerae, Lian Qiao Fructus
Forsythiae and Bai Jiang Cao Herba Patriniae (see also Ch. 51 on fever after childbirth). Three Treasures remedy
– STIR FIELD OF ELIXIR This remedy is a variation of the formula Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction which invigorates Blood and eliminates stasis in the Lower Burner. The remedy has been modified with the addition of a herb to invigorate Blood and stop bleeding. The tongue presentation appropriate to this remedy is a Purple body. Summary Blood stasis
Clinical manifestations
Persistent lochial discharge that is dark, scanty and with clots, abdominal pain that is relieved by the passing of clots. Tongue: Purple. Pulse: Wiry. Treatment principle
Invigorate Blood, eliminate stasis, stop bleeding. Acupuncture
SP-10 Xuehai, LIV-6 Zhongdu, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), BL-17 Geshu, Ren-4 Guanyuan, SP-1 Yinbai. All with even method. Moxa may be used if there are Cold symptoms.
Herbal treatment
Pre scription
• SHENG HUA TANG and SHI XIAO SAN Generating and Resolving Decoction and Breaking into a Smile Powder Three Treasures remedy
• STIR FIELD OF ELIXIR
Blood-Heat
Clinical manifestations Persistent lochial discharge that is dark in colour and dilute, red face, thirst, a feeling of heat, mental restlessness, abdominal pain, dry stools. Tongue: Red, with yellow coating in case of Full-Heat and without coating in case of Empty-Heat. Pulse: Rapid and Overflowing in case of Full-Heat; Rapid and Fine in case of Empty-Heat. Treatment principle Clear Heat, cool Blood, stop bleeding, nourish Yin. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, LIV-3 Taichong, SP-8 Diji, Ren-4 Guanyuan, SP-1 Yinbai. All with even method. No moxa. Explanation
– LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and nourish Yin. – L.I.-11 and SP-10 cool Blood. – KI-2 and LIV-3, in combination, cool Blood. – SP-8 regulates the Uterus and stops bleeding.
– Ren-4 regulates the Uterus and strengthens the Directing and Penetrating Vessels. – SP-1 stops uterine bleeding. Herbal treatment
Full-Heat
Prescription
– DAN ZHI XIAO YAO SAN – Moutan-Gardenia Free and Easy Wanderer Powder Explanation
This is a variation of Xiao Yao San Free and Easy Wanderer Powder with the addition of Shan Zhi Zi and Mu Dan Pi to clear Heat. This formula is specific to clear Liver-Heat deriving from the transformation of stagnant Qi into Heat. Modifications
• Huang Qin Radix Scutellariae and Ou Jie Nodus Nelumbinis rhizomatis are frequently added to this formula to clear Heat and stop bleeding.
• If the lochial discharge is profuse, remove Dang Gui and add Di Yu Radix Sanguisorbae, Huai Hua Flos Sophorae immaturus, Wu Zei Gu Endoconcha Sepiae and Yi Mu Cao Herba Leonuri. • If there is a headache and eye ache, add Xia Ku Cao Spica Prunellae and Gou Teng Ramulus Uncariae cum Uncis. • If there is a dry throat and tongue, add Sheng Di Huang Radix Rehmanniae, Mai Men Dong Radix Ophiopogonis and Shi Hu Herba Dendrobii. • If there is a feeling of heaviness and a sticky, yellow tongue coating, add Yin Chen Hao Herba Artemisiae scopariae and Huo Xiang Herba Pogostemonis. Women’s Treasure remedy
– COOL THE MENSES This remedy cools Blood and stops bleeding. The tongue presentation appropriate to this remedy is a Red body with yellow coating. Empty-Heat
Prescription
– BAO YIN JIAN – Protecting Yin Decoction Explanation
This formula, already explained, nourishes Yin, clears Empty-Heat and consolidates the Directing and Penetrating Vessels. Modifications
• If there are palpitations and breathlessness, add Ren Shen Radix Ginseng, Mai Men Dong Radix Ophiopogonis and Wu Wei Zi Fructus Schisandrae (i.e. the formula Sheng Mai San Generating the Pulse Powder). • If there is hypochondrial distension, add Yu Jin Radix Curcumae, Chuan Lian Zi Fructus Toosendan and Xiang Fu Rhizoma Cyperi. • If the lochial discharge has clots and there is lower abdominal pain, add Qian Cao Gen Radix Rubiae, Wu Zei Gu Endoconcha Sepiae and Yi Mu Cao Herba Leonuri. • If the lochial discharge has a foul smell, add Bai Jiang Cao Herba Patriniae. Women’s Treasure remedy
– CLEAR EMPTY-HEAT AND COOL THE MENSES This remedy cools Blood, nourishes Yin, clears Empty-Heat and stops bleeding. The tongue presentation appropriate to this remedy is a Red body without coating. Summary Blood-Heat
Clinical manifestations
Persistent lochial discharge that is dark in colour and dilute, red face, thirst, a feeling of heat, mental restlessness, abdominal pain, dry stools. Tongue: Red, with yellow coating in case of Full-Heat and without coating in case of Empty-Heat. Pulse: Rapid and Overflowing in case of Full-Heat; Rapid and Fine in case of Empty-Heat. Treatment principle
Clear Heat, cool Blood, stop bleeding, nourish Yin. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, LIV-3 Taichong, SP-8 Diji, Ren-4 Guanyuan, SP-1 Yinbai. All with even method. No moxa. Herbal treatment
Full He at
Prescription
• DAN ZHI XIAO YAO SAN Moutan-Gardenia Free and Easy Wanderer Powder Women’s Treasure remedy
• COOL THE MENSES
Empty Heat
Pre scription
• BAO YIN JIAN Protecting Yin Decoction Women’s Treasure remedy
• CLEAR EMPTY-HEAT AND COOL THE MENSES
Ancient acupuncture prescriptions for Persistent Lochial Discharge 1
1. Ren-3 Zhongji (Thousand Golden Ducat Prescriptions, Qian Jin Yao Fang, AD 652). 2. LIV-6 Zhongdu, Ren-4 Guanyuan, Ren-3 Zhongji, Ren-5 Shimen (Experience of Acupuncture and Moxibustion, Zhen Jiu Zi Sheng Jing, 1220).
Prognosis and prevention Both acupuncture and herbs are effective at treating persistent lochial discharge; their effectiveness is about what one would expect in treating Flooding and Trickling. Herbal medicine is more effective than acupuncture. The most difficult pattern to treat is that from Blood-Heat deriving from Empty-Heat. Generally speaking, one should expect results within a week.
Western view Lochia refers to the bloody discharge coming from the placental site. For the first 3 or 4 days after delivery the lochia is red; as the site begins to heal the discharge decreases in amount and its colour becomes lighter and eventually serous. For this reason, three different types of lochia are distinguished: lochia rubra meaning ‘red lochia’, lochia serosa meaning ‘serous lochia’ which appears 5 to 6 days after delivery, and lochia alba meaning ‘white lochia’, the final lochial discharge in which there is little blood, mostly white blood cells. The average time that it takes for the lochia to become colourless is about 3 to 4 weeks. Lochia that remains red and abundant for longer than normal (which the Chinese referred to as excessive lochia) indicates delayed involution of the uterus (the progressive shrinking of the uterus after delivery) which may be due to retention of a piece of placenta within the uterus or to infection. If placental tissue is retained, the uterus remains enlarged and this will show on an ultrasound scan. Lochia with offensive odour may indicate infection (although in infection with haemolytic streptococci there is no offensive odour).
Appendix: retention of lochia Retention of lochia is characterized by the complete absence of lochial discharge or by a very scanty discharge, usually accompanied by abdominal pain.
Aetiology and pathology The pathology of the condition is always stasis of Blood. This may derive either from stagnation of Qi or from invasion of Cold in the Uterus. Thus, the aetiology of the condition is either emotional problems leading to stagnation of Qi and stasis of Blood, or invasion of external cold during or after labour.
Identification of patterns and treatment The patterns are: • Qi and Blood stagnation • Stagnation of Cold and stasis of Blood. Qi and Blood stagnation
Clinical manifestations
No lochial discharge or scanty discharge with clots, or a discharge that stops and starts, abdominal pain. Tongue: Purple. Pulse: Wiry. Treatment principle
Move Qi, invigorate Blood, eliminate stasis. Acupuncture
SP-10 Xuehai, Ren-6 Qihai, KI-14 Siman, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), BL-17 Geshu, SP-6 Sanyinjiao. All with reducing method. Explanation
– SP-10 and BL-17 invigorate Blood and eliminate stasis.
– Ren-6 moves Qi in the lower abdomen. – KI-14, a point of the Penetrating Vessel, moves Qi and Blood and eliminates stagnation from this vessel. – SP-4 and P-6 regulate the Penetrating Vessel (which is also the Sea of Blood) and invigorate Blood. – SP-6 invigorates Blood and stops abdominal pain. Prescription from the Great Compendium of Acupuncture2 For retention of lochia: Ren-3 Zhongji and G.B.-21 Jianjing. Herbal treatment
Prescription
– XIANG AI XIONG DANG YIN – Cyperus-Artemisia-Ligusticum-Angelica Decoction Explanation
– Xiang Fu moves Qi and eliminates stagnation. – Ai Ye warms the Uterus. – Chuan Xiong, Dang Gui and Yan Hu Suo invigorate Blood and eliminate stasis.
Modifications
• If there is hypochondrial pain, add Yu Jin Radix Curcumae and Zhi Ke Fructus Aurantii. • If there is scanty discharge with clots and abdominal pain, add Pu Huang Pollen Typhae, Wu Ling Zhi Faeces Trogopteri and Yi Mu Cao Herba Leonuri. • If there is belching and poor appetite, add Bai Zhu Rhizoma Atractylodis macrocephalae, Chen Pi Pericarpium Citri reticulatae and Sha Ren Fructus Amomi. • If there is irritability and headache, add Shan Zhi Zi Fructus Gardeniae, Mu Dan Pi Cortex Moutan, Ju Hua Flos Chrysanthemi and Zhen Zhu Mu Concha Margaritiferae usta. • If there are Cold symptoms and abdominal pain, add Gui Zhi Ramulus Cinnamomi and Pao Jiang Rhizoma Zingiberis preparatum (toasted). Three Treasures remedy
– STIR FIELD OF ELIXIR This remedy invigorates Blood and eliminates stasis in the Lower Burner. The tongue presentation appropriate to this remedy is a Purple body. Summary Qi and Blood stagnation
Clinical manife stations
No lochial discharge or scanty discharge with clots, or a discharge that stops and starts, abdominal pain. Tongue: Purple. Pulse: Wiry. Tre atme nt principle
Move Qi, invigorate Blood, eliminate stasis. Acupuncture
SP-10 Xuehai, Ren-6 Qihai, KI-14 Siman, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), BL-17 Geshu, SP-6 Sanyinjiao. All with reducing method. He rbal tre atme nt
Prescription
• XIANG AI XIONG DANG YIN Cyperus-Artemisia-Ligusticum-Angelica Decoction Three Treasures re me dy
• STIR FIELD OF ELIXIR
Stagnation of Cold and stasis of Blood
Clinical manifestations
Absent or scanty, dark lochial discharge with small, stringy clots, abdominal pain relieved by the application of heat, cold limbs. Tongue: Bluish-Purple. Pulse: Deep, Tight, Slow.
Treatment principle
Warm the Uterus, scatter Cold, invigorate Blood and eliminate stasis. Acupuncture
SP-10 Xuehai, Ren-6 Qihai, KI-14 Siman, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), BL-17 Geshu, SP-6 Sanyinjiao. All with reducing method, moxa must be used. Explanation
These points are the same as those for stagnation of Qi and Blood, except that moxa should be used, either as a warming needle or with a moxa stick. Herbal treatment
Prescription
– QI ZHEN SAN – Raising the Pillow Powder Explanation
– Rou Gui warms the Uterus and expels Cold. – Dang Gui, Chi Shao, Mu Dan Pi, Chuan Xiong, Pu Huang, Wu Ling Zhi,
Yan Huo Suo and Mo Yao invigorate Blood and eliminate stasis. – Bai Zhi fragrantly opens the orifices and helps to invigorate Blood. By opening the orifices it also helps to promote the expulsion of lochia. Modifications
• If the patient is very tired and without strength, add Dang Shen Radix Codonopsis and Huang Qi Radix Astragali. • If there is lower abdominal pain, add Xiang Fu Rhizoma Cyperi and Mu Xiang Radix Aucklandiae. • If there is epigastric pain, poor appetite and loose stools, add Bai Dou Kou Fructus Amomi rotundus, Bai Zhu Rhizoma Atractylodis macrocephalae and Sha Ren Fructus Amomi. Summary Stagnation of Cold and stasis of Blood
Clinical manifestations
Absent or scanty, dark lochial discharge with small, stringy clots, abdominal pain relieved by the application of heat, cold limbs. Tongue: Bluish-Purple. Pulse: Deep, Tight, Slow. Treatment principle
Warm the Uterus, scatter Cold, invigorate Blood and eliminate stasis. Acupuncture
SP-10 Xuehai, Ren-6 Qihai, KI-14 Siman, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), BL-17 Geshu, SP-6 Sanyinjiao. All with reducing
method, moxa must be used. Herbal treatment
Prescription • QI ZHEN SAN Raising the Pillow Powder
Ancient acupuncture prescriptions for retention of lochia3
1. BL-60 Kunlun (ABC of Acupuncture, Zhen Jiu Jia Yi Jing, AD 259). 2. ST-28 Shuidao on the left and LIV-13 Zhangmen for retention of lochia with abdominal masses (Thousand Golden Ducat Prescriptions, Qian Jin Yao Fang, AD 652). 3. Ren-3 Zhongji and G.B.-21 Jianjing (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601). End note 1. Chen You Bang 1990 Chinese Acupuncture Therapy (Zhong Guo Zhen Jiu Zhi Liao Xue
), China Scientific Publishing House, Beijing, p. 920..
2. Heilongjiang Province National Medical Research Group 1984 An Explanation of the Great Compendium of Acupuncture (Zhen Jiu Da Cheng Jiao Shi
), People’s Health Publishing House, Beijing, p. 1108. The Great Compendium of Acupuncture itself was published in 1601..
3. Chinese Acupuncture Therapy, p. 918..
CHAPTER 48 Urinary Difficulty after Childbirth
AETIOLOGY 615 PATHOLOGY 615 IDENTIFICATION OF PATTERNS AND TREATMENT 616 Spleen-Qi deficiency 616 Kidney-Qi deficiency 618 Injury to the Bladder 619 Liver-Qi stagnation 619 Bladder-Heat and Kidney-Yin deficiency 621 Lung- and Spleen-Qi deficiency 622 PROGNOSIS AND PREVENTION 623 Urinary Difficulty after Childbirth includes a range of urinary problems, from difficulty in urination and retention of urine, to their opposites, frequency of urination and incontinence of urine. They can be dealt with together because the cause is always a deficiency occurring after childbirth, and addressing the underlying deficiency cures the urinary problems. It is important to stress that the mother’s conditions included under this chapter’s heading are urinary problems without fever or pain; thus, from a Western point of view, they are urinary problems without a urinary infection. Strangely enough, modern Chinese obstetrics books do not seem to discuss urinary infections separately from the heading of Fever after Childbirth (see Ch. 51). As urinary infections (from the Chinese point of view Painful-
Urination Syndrome) have very specific symptoms and treatment, I shall discuss them in this chapter rather than in that on fever after childbirth.
Aetiology
Excessive strain during labour The strain of labour taxes the mother’s Qi greatly, and if labour is prolonged it induces a state of Spleen-Qi deficiency. Deficient Spleen-Qi fails to raise Qi and this affects the Bladder’s Qi which therefore sinks causing frequency of urination or even incontinence of urine. However, Qi deficiency affecting the Bladder may also work the other way and cause difficulty or retention of urine: this happens because the deficient Qi fails to transform and excrete fluids in the Bladder which are therefore retained. Excessive strain during labour also taxes the Kidneys and, in women who might have a pre-existing Kidney deficiency, it causes a deficiency of Kidney-Qi. As the Kidneys provide Qi to the Bladder for its function of Qi transformation, the Bladder has not enough Qi to transform and excrete fluids and this may cause either frequency and incontinence of urine or its opposite, difficulty and retention of urine. The reasons why a deficiency of Kidney-Qi may cause opposite types of problems are the same as those explained for the Spleen above. Injury to the bladder The bladder itself may be injured by a prolonged labour or by surgical procedures during childbirth and therefore give rise to either retention or incontinence of urine, more usually the latter. In some cases, this may persist for a long time after childbirth. Injury to the bladder may also manifest with symptoms of Qi stagnation affecting the Bladder.
Pathology The pathology of Urinary Difficulty after Childbirth, according to the traditional theory, is always one of deficiency and primarily of the Spleen or Kidneys. Deficient Spleen-Qi may cause sinking of the Qi of the Bladder and thus frequent urination or incontinence; or it may fail to transform and transport fluids so that urine is retained. Deficient Kidney-Qi fails to provide Qi to the Bladder for its function of Qi transformation, there is not enough Qi to hold the urine, and frequency and incontinence result. Alternatively, Kidney-Qi may be so deficient that there is no strength to push the urine out and retention of urine ensues. This type of Kidney-Qi deficiency always occurs against a background of Kidney-Yang deficiency. However, according to my experience, urinary problems after childbirth may also manifest with symptoms of Qi stagnation. This may derive either from injury to the bladder or from emotional problems. The time immediately after childbirth is a difficult one for a woman who is exhausted from labour, has to cope with the demands of the baby on a physical and emotional level, and may have a feeling of anticlimax. All this may easily lead to stagnation of Liver-Qi, especially if there was some pre-existing Qi stagnation: the Liver channel and its Connecting channel flow to the external genitalia, urethra and bladder, and stagnation in these channels is a very frequent cause of urinary problems in women. After childbirth, it causes a slight difficulty in micturition, an uncomfortable sensation during it, and hypogastric pain and distension.
Identification of patterns and treatment The patterns discussed are: • Spleen-Qi deficiency • Kidney-Qi deficiency • injury to the Bladder • Liver-Qi stagnation • Bladder-Heat and Kidney-Yin deficiency • Lung- and Spleen-Qi deficiency.
Spleen-Qi deficiency
Clinical manifestations Slight retention of urine after childbirth, a feeling of fullness and distension in the hypogastrium, or frequency or incontinence of urine, tiredness, weariness, loose stools, poor appetite, pale complexion, sweating. Tongue: Pale. Pulse: Weak. Treatment principle Tonify Qi, strengthen the Spleen. Acupuncture Ren-12 Zhongwan, Ren-6 Qihai, Ren-3 Zhongji, ST-36 Zusanli, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, BL-28 Pangguangshu, Du-20 Baihui, BL-20 Pishu. All with reinforcing method, moxa is applicable. Explanation
– Ren-12, ST-36, SP-6 and BL-20 tonify the Spleen. – Ren-6 tonifies Qi in general. – Ren-3 strengthens the Bladder and regulates urination. – BL-22 promotes the transformation and excretion of fluids in the Lower Burner.
– BL-28 tonifies the Bladder. – Du-20 raises Qi and treats frequency or incontinence of urine. Herbal treatment
Prescription
– BU ZHONG YI QI TANG Variation – Tonifying the Centre and Benefiting Qi Decoction Variation Explanation This formula, already explained, tonifies and raises Qi and can treat urinary problems by promoting the ascending of clear Qi to the top: by doing this, it automatically causes impure Qi to descend and therefore regulates urination. For this reason, it can be effective both for retention and incontinence of urine. – Dong Kui Zi drains Dampness from the urinary passages. – Tong Cao removes obstructions from the Connecting channels of the urinary passages. – Jie Geng directs Qi upwards: this stimulates the ascending of clear Qi and descending of turbid Qi. Modifications
• If there is frequent urination and a feeling of distension in the hypogastrium, add Zhi Ke Fructus Aurantii and Xiao Hui Xiang Fructus Foeniculi. • If the woman feels cold and the pulse is Deep, add Bu Gu Zhi Fructus Psoraleae and Rou Gui Cortex Cinnamomi. • If there is pain on urination and the tongue is Purple, add Pu Huang Pollen Typhae, Hu Po Succinum and Ze Lan Herba Lycopi. • If there is frequency and incontinence of urine, add Yi Zhi Ren Fructus Alpiniae oxyphyllae, Shan Zhu Yu Fructus Corni and Wu Wei Zi Fructus Schisandrae. Three Treasures remedy
– SEPARATE CLEAR AND TURBID This remedy is a variation of the formula Bi Xie Fen Qing Tang Dioscorea Separating the Clear Decoction which tonifies Kidney-Yang, warms the Bladder and promotes the transformation and excretion of urine. It has been modified to tonify Qi and to promote the ascending of clear Qi and descending of impure Qi so as to regulate urination. The tongue presentation appropriate to this remedy is a Pale body with a sticky coating. The recommended starting dosage is one tablet three times a day. Summary Spleen-Qi deficiency
Clinical manifestations
Slight retention of urine after childbirth, a feeling of fullness and distension in the hypogastrium, or frequency or incontinence of urine, tiredness, weariness, loose stools, poor appetite, pale complexion, sweating. Tongue: Pale. Pulse: Weak. Treatment principle
Tonify Qi, strengthen the Spleen. Acupuncture
Ren-12 Zhongwan, Ren-6 Qihai, Ren-3 Zhongji, ST-36 Zusanli, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, BL-28 Pangguangshu, Du-20 Baihui, BL-20 Pishu. All with reinforcing method, moxa is applicable. Herbal treatment
Pre scription
• BU ZHONG YI QI TANG Variation Tonifying the Centre and Benefiting Qi Decoction Variation Thre e Tre asure s remedy
• SEPARATE CLEAR AND TURBID
Case history A 38-year-old woman had been suffering from slight urinary incontinence since the birth of her child 9 months before. Her labour had been long, forceps had to be used, her perineal muscles tore and she developed an infection. Her urination was frequent and she could not hold
her urine for very long; occasionally, she would be slightly incontinent. Apart from this, she suffered from palpitations, backache, chilliness and dizziness. Her tongue was Pale and her pulse was Weak in general. Diagnosis This is a clear example of urinary incontinence from Spleen- and Kidney-Qi deficiency. The urinary incontinence is due to both Spleen- and Kidney-Qi sinking and being unable to hold urine. Since her Kidney pulse was not particularly weaker than the others, I concluded that Spleen-Qi deficiency predominated over Kidney-Qi deficiency. Treatment principle The treatment principle adopted was to tonify the Spleen and raise Qi. I treated her with both acupuncture and herbs. Acupuncture
The points used were: • Ren-6 with direct moxa cones to tonify and raise Qi. • ST-36 Zusanli and SP-6 Sanyinjiao, with warm needle, to tonify and warm Spleen-Qi. • Du-20 to raise Qi. • BL-20 Pishu and BL-21 Weishu to tonify Spleen-Qi. Herbal treatment
I used a variation of Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction as indicated above:
• Huang Qi Radix Astragali 9 g • Ren Shen Radix Ginseng 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Sheng Ma Rhizoma Cimicifugae 3 g • Chai Hu Radix Bupleuri 3 g • Dong Kui Zi Fructus Malvae 6 g • Jie Geng Radix Platycodi 3 g • Du Zhong Cortex Eucommiae 4 g
Explanation The first seven herbs constitute the root formula Bu Zhong Yi Qi Tang which tonifies and raises Qi. • Dong Kui Zi regulates the Water passages of the Bladder. • Jie Geng raises Qi. • Du Zhong tonifies Kidney-Yang.
After 3 months of treatment her urinary problem had improved by about 80%.
Kidney-Qi deficiency
Clinical manifestations Retention of urine after childbirth or frequency/incontinence of urine, a feeling of distension and fullness of the hypogastrium, pale complexion, backache, dizziness, tinnitus, feeling cold. Tongue: Pale and wet. Pulse: Deep, Slow, Weak. Treatment principle Strengthen Kidney-Qi, tonify Kidney-Yang. Acupuncture BL-23 Shenshu, BL-28 Pangguangshu, BL-22 Sanjiaoshu, KI-7 Fuliu, Ren4 Guanyuan, Ren-3 Zhongji, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Du-20 Baihui, Ren-8 Shenque. All with reinforcing method; moxa must be used. Explanation
– BL-23 and KI-7 tonify Kidney-Yang. – BL-28 and Ren-3, Back-Transporting and Front-Collecting points of the Bladder respectively, regulate the Bladder and urination. – BL-22 promotes the transformation and excretion of fluids in the Lower Burner.
– Ren-4, with moxa cones, tonifies Kidney-Yang. – LU-7 and KI-6 regulate the Directing Vessel and the Bladder. – Du-20 raises Qi and regulates urination by promoting the ascending of clear Qi and descending of impure Qi. It is particularly effective for the urinary function in combination with LU-7 and KI-6. – Ren-8 is filled with sea salt first. Then take about ten stems of spring onions (scallions, i.e. Allium fistulosum), tie them in a bundle, cut to about the size of a finger’s thickness, place over the salt and apply moxibustion with a moxa stick. This promotes urination in case of urinary retention. Herbal treatment
Prescription
– JIN GUI SHEN QI WAN – Golden Chest Kidney-Qi Pill Explanation This formula, already explained, tonifies and warms Kidney-Yang. Please note that the use of Fu Zi Radix Aconiti lateralis preparata may be prohibited in certain countries and, if so, it can be removed from the prescription. If the symptoms of Cold are pronounced, Gui Zhi Ramulus Cinnamomi could be added instead. Modifications
• If there is a sallow complexion, dizziness and palpitation, add Huang Qi Radix Astragali and Bai Shao Radix Paeoniae alba. • If there is hypochondrial pain, add Chai Hu Radix Bupleuri, Yu Jin Radix Curcumae and Xiang Fu Rhizoma Cyperi. • If there is pain on urination and some blood in the urine, add Pu Huang Pollen Typhae, Hu Po Succinum and Bai Ji Rhizoma Bletillae. • If there is urinary retention, add Tong Cao Medulla Tetrapanacis and Che Qian Zi Semen Plantaginis. • If there is frequency of urination or incontinence, add Sang Piao Xiao Ootheca Mantidis, Fu Pen Zi Fructus Rubi and Bu Gu Zhi Fructus Psoraleae. Three Treasures remedies
– STRENGTHEN THE ROOT This remedy is a variation of You Gui Wan Restoring the Right [Kidney] Pill which tonifies and warms Kidney-Yang and consolidates the Governing Vessel. It is a good alternative to the use of Jin Gui Shen Qi Wan if there are worries about using Fu Zi. The tongue presentation appropriate to this remedy is a Pale and wet body. – SEPARATE CLEAR AND TURBID This remedy is a variation of the formula Bi Xie Fen Qing Tang Dioscorea Separating the Clear Decoction which tonifies Kidney-Yang, warms the Bladder and promotes the transformation and excretion of urine. It has been modified to tonify Qi and to promote the ascending of clear Qi and descending of impure Qi so as to regulate urination. The tongue
presentation appropriate to this remedy is a Pale body with sticky coating. The recommended starting dosage is one tablet three times a day. Summary Kidney-Qi deficiency
Clinical manifestations
Retention of urine after childbirth or frequency/incontinence of urine, a feeling of distension and fullness of the hypogastrium, pale complexion, backache, dizziness, tinnitus, feeling cold. Tongue: Pale and wet. Pulse: Deep, Slow, Weak. Treatment principle
Strengthen Kidney-Qi, tonify Kidney-Yang. Acupuncture
BL-23 Shenshu, BL-28 Pangguangshu, BL-22 Sanjiaoshu, KI-7 Fuliu, Ren4 Guanyuan, Ren-3 Zhongji, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Du-20 Baihui, Ren-8 Shenque. All with reinforcing method; moxa must be used. Herbal treatment
Pre scription
• JIN GUI SHEN QI WAN Golden Chest Kidney-Qi Pill
Three Treasures remedies
• STRENGTHEN THE ROOT • SEPARATE CLEAR AND TURBID
Injury to the Bladder
Clinical manifestations Incontinence of urine after childbirth, often with blood in the urine. Tongue: normal. Pulse: Wiry on the left Rear position. Treatment principle Tonify and firm Qi. Acupuncture BL-28 Pangguangshu, Ren-3 Zhongji, BL-32 Ciliao, BL-63 Jinmen, BL-53 Baohuang, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Du-20 Baihui. All with reinforcing method; moxa is applicable. Explanation
– BL-28 and Ren-3, Back-Transporting and Front-Collecting points of the Bladder respectively, tonify the Bladder. – BL-32 removes obstructions from the Bladder channel and promotes urination. – BL-63, Accumulation point of the Bladder, stops pain and treats acute syndromes. – BL-53 affects the Bladder.
– LU-7 and KI-6 regulate the Directing Vessel and the Bladder. – Du-20, particularly in combination with LU-7 and KI-6, regulates Bladder-Qi and promotes the ascending of clear Qi and descending of impure Qi. Herbal treatment
Prescription
– HUANG QI DANG GUI SAN – Astragalus-Angelica Powder Explanation
– Huang Qi, Ren Shen and Bai Zhu tonify Qi. – Dang Gui and Bai Shao nourish and invigorate Blood. – Gan Cao, Sheng Jiang and Da Zao harmonize. The original prescription recommends decocting the above herbs with a pig’s bladder. Summary Injury to the Bladder
Clinical manife stations
Incontinence of urine after childbirth, often with blood in the urine. Tongue: normal. Pulse: Wiry on the left Rear position. Tre atme nt principle
Tonify and firm Qi. Acupuncture
BL-28 Pangguangshu, Ren-3 Zhongji, BL-32 Ciliao, BL-63 Jinmen, BL-53 Baohuang, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Du-20 Baihui. All with reinforcing method; moxa is applicable. He rbal tre atme nt
Prescription
• HUANG QI DANG GUI SAN Astragalus-Angelica Powder
Liver-Qi stagnation
Clinical manifestations Difficulty in urination after childbirth, pain and distension of the hypogastrium, uncomfortable sensation during urination, irritability. Tongue: may be normal or slightly Red on the sides. Pulse: Wiry. Treatment principle Pacify the Liver, move Qi, eliminate stagnation, settle the Ethereal Soul. Acupuncture Ren-3 Zhongji, Ren-5 Shimen, BL-28 Pangguangshu, LIV-3 Taichong, LIV5 Ligou, LIV-8 Ququan, BL-63 Jinmen, SP-6 Sanyinjiao, Ren-6 Qihai, LU7 Lieque, KI-6 Zhaohai. All with reducing or even method. Ancient prescription: KI-1 Yongquan, G.B.-34 Yanglingquan and Ren5 Shimen (Gatherings from Eminent Acupuncturists, Zheng Jiu Ju Ying, 1529).1 Explanation
– Ren-3 and BL-28, respectively Front-Collecting and Back-Transporting points of the Bladder, regulate Qi in the Bladder. – Ren-5, Front-Collecting point of the Triple Burner, eliminates stagnation in the Lower Burner and frees the Water passages.
– LIV-3 moves Liver-Qi and eliminates stagnation. – LIV-5 moves Liver-Qi in the Liver Connecting channel which flows to the urethra and genitalia. – LIV-8 moves Liver-Qi in the Liver channel in the hypogastric region. – BL-63, Accumulation point, stops pain. – SP-6 regulates Qi, soothes the Liver, opens the Water passages and stops pain. – Ren-6 moves Qi in the lower abdomen. – LU-7 and KI-6 in combination regulate Directing Vessel. This can be used, with Ren-6, in women to regulate Qi in the hypogastrium. Herbal treatment
Prescription
– CHEN XIANG SAN – Aquilaria Powder Explanation This formula is specific for Painful-Urination Syndrome from Qi stagnation. – Chen Xiang regulates Qi.
– Shi Wei, Hua Shi and Dong Kui Zi drain Dampness from the Bladder and open the Water passages. – Dang Gui, Wang Bu Liu Xing and Bai Shao invigorate Blood. Bai Shao also pacifies the Liver and stops pain. – Chen Pi drains Dampness and moves Qi. – Gan Cao harmonizes and, in combination with Bai Shao, it smooths roughness and stops pain. Modifications
• To enhance this formula’s moving Qi action, add Xiang Fu Rhizoma Cyperi, Wu Yao Radix Linderae and Xiao Hui Xiang Fructus Foeniculi. • If there is Blood stasis, add Hong Hua Flos Carthami, Tao Ren Semen Persicae and Niu Xi Radix Achyranthis bidentatae seu Cyathulae. Summary Liver-Qi stagnation
Clinical manife stations
Difficulty in urination after childbirth, pain and distension of the hypogastrium, uncomfortable sensation during urination, irritability. Tongue: may be normal or slightly Red on the sides. Pulse: Wiry. Tre atme nt principle
Pacify the Liver, move Qi, eliminate stagnation, settle the Ethereal Soul.
Acupuncture
Ren-3 Zhongji, Ren-5 Shimen, BL-28 Pangguangshu, LIV-3 Taichong, LIV5 Ligou, LIV-8 Ququan, BL-63 Jinmen, SP-6 Sanyinjiao, Ren-6 Qihai, LU7 Lieque, KI-6 Zhaohai. All with reducing or even method. He rbal tre atme nt
Prescription
• CHEN XIANG SAN Aquilaria Powder
Case history A 30-year-old woman began suffering from urinary problems after the birth of her second child. She complained of hypogastric pain and distension, soreness during urination and cramping after it, slightly cloudy urine, vaginal pain and pain on intercourse. She also developed post-natal depression and felt very tired. Her tongue was rather unremarkable, of a normal colour and with a slightly sticky coating. Her pulse was Wiry. Her eyes were rather dull, lacking shen. She had seen another practitioner for Chinese herbal medicine but it had not helped. Diagnosis
I diagnosed that her urinary problem was due to stagnation of Liver-Qi affecting the Bladder. I contacted the practitioner who treated her and learned that he had prescribed mostly herbs to tonify Qi and Blood. This was the correct approach according to the traditional view that urinary problems after childbirth are always due to a deficiency. The post-natal depression seemed to confirm this. However, as mentioned in the introduction to this chapter, some post-partum urinary problems are due to stagnation of Qi. What confirmed for me that stagnation of Qi was the main problem were
chiefly the cramping sensation after micturition, the hypogastric pain and distension, the Wiry pulse and the lack of glitter in the eyes from emotional problems. Treatment principle
I adopted the treatment principle of pacifying the Liver, moving Qi, eliminating stagnation and settling the Ethereal Soul. I treated her only with Chinese herbs and I used a variation of Bi Xie Fen Qing Yin Dioscorea Separating the Clear Decoction. Although this formula is actually for Turbid Painful Urinary Syndrome with cloudy urine, I use variations of it for other types of urinary problems as I find it extremely effective. The variation I used was: • Bi Xie Rhizoma Dioscoreae hypoglaucae 6 g • Shi Chang Pu Rhizoma Acori tatarinowii 4.5 g • Wu Yao Radix Linderae 6 g • Xiang Fu Rhizoma Cyperi 6 g • Gan Cao Radix Glycyrrhizae 4.5 g • Bai Shao Radix Paeoniae alba 6 g • Qu Mai Herba Dianthi 6 g • Che Qian Zi Semen Plantaginis 6 g • Yan Hu Suo Rhizoma Corydalis 4.5 g • Wu Ling Zhi Faeces Trogopterori 4.5 g • Ze Lan Herba Lycopi 4.5 g • Mai Ya Fructus Hordei germinatus 6 g Explanation
• Bi Xie promotes the transformation and excretion of fluids in the Bladder. • Shi Chang Pu, together with Bi Xie, promotes the transformation of fluids by opening the orifices. • Wu Yao and Xiang Fu pacify the Liver, move Qi and eliminate stagnation. • Gan Cao and Bai Shao stop pain and moderate ‘urgency’: these two herbs in combination are effective in urinary problems characterized by pain, urgency and discomfort. • Qu Mai and Che Qian Zi drain Damp-Heat and stop urinary pain. • Yan Hu Suo, Wu Ling Zhi and Ze Lan were added to stop pain, as she also had pain on intercourse and vaginal pain. Ze Lan also facilitates the Water passages. • Mai Ya was added to aid the digestion of the herbs.
After five packets of this decoction, there was a noticeable improvement with considerable relief from the hypogastric pain and distension. I then prescribed the same herbs with the addition of Huang Qi Radix Astragali to provide some tonification and also to treat her depression. Interestingly, she grew worse with the second prescription; presumably, using the Qi tonic aggravated the stagnation. I therefore reverted to the original prescription which she took for 6 weeks with a complete disappearance of her urinary symptoms. After that, I prescribed the remedy Precious Sea (a variation of Ba Zhen Wan Eight Precious Pill) to tonify Qi and Blood.
Bladder-Heat and Kidney-Yin deficiency
Clinical manifestations Frequency of urination after childbirth, blood in urine, burning on urination, mental restlessness, feeling of heat, malar flush, dry lips, dry mouth with a desire to drink in small sips. Tongue: Red without coating with sticky, yellow coating on the root. Pulse: Fine, Rapid. Treatment principle Nourish Yin, clear Empty-Heat, cool Blood. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-3 Zhongji, SP-9 Yinlingquan, BL-63 Jinmen, BL-22 Sanjiaoshu, BL-28 Pangguangshu, BL-32 Ciliao, BL-53 Baohuang, KI-2 Rangu, SP-10 Xuehai, KI-3 Taixi, SP-6 Sanyinjiao. All with even method, except for KI-3 which should be needled with reinforcing method. Explanation
– LU-7 and KI-6 regulate the Directing Vessel and nourish Kidney-Yin. – Ren-3, Front-Collecting point of the Bladder, clears Bladder-Heat. – SP-9, BL-28, BL-32 and BL-53 clear Bladder Damp-Heat. – BL-63, Accumulation point, clears Heat and stop urinary pain.
– BL-22 regulates the Water passages of the Lower Burner. – KI-2 clears Empty-Heat. – SP-10 cools Blood. – KI-3 and SP-6 nourish Kidney-Yin. Herbal treatment
Prescription
– ZHI BO DI HUANG WAN – Anemarrhena-Phellodendron-Rehmannia Pill Explanation This formula, already explained, nourishes Kidney-Yin, clears Empty-Heat and resolves Damp-Heat from the Bladder. The tongue presentation appropriate to this formula is a Red body without coating. Three Treasures remedy
– WATER PASSAGES This remedy is a variation of Zhi Bo Di Huang Wan AnemarrhenaPhellodendron-Rehmannia Pill which tonifies Kidney-Yin and resolves Damp-Heat from the Lower Burner.
Summary Bladder-Heat and Kidney-Yin deficiency
Clinical manifestations
Frequency of urination after childbirth, blood in urine, burning on urination, mental restlessness, feeling of heat, malar flush, dry lips, dry mouth with a desire to drink in small sips. Tongue: Red without coating with sticky, yellow coating on the root. Pulse: Fine, Rapid. Treatment principle
Nourish Yin, clear Empty-Heat, cool Blood. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-3 Zhongji, SP-9 Yinlingquan, BL-63 Jinmen, BL-22 Sanjiaoshu, BL-28 Pangguangshu, BL-32 Ciliao, BL-53 Baohuang, KI-2 Rangu, SP-10 Xuehai, KI-3 Taixi, SP-6 Sanyinjiao. All with even method, except for KI-3 which should be needled with reinforcing method. Herbal treatment
Pre scription
• ZHI BO DI HUANG WAN Anemarrhena-Phellodendron-Rehmannia Pill Three Treasures remedy
• WATER PASSAGES
Lung- and Spleen-Qi deficiency
Clinical manifestations Urinary retention after childbirth, no abdominal distension or pain, dizziness, breathlessness, sweating, dislike of speaking, depression, tiredness, poor appetite, pale complexion. Tongue: Pale. Pulse: Weak. Treatment principle Tonify Lung- and Spleen-Qi, open the Water passages. Acupuncture Du-20 Baihui, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-3 Zhongwan, BL-22 Sanjiaoshu, BL-13 Feishu, BL-20 Pishu. BL-13 and BL-20 with reinforcing method, the other points with even method. Explanation
– Du-20, LU-7, KI-6 and Ren-3 regulate the Directing Vessel and open the Water passages of the urinary system by harmonizing the ascending and descending of Qi in the Bladder. – BL-22 opens the Water passages in the Lower Burner. – BL-13 and BL-20 tonify the Lung- and Spleen-Qi. Herbal treatment
Prescription
– TONG PAO YIN – Penetrating the Bladder Decoction Explanation
– Huang Qi, Wu Wei Zi and Mai Men Dong tonify Lung-Qi. – Tong Cao opens the Water passages and removes obstructions from the Connecting channels. – Huai Niu Xi attracts Qi downwards and is used to stimulate urination by this action. – Fu Ling resolves Dampness. – Shan Yao tonifies the Spleen. Summary Lung- and Spleen-Qi Deficiency
Clinical manife stations
Urinary retention after childbirth, no abdominal distension or pain, dizziness, breathlessness, sweating, dislike of speaking, depression, tiredness, poor appetite, pale complexion. Tongue: Pale. Pulse: Weak.
Tre atme nt principle
Tonify Lung- and Spleen-Qi, open the Water passages. Acupuncture
Du-20 Baihui, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-3 Zhongwan, BL-22 Sanjiaoshu, BL-13 Feishu, BL-20 Pishu. BL-13 and BL-20 with reinforcing method, the other points with even method. He rbal tre atme nt
Prescription
• TONG PAO YIN Penetrating the Bladder Decoction
Prognosis and prevention Both acupuncture and herbs are excellent to treat urinary problems after childbirth. Since such urinary problems are due to a depletion of Qi after childbirth affecting the Directing Vessel or to an injury to the bladder, acupuncture is probably the best therapy because it’s the most direct, affecting the Directing Vessel and the bladder directly. In fact, Chinese medicine has much to offer in the treatment of a condition which, if left untreated, may last for a long time or even become permanent. In my practice, I have occasionally seen women who developed stress incontinence following childbirth; if this condition is not treated fairly soon after childbirth, it then becomes very difficult or impossible to treat. There is no Western view of this problem as obstetrics textbook normally refer only to urinary infections. End note 1. Gao Wu 1529 Gatherings from Eminent Acupuncturists (Zhen Jiu Ju Ying), cited in Yang Jia San 1989 Acupuncture (Zhen Jiu Xue
), People’s Hygiene Publishing House, Beijing, p. 665..
CHAPTER 49 Sweating after Childbirth
AETIOLOGY 625 PATHOLOGY 625 IDENTIFICATION OF PATTERNS AND TREATMENT 626 Qi deficiency 626 Yin deficiency 627 PROGNOSIS AND PREVENTION 628 The condition Sweating after Childbirth refers to either day-time or night-time sweating. After childbirth, Qi and Blood are deficient and skin pores are open. Sweating is likely to occur when eating or during sleep. It usually stops spontaneously in a few days. Profuse sweating that continues for a long time is pathological. Sweating after childbirth is one of the three acute conditions, called san ji, during the post-partum stage. Thus it should be arrested as soon as possible lest collapse of Yin or collapse of Yang develop.
Aetiology
Excessive strain during labour Prolonged labour taxes the woman’s Qi greatly. Deficient Qi fails to hold the fluids in the space between skin and muscles and they leak out in the form of sweat. Severe blood loss Profuse blood loss during labour may induce a state of deficiency of Blood and Yin. Deficient Yin-Qi fails to hold the fluids which are close to the bones and night-time sweating ensues. The General Treatise on the Aetiology and Symptoms of Diseases (AD 610) says: Blood is Yin, childbirth consumes Blood and thus causes deficiency of Yin. Qi is Yang, excess of Qi means supremacy of Yang over Yin, and this causes sweating. Deficiency of Yin failing to be restored leads to continuous sweating. Because of deficiency of Blood after childbirth, profuse sweating occurs. Convulsions may follow in case of exposure to wind. Even if convulsions do not occur, there may appear lassitude, shortness of breath, loss of body weight, dryness of the mouth and lips, and in prolonged cases, amenorrhoea, and exhaustion of body fluids.1 The Golden Mirror of Medicine (1742) says: Excess loss of blood during labour leads to deficiency of Yin, which then causes excess of Yang. Mild spontaneous sweating indicates harmony between Nutritive and Defensive Qi, and it is not harmful. Absence of sweating all over the body except on the head indicates deficiency of Yin and upward floating of Yang. Profuse sweating both
on the head and other parts of the body may lead to collapse of Yang.2
Pathology The pathology of Sweating after Childbirth is always one of deficiency. Qi deficiency causes sweating in day-time and deficiency of Yin sweating at night. The type of fluids lost in day-time is different from that lost at night. In day-time sweating, it is the superficial fluids that circulate with the Defensive Qi in the space between the skin and muscles that leak out; in night-time sweating, the Yin essence from the Yin portion. Because these fluids come from the deep, Yin, energetic layers, this type of sweating is also called ‘steaming from the bones’. Sweating is always taken seriously in Chinese medicine because it is a self-perpetuating pathological process. In fact, in day-time sweating the loss of fluids from the space between skin and muscles induces a deficiency of Qi because that is where Defensive Qi circulates. In night-time sweating, the fluids leaking from the Yin energetic layers represent a loss of precious Yin essences. Because of this, night-time sweat is supposed to taste sweet being composed of Yin essences, whereas day-time sweat tastes salty. The organs affected are mostly the Lungs and Kidneys: the Lungs are affected in day-time sweating as they govern Qi, control the Defensive Qi and the space between skin and muscles. In night-time sweating, the Lungs and/or the Kidneys are affected.
Identification of patterns and treatment The patterns discussed are: • Qi deficiency • Yin deficiency.
Qi deficiency
Clinical manifestations Day-time sweating after labour, pallor, shortness of breath, weak voice, tiredness. Tongue: Pale. Pulse: Weak. Treatment principle Tonify Qi, consolidate the Exterior. Acupuncture L.I.-4 Hegu, KI-7 Fuliu, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, LU-9 Taiyuan, Ren-6 Qihai, BL-13 Feishu. All with reinforcing method, except for L.I.-4 which should be needled with reducing method. Moxa can be used. Explanation
– L.I.-4 and KI-7, in combination, stop sweating if L.I.-4 is needled with reducing method and KI-7 with reinforcing method. – Ren-12, ST-36 and SP-6 tonify Qi. – LU-9 and BL-13 tonify Lung-Qi and stop sweating.Ren-6 tonifies Qi in general. Herbal treatment
a Prescription
– HUANG QI TANG – Astragalus Decoction Explanation
– Huang Qi and Bai Zhu tonify Qi and consolidate the Exterior. – Fang Feng is added here not to expel Wind but as a messenger herb to reach the space between the skin and muscles: this is the energetic layer from which day-time sweat comes. Also, in conjunction with Huang Qi and Bai Zhu, Fang Feng consolidates the Exterior: in fact, these three herbs form the prescription Yu Ping Feng San Jade Wind-Screen Powder which tonifies Qi and consolidates the Exterior. – Shu Di Huang nourishes Blood and tonifies the Kidneys. – Mu Li is absorbent and is added to stop sweating. – Fu Ling resolves Dampness. – Mai Dong is added to tonify Lung-Qi to stop sweating as Lung-Qi governs the Defensive Qi which circulates in the space between skin and muscles. – Gan Cao and Da Zao harmonize. b Prescription
– YU PING FENG SAN Variation – Jade Wind-Screen Powder Variation Explanation
– Huang Qi, Bai Zhu and Fang Feng form the prescription Yu Ping Feng San which tonifies Qi and consolidates the Exterior. – Dang Shen tonifies Qi. – Fu Xiao Mai stops sweating. – Mu Li is absorbent and stops sweating. – Da Zao harmonizes. Modifications
• If there is a feeling of cold, add Gui Zhi Ramulus Cinnamomi. • If there is poor appetite and loose stools, add Shan Yao Rhizoma Dioscoreae. • If the limbs are cold, add Sheng Jiang Rhizoma Zingiberis recens, Gui Zhi Ramulus Cinnamomi and Ren Shen Radix Ginseng. • If there is an invasion of external Wind with the symptoms of shivers, spontaneous sweating and cold limbs, use Gui Zhi Tang Ramulus Cinnamomi Decoction.
• If there is profuse sweating with the danger of collapse of Yang, add Shen Fu Tang Ginseng-Aconitum Decoction or Du Shen Tang Solitary Ginseng Decoction (see Ch. 55 on collapse after childbirth). Summary Qi deficiency
Clinical manife stations
Day-time sweating after labour, pallor, shortness of breath, weak voice, tiredness. Tongue: Pale. Pulse: Weak. Tre atme nt principle
Tonify Qi, consolidate the Exterior. Acupuncture
L.I.-4 Hegu, KI-7 Fuliu, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, LU-9 Taiyuan, Ren-6 Qihai, BL-13 Feishu. All with reinforcing method, except for L.I.-4 which should be needled with reducing method. Moxa can be used. He rbal tre atme nt
Prescriptions
• HUANG QI TANGAstragalus Decoction • YU PING FENG SAN Variation Jade Wind-Screen Powder Variation
Yin deficiency
Clinical manifestations Night-time sweating after delivery, insomnia, malar flush, dry throat, dizziness, tinnitus, five-palm heat. Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty. Treatment principle Nourish Yin, strengthen the Lungs and stop sweating. Acupuncture LU-9 Taiyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), BL-13 Feishu, Ren-12 Zhongwan, Ren-6 Qihai, Ren-4 Guanyuan, HE-6 Yinxi, KI-7 Fuliu, L.I.-4 Hegu, ST-36 Zusanli. All with reinforcing method except for L.I.-4 and HE-6 which should be needled with reducing method. No moxa. Explanation
– LU-9 and BL-13 tonify the Lungs. – Ren-12 and ST-36 tonify Earth to nourish Metal. – LU-7 and KI-6 regulate the Directing Vessel and nourish both Lungand Kidney-Yin. – Ren-6 tonifies the Lungs as its channel starts in the Ren-12 area and
flows down to the Ren-6 area before flowing upwards. – Ren-4 nourishes Kidney-Yin. – HE-6 and KI-7 stops night sweating. – L.I.-4, in combination with KI-7, stops sweating. Herbal treatment
Prescription
– ZHI HAN SAN and SHENG MAI SAN – Stopping Sweating Powder and Generating the Pulse Powder Explanation The first seven herbs constitute the formula Zhi Han San. This formula contains Ren Shen which, with Mai Men Dong and Wu Wei Zi, forms the prescription Sheng Mai San. – Ren Shen tonifies Qi. – Dang Gui and Shu Di Huang nourish Blood. – Ma Huang Gen and Fu Xiao Mai stop sweating. – Huang Lian clears Heat deriving from Yin deficiency. – Da Zao harmonizes.
– Mai Men Dong and Wu Wei Zi tonify the Lungs and nourish Yin. Modifications
• If there is a dry mouth and throat, add Shi Hu Herba Dendrobii, Lu Gen Rhizoma Phragmitis and Yu Zhu Rhizoma Poligonati odorati. • If there is five-palm heat, add Bai Ji Rhizoma Bletillae and Ze Xie Rhizoma Alismatis. • If there is profuse sweating and constipation (from exhaustion of body fluids), add Tian Hua Fen Radix Trichosanthis and Shou Wu Radix Polygoni multiflori preparata. • If night sweating occurs with a complicated condition of deficiency and excess, such as deficiency of Yin with Liver-Fire and Damp-Heat, the symptoms being a bitter taste in the mouth, thirst, restlessness, insomnia, poor appetite, bilateral hypochondrial pain, a Red tongue with little coating, or with a thin, yellow and sticky coating, use Dan Zhi Xiao Yao San Moutan-Gardenia Free and Easy Wanderer Powder plus Sheng Di Huang Radix Rehmanniae and Fu Xiao Mai Semen Tritici levis. • If there is deficiency of Yin with Damp-Heat with the symptoms of dizziness, a sensation of heaviness of the head, poor appetite, a Red tongue that is peeled in the centre but with a yellow, sticky coating on the root, use Zhi Bo Di Huang Tang Anemarrhena-Phellodendron-Rehmannia Decoction. Summary Yin deficiency
Clinical manife stations
Night-time sweating after delivery, insomnia, malar flush, dry throat, dizziness, tinnitus, five-palm heat. Tongue: without coating; Red if there is Empty-Heat.Pulse: Floating-Empty. Tre atme nt principle
Nourish Yin, strengthen the Lungs and stop sweating. Acupuncture
LU-9 Taiyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), BL-13 Feishu, Ren-12 Zhongwan, Ren-6 Qihai, Ren-4 Guanyuan, HE-6 Yinxi, KI-7 Fuliu, L.I.-4 Hegu, ST-36 Zusanli. All with reinforcing method except for L.I.-4 and HE-6 which should be needled with reducing method. No moxa. He rbal tre atme nt
Prescription
• ZHI HAN SAN and SHENG MAI SANStopping Sweating Powder and Generating the Pulse Powder
Prognosis and prevention Both acupuncture and herbs are very effective to stop sweating after childbirth and in most cases there should be results within 2 to 3 weeks. The pattern from Yin deficiency is obviously more difficult to treat, and for this pattern herbs are slightly better than acupuncture. A woman suffering from sweating after childbirth should not overexert herself. Although in itself it depletes the body’s Qi or Yin, sweating might not even be perceived as a problem by most people, and we should advise patients accordingly. There is no Western view of this condition. End note 1. Chao Yuan Fang AD 610 General Treatise on the Aetiology and Symptoms of Diseases (Zhu Bing Yuan Hou Lun) cited in Nanjing College of Traditional Chinese Medicine 1979 Gynaecology in Chinese Medicine (Zhong Yi Fu Ke Xue
), Nanjing College of Traditional Chinese Medicine, Nanjing, p. 130..
2. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian
), People’s Health Publishing House, Beijing, Vol. 3, p. 84. First published in 1742..
CHAPTER 50 Constipation and Haemorrhoids after Childbirth
AETIOLOGY AND PATHOLOGY 629 IDENTIFICATION OF PATTERNS AND TREATMENT 629 Blood deficiency 629 Kidney-Yang deficiency 630 Kidney-Yin deficiency 631 PROGNOSIS AND PREVENTION 632 WESTERN VIEW 632 APPENDIX: HAEMORRHOIDS 632 Identification of patterns and treatment 633 INTERNAL HAEMORRHOIDS 633> Blood-Heat and Blood deficiency 633 Toxic-Heat, Blood stasis, Dampness 634 Damp-Heat, Heart-Heat 634 EXTERNAL HAEMORRHOIDS 635 Blood stasis, Qi stagnation, Blood-Heat, Damp-Heat 635 Damp-Heat 636 Constipation after Childbirth refers to difficult, dry or very infrequent
defaecation.
Aetiology and pathology Constipation occurring after childbirth in a woman who previously had regular bowel movements is usually due to Blood deficiency and dryness following excessive blood loss during labour. When Blood and fluids are exhausted, the Large Intestine is affected and deficiency of fluids in this organ makes the passage of stools difficult. A state of dryness may also occur as a result of profuse spontaneous sweating after childbirth, but this is rare (see previous chapter). Apart from the Large Intestine, the pathology of constipation after childbirth is also related to the Liver when deficient Liver-Blood fails to moisten the faeces, and to the Lungs when deficient Lung-Qi fails to descend to the Large Intestine to provide Qi for the effort of defaecation.
Identification of patterns and treatment The patterns discussed are: • Blood deficiency • Kidney-Yang deficiency • Kidney-Yin deficiency.
Blood deficiency
Clinical manifestations Constipation after childbirth, difficult defaecation with dry stools, pale complexion, dizziness, blurred vision, tiredness, depression. Tongue: Pale and Thin. Pulse: Choppy. Treatment principle Nourish Blood, strengthen the Liver, moisten the Intestines. Acupuncture LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, SP-15 Daheng, SP-14 Fujie, Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left). All with reinforcing method. Explanation
– LIV-8 nourishes Liver-Blood. – ST-36 and SP-6 tonify Qi and Blood. – SP-15 and SP-14 promote bowel movement. – Ren-4 nourishes Blood. – LU-7 and KI-6 regulate the Directing Vessel and nourish Yin and Body Fluids. KI-6 on its own also promotes bowel movement in constipation from
dryness. Herbal treatment
Prescription
– SI WU TANG Variation – Four Substances Decoction Variation Explanation The first four herbs constitute the formula Si Wu Tang which nourishes Blood. – Rou Cong Rong tonifies the Kidneys and promotes bowel movement. – Bai Zi Ren nourishes Blood, calms the Mind and promotes bowel movement. – Shou Wu nourishes Blood and Body Fluids. – Huo Ma Ren nourishes Blood and promotes bowel movement. Modifications
• If there is also Yin deficiency, add Sheng Di Huang Radix Rehmanniae and Xuan Shen Radix Scrophulariae. • If there is also Qi deficiency, add Dang Shen Radix Codonopsis and
Shan Yao Rhizoma Dioscoreae. • If the Qi deficiency is pronounced with sweating and a pulse that is Empty but Floating, add Huang Qi Radix Astragali and Ren Shen Radix Ginseng, the latter in a fairly high dose (i.e. at least 9 g). • If constipation is very stubborn, add Yu Li Ren Semen Pruni and Tao Ren Semen Persicae. Women’s Treasure remedy
– PRECIOUS SEA This remedy nourishes Blood in general and moistens dryness. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Blood deficiency
Clinical manifestations
Constipation after childbirth, difficult defaecation with dry stools, pale complexion, dizziness, blurred vision, tiredness, depression. Tongue: Pale and Thin. Pulse: Choppy. Treatment principle
Nourish Blood, strengthen the Liver, moisten the Intestines. Acupuncture
LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, SP-15 Daheng, SP-14 Fujie, Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left). All with reinforcing method. Herbal treatment
Pre scription
• SI WU TANG Variation Four Substances Decoction Variation Women’s Treasure re me dy
• PRECIOUS SEA
Kidney-Yang deficiency
Clinical manifestations Difficulty in defaecation, exhaustion and sweating after defaecation, stools not dry, sore back and knees, feeling cold, frequent, pale urination. Tongue: Pale and wet. Pulse: Deep and Weak. This is a pattern of mostly Kidney-Yang deficiency. Normally, when Kidney-Yang is deficient, the stools are loose. However, it may also have the opposite effect when the deficient Kidney-Yang fails to move Qi in the Intestines and the bowels do not move. In addition, when Kidney-Yang is deficient, internal Cold results and this contracts the muscles in the Lower Burner, again impairing the normal bowel peristalsis. Treatment principle Tonify the Kidneys, warm the Lower Burner and moisten the Intestines. Acupuncture ST-36 Zusanli, SP-6 Sanyinjiao, BL-23 Shenshu, BL-25 Dachangshu, Ren4 Guanyuan, KI-7 Fuliu, SP-15 Daheng, SP-14 Fujie. Reinforcing method; moxa should be used. Explanation
– ST-36 and SP-6, with moxa on the needle, tonify Yang. ST-36 promotes bowel movement.
– BL-23 and KI-7 tonify Kidney-Yang. Direct moxa may be used on BL23. – BL-25 stimulates the Intestines and promotes bowel movement. – Ren-4, with direct moxa, tonifies Kidney-Yang and the Original Qi. – SP-15 and SP-14 (which can be needled only on the left side) promote bowel movement. Herbal treatment
Prescription
– JI CHUAN JIAN – Benefiting the River Decoction Explanation
– Dang Gui moistens the Intestines and promotes bowel movement. – Niu Xi has a descending movement and therefore promotes bowel movement. – Rou Cong Rong tonifies Kidney-Yang and promotes bowel movement. It is one of the very few Kidney-Yang tonics which promote bowel movement. – Ze Xie drains Dampness via urination: it therefore has a downwards
movement and helps Rou Cong Rong to move downwards. Because it also clears Empty-Heat, it prevents excessive heating from Rou Cong Rong. – Zhi Ke moves Qi in the lower abdomen and helps the other herbs to stimulate the bowels. – Sheng Ma has an ascending movement and it raises clear Yang to the top. Raising the clear Yang towards the upper part of the body makes it easier for the impure Qi to flow downwards, and this therefore stimulates bowel movement. Summary Kidney-Yang deficiency
Clinical manife stations
Difficulty in defaecation, exhaustion and sweating after defaecation, stools not dry, sore back and knees, feeling cold, frequent, pale urination. Tongue: Pale and wet. Pulse: Deep and Weak. Tre atme nt principle
Tonify the Kidneys, warm the Lower Burner and moisten the Intestines. Acupuncture
ST-36 Zusanli, SP-6 Sanyinjiao, BL-23 Shenshu, BL-25 Dachangshu, Ren4 Guanyuan, KI-7 Fuliu, SP-15 Daheng, SP-14 Fujie. Reinforcing method; moxa should be used. He rbal tre atme nt
Prescription
• JI CHUAN JIAN Benefiting the River Decoction
Kidney-Yin deficiency
Clinical manifestations Dry stools, thirst with desire to sip water, dry mouth and throat especially in the evening, sore back and knees, dizziness, tinnitus, night sweating. Tongue: without coating, cracks; Red if there is Empty-Heat. Pulse: Floating-Empty. This condition is more frequent in older women with Kidney-Yin deficiency. The tongue will lack a coating; in less serious cases it may only partially lack coating or have a rootless coating; and in still milder cases it may have a normal colour with a dry rootless coating. In all these cases, if there is Empty-Heat, the body colour will be Red. Treatment principle Nourish Yin, tonify the Kidneys and moisten the Intestines. Acupuncture ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, KI-3 Taixi, KI-6 Zhaohai, BL-23 Shenshu, BL-25 Dachangshu, SP-15 Daheng. Reinforcing method, no moxa. Explanation
– ST-36 and SP-6 nourish Stomach-Yin. ST-36 also promotes bowel movement. – Ren-4, KI-3 and KI-6 nourish Kidney-Yin. KI-6 also promotes bowel
movement. – BL-23 tonifies the Kidneys. – BL-25 and SP-15 promote bowel movement. Herbal treatment
a Prescription
– ZENG YE TANG – Increasing Fluids Decoction Explanation All these three herbs nourish Stomach- and Kidney-Yin. This formula originally was for dryness in the Intestines after a Bright Yang-Organ pattern condition in the course of a febrile disease. Such a pattern is characterized by Fire which dries up the Body Fluids and causes severe dryness in the Intestines and therefore constipation. Apart from its original use, this formula may be used simply to nourish Yin and moisten the Intestines in chronic constipation from Yin deficiency. Modifications
• In order to enhance the effect of this formula on bowel movement, add Huo Ma Ren Semen Cannabis and Yu Li Ren Semen Pruni.
b. Prescription
– TONG YOU TANG – Penetrating the Deep Decoction Explanation
– Sheng Di Huang and Shu Di Huang nourish Yin and Blood. – Dang Gui nourishes Blood and moistens the Intestines. – Tao Ren and Hong Hua move Blood. Tao Ren also moistens the Intestines. – Sheng Ma raises the clear Yang and, by so doing, helps the impure Qi to descend. This helps to stimulate bowel movement. – Zhi Gan Cao harmonizes. This formula is suitable if there is also some stasis of Blood and the tongue is slightly Purple. Summary Kidney-Yin deficiency
Clinical manife stations
Dry stools, thirst with desire to sip water, dry mouth and throat especially in the evening, sore back and knees, dizziness, tinnitus, night sweating. Tongue:
without coating, cracks; Red if there is Empty-Heat. Pulse: Floating-Empty. Tre atme nt principle
Nourish Yin, tonify the Kidneys and moisten the Intestines. Acupuncture
ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, KI-3 Taixi, KI-6 Zhaohai, BL-23 Shenshu, BL-25 Dachangshu, SP-15 Daheng. Reinforcing method, no moxa. He rbal tre atme nt
Prescriptions
• ZENG YE TANG Increasing Fluids Decoction • TONG YOU TANG Penetrating the Deep Decoction
Prognosis and prevention Both acupuncture and herbs are excellent to treat this type of constipation and results should be obtained within 1 week. The Chinese treatment based on nourishing Blood is much better than the Western treatment based on purgatives of the anthraquinone type, such as Cassia (Senakot, Dosalax, Senexone, etc.). Exercise aimed at improving the tone of the abdominal muscles is essential after childbirth to restore bowel function to normal.
Western view From a Western perspective, constipation after childbirth may be due to a combination of factors including a lesser food intake, dehydration during labour, laxity of the abdominal muscles or perineal lacerations that make defaecation painful. Moreover, the progesterone in circulation inhibits smooth muscle motility. Treatment is based on the administration of bulk laxatives, such as methylcellulose, or purgatives of the anthraquinone type such as Cassia.
Appendix: haemorrhoids Haemorrhoids are varicose veins in the rectum wall. They are usually classified as first, second or third degree. First-degree haemorrhoids do not prolapse; second-degree ones prolapse on defaecation but return into position spontaneously; third-degree ones remain prolapsed outside the anus. Haemorrhoids are due to congestion in the pelvic veins; this occurs frequently during pregnancy and after labour due to the pressure of the fetus on the pelvic veins and to the bearing-down efforts during labour. The development of constipation during pregnancy is also a contributory factor. The main symptoms of haemorrhoids are rectal discomfort or pain, anal itching and bleeding. In Chinese medicine, the pathology of haemorrhoids consists of Qi deficiency, Damp-Heat and Toxic-Heat. Deficient Qi fails to lift the organs and this may cause the sagging of veins in the rectum. Damp-Heat in the Large Intestine causes the pain and itching of the anus; Toxic-Heat causes more intense anal pain. When Heat invades the Blood, anal bleeding from the haemorrhoids occurs. Thus, the main treatment principles for haemorrhoids are to tonify and raise Qi, resolve Dampness, clear Heat, resolve Toxic-Heat and cool the Blood. The formulae used are distinguished according to internal or external haemorrhoids.
Identification of patterns and treatment Before discussing the treatment of individual patterns, a few remarks should be made about how to adapt the treatment when helping women after childbirth. As a general principle, Blood tonics (such as Dang Gui Radix Angelicae sinensis and Shu Di Huang Radix Rehmanniae preparata) should be added to all the following formulae for both internal and external haemorrhoids. To nourish Blood with acupuncture, use ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, BL-23 Shenshu and BL-20 Pishu. If there are symptoms of Qi deficiency (which is very likely), add also some Qi tonics and especially Huang Qi Radix Astragali which also raises Qi: raising Qi will help to lift the sagging veins in the rectum. With acupuncture, the use of the point Du-20 Baihui will have the same effect.
Internal haemorrhoids
Blood-Heat and Blood deficiency
Clinical manifestations Bleeding haemorrhoids, discomfort and pain in the anus, a feeling of heat, thirst, mental restlessness, blurred vision, dizziness, scanty periods. Tongue: Red. Pulse: Rapid, Wiry. Treatment principle Clear Heat, cool Blood, nourish Blood. Acupuncture L.I.-11 Quchi, SP-10 Xuehai, P-3 Quze, LIV-2 Xingjian, LIV-3 Taichong, KI-2 Rangu, SP-6 Sanyinjiao, ST-36 Zusanli, LIV-8 Ququan, BL-57 Chengshan, BL-58 Feiyang. All with reducing or even method, except for ST-36, SP-6 and LIV-8 which should be needled with reinforcing method. Explanation
– L.I.-11 and SP-10 clear Heat and cool Blood. – P-3 and LIV-2 cool Blood. – LIV-3 and KI-2, in combination, cool Blood. – SP-6, ST-36 and LIV-8 nourish Blood. – BL-57 and BL-58 are empirical points for haemorrhoids.
Herbal treatment
Prescription
– ZHI LING WAN – Haemorrhoids Miraculous Pill Explanation
– Chuan Shan Jia invigorates Blood, eliminates stasis and stops bleeding. – Dang Gui, Dan Shen and Chi Shao nourish and invigorate Blood. – Bai Zhi, Fang Feng and Wu Wei Zi resolve Dampness, open the orifices, stop itching and astringe fluids (to help to stop bleeding). – Huai Hua and Di Yu assist in stopping bleeding. – Sheng Di Huang and Mu Dan Pi cool Blood. Sheng Di Huang also nourishes Blood. – Da Huang drains Fire via the bowel movement. Summary Blood-Heat and Blood deficiency
Clinical manife stations
Bleeding haemorrhoids, discomfort and pain in the anus, a feeling of heat, thirst, mental restlessness, blurred vision, dizziness, scanty periods. Tongue: Red. Pulse: Rapid, Wiry. Tre atme nt principle
Clear Heat, cool Blood, nourish Blood. Acupuncture
L.I.-11 Quchi, SP-10 Xuehai, P-3 Quze, LIV-2 Xingjian, LIV-3 Taichong, KI-2 Rangu, SP-6 Sanyinjiao, ST-36 Zusanli, LIV-8 Ququan, BL-57 Chengshan, BL-58 Feiyang. All with reducing or even method, except for ST-36, SP-6 and LIV-8 which should be needled with reinforcing method. He rbal tre atme nt
Prescription
• ZHI LING WAN Haemorrhoids Miraculous Pill
Toxic-Heat, Blood stasis, Dampness
Clinical manifestations Anal bleeding, discomfort and intense pain in the anus, itching, swelling of the anus. Tongue: Red or Reddish-Purple, sticky, yellow coating. Pulse: Slippery and Rapid. Treatment principle Resolve Toxic-Heat, cool and invigorate Blood, drain Dampness. Acupuncture L.I.-11 Quchi, P-3 Quze, LIV-2 Xingjian, LIV-3 Taichong, KI-2 Rangu, BL-17 Geshu, SP-10 Xuehai, SP-6 Sanyinjiao, SP-9 Yinlingquan, BL-22 Sanjiaoshu. All with reducing or even method. Explanation
– L.I.-11 and P-3 resolve Toxic-Heat. – LIV-2, LIV-3 and KI-2 cool Blood. LIV-3 also invigorates Blood. – BL-17 and SP-10 invigorate Blood. – SP-6, SP-9 and BL-22 drain Dampness. Herbal treatment
Prescription
– XIAO ZHI TANG – Dissolving Haemorrhoids Decoction Explanation
– Wu Mei and Wu Wei Zi are astringent and are used to help the other ingredients to stop bleeding and shrink the haemorrhoids. – Ku Shen resolves Dampness and Toxic-Heat and stops itching. – She Gan resolves Toxic-Heat. – Chuan Shan Jia invigorates Blood, eliminates stasis and softens masses. – Mu Li helps to stops bleeding and prevents the sagging of the haemorrhoids. – Huo Ma Ren nourishes Blood and promotes bowel movement. Summary Toxic-Heat, Blood stasis, Dampness
Clinical manife stations
Anal bleeding, discomfort and intense pain in the anus, itching, swelling of the
anus. Tongue: Red or Reddish-Purple, sticky, yellow coating. Pulse: Slippery and Rapid. Tre atme nt principle
Resolve Toxic-Heat, cool and invigorate Blood, drain Dampness. Acupuncture
L.I.-11 Quchi, P-3 Quze, LIV-2 Xingjian, LIV-3 Taichong, KI-2 Rangu, BL-17 Geshu, SP-10 Xuehai, SP-6 Sanyinjiao, SP-9 Yinlingquan, BL-22 Sanjiaoshu. All with reducing or even method. He rbal tre atme nt
Prescription
• XIAO ZHI TANG Dissolving Haemorrhoids Decoction
Damp-Heat, Heart-Heat
Clinical manifestations Bleeding haemorrhoids, itching and swelling in the anus, mental restlessness, insomnia, thirst, palpitations. Tongue: Red, redder tip, sticky, yellow coating. Pulse: Slippery-Rapid. Treatment principle Resolve Dampness, clear Heat, clear Heart-Heat, calm the Mind. Acupuncture SP-6 Sanyinjiao, SP-9 Yinlingquan, BL-22 Sanjiaoshu, BL-32 Ciliao, BL34 Xialiao, HE-3 Shaohai, HE-8 Shaofu, BL-57 Chengshan, BL-58 Feiyang. All with reducing or even method. Explanation
– SP-6, SP-9 and BL-22 resolve Dampness. – BL-32 resolves Dampness from the Lower Burner. – BL-34 is a local point for haemorrhoids. – HE-3 and HE-8 clear Heart-Heat. – BL-57 and BL-58 are empirical points for haemorrhoids.
Herbal treatment
Prescription
– CHUN GEN HONG HUA TANG – Ailanthus-Carthamus Decoction Explanation
– Chun Gen Bai Pi stops bleeding. – Hong Hua and Dang Gui nourish and invigorate Blood. – Deng Xin Cao drains Damp-Heat and clears Heart-Heat. – Zhu Ye clears Heart-Heat. – Gan Cao harmonizes. Summary Damp-Heat, Heart-Heat
Clinical manife stations
Bleeding haemorrhoids, itching and swelling in the anus, mental restlessness, insomnia, thirst, palpitations. Tongue: Red, redder tip, sticky, yellow coating. Pulse: Slippery-Rapid.
Tre atme nt principle
Resolve Dampness, clear Heat, clear Heart-Heat, calm the Mind. Acupuncture
SP-6 Sanyinjiao, SP-9 Yinlingquan, BL-22 Sanjiaoshu, BL-32 Ciliao, BL34 Xialiao, HE-3 Shaohai, HE-8 Shaofu, BL-57 Chengshan, BL-58 Feiyang. All with reducing or even method. He rbal tre atme nt
Prescription
• CHUN GEN HONG HUA TANG Ailanthus-Carthamus Decoction
External haemorrhoids
Blood stasis, Qi stagnation, Blood-Heat, Damp-Heat
Clinical manifestations Intense anal pain, itching and swelling, bleeding, abdominal distension and pain. Tongue: Red or Reddish-Purple. Pulse: Rapid, Wiry, Slippery. Treatment principle Cool Blood, move Qi and eliminate stagnation, invigorate Blood and eliminate stasis, resolve Dampness. Acupuncture L.I.-11 Quchi, SP-10 Xuehai, BL-17 Geshu, LIV-3 Taichong, KI-2 Rangu, SP-6 Sanyinjiao, SP-9 Yinlingquan, BL-22 Sanjiaoshu, BL-57 Chengshan, BL-58 Feiyang, BL-34 Ciliao. All with reducing or even method. Explanation
– L.I.-11 and SP-10 cool and invigorate Blood. – BL-17 and LIV-3, in combination, invigorate Blood. – LIV-3 and KI-2, in combination, cool Blood. – SP-6, SP-9 and BL-22 resolve Dampness. – BL-57 and BL-58 are empirical points for haemorrhoids.
– BL-34 is a local point for haemorrhoids. Herbal treatment
a Prescription
– HUA YU LIAO ZHI TANG – Eliminating Stasis and Treating Haemorrhoids Decoction Explanation
– Huai Hua and Di Yu cool and invigorate Blood and stop bleeding. – Ku Shen resolves Dampness. – Mo Yao, Chi Shao, Mu Dan Pi, Tao Ren and Hong Hua invigorate Blood and eliminate stasis. – Yan Hu Suo moves Qi and eliminates stagnation. – Ji Xue Teng invigorates and nourishes Blood. b Prescription
– QU YU DING TONG TANG – Eliminating Stasis and Stopping Pain Decoction
Explanation
– Ru Xiang, Mo Yao, Chuan Niu Xi and Mu Dan Pi invigorate and cool Blood and eliminate stasis. – Mu Tong, Ze Xie and Chi Xiao Dou drain Damp-Heat. – Bai Zhi opens the orifices and helps to drain Dampness. Compared with the previous formula, the present one places a greater emphasis on draining Dampness. Summary Blood stasis, Qi stagnation, Blood-Heat, Damp-Heat
Clinical manife stations
Intense anal pain, itching and swelling, bleeding, abdominal distension and pain. Tongue: Red or Reddish-Purple. Pulse: Rapid, Wiry, Slippery. Tre atme nt principle
Cool Blood, move Qi and eliminate stagnation, invigorate Blood and eliminate stasis, resolve Dampness. Acupuncture
L.I.-11 Quchi, SP-10 Xuehai, BL-17 Geshu, LIV-3 Taichong, KI-2 Rangu, SP-6 Sanyinjiao, SP-9 Yinlingquan, BL-22 Sanjiaoshu, BL-57 Chengshan, BL-58 Feiyang, BL-34 Ciliao. All with reducing or even method. He rbal tre atme nt
Prescriptions
• HUA YU LIAO ZHI TANG Eliminating Stasis and Treating Haemorrhoids Decoction • QU YU DING TONG TANG Eliminating Stasis and Stopping Pain Decoction
Damp-Heat
Clinical manifestations Intense itching and swelling of the anus, bleeding, mucus in the stools, a feeling of heaviness in the rectum. Tongue: sticky, yellow coating. Pulse: Slippery and Rapid. Treatment principle Resolve Dampness and clear Heat. Acupuncture SP-6 Sanyinjiao, SP-9 Yinlingquan, BL-22 Sanjiaoshu, BL-34 Xialiao, BL32 Ciliao, BL-57 Chengshan, BL-58 Feiyang, Ren-12 Zhongwan, BL-20 Pishu. All with reducing or even method except for Ren-12 and BL-20 which should be needled with reinforcing method. Explanation
– SP-6, SP-9, BL-22 and BL-32 resolve Dampness. – BL-34 is a local point for haemorrhoids. – BL-57 and BL-58 are empirical points for haemorrhoids. – Ren-12 and BL-20 tonify the Spleen to resolve Dampness. Herbal treatment
Prescription
– DI YU HUANG BO FANG – Sanguisorba-Phellodendron Formula Explanation
– Chi Xiao Dou, Huang Bo and Cang Zhu drain Damp-Heat. Huang Bo and Cang Zhu form the prescription Er Miao San Two Wonderful Powder which drains Damp-Heat from the Lower Burner. – Sheng Di Huang and Di Yu cool Blood and stop bleeding. – Dang Gui invigorates Blood and helps the formula to enter the Blood portion. – Huai Jiao cools Blood and stops bleeding: it is specific to treat inflamed haemorrhoids. – Qin Jiao and Fang Feng resolve Dampness, expel Wind and stop itching. – Tao Ren invigorates Blood. – Bai Zhi opens the orifices and helps to resolve Dampness. Summary Damp-Heat
Clinical manife stations
Intense itching and swelling of the anus, bleeding, mucus in the stools, a feeling of heaviness in the rectum. Tongue: sticky, yellow coating. Pulse: Slippery and Rapid. Tre atme nt principle
Resolve Dampness and clear Heat. Acupuncture
SP-6 Sanyinjiao, SP-9 Yinlingquan, BL-22 Sanjiaoshu, BL-34 Xialiao, BL32 Ciliao, BL-57 Chengshan, BL-58 Feiyang, Ren-12 Zhongwan, BL-20 Pishu. All with reducing or even method except for Ren-12 and BL-20 which should be needled with reinforcing method. He rbal tre atme nt
Prescription
• DI YU HUANG BO FANG Sanguisorba-Phellodendron Formula
CHAPTER 51 Fever after Childbirth
AETIOLOGY AND PATHOLOGY 639 IDENTIFICATION OF PATTERNS AND TREATMENT 640 Invasion of external toxins 640 Invasion of external Wind 643 Blood deficiency 645 Blood stasis 646 Steaming breast 647 Retention of food 648 PROGNOSIS AND PREVENTION 649 WESTERN VIEW 649 Fever after Childbirth may consist in a fever that is continuous but relatively low or in one that is sudden and high. If a slight temperature appears 1 or 2 days after childbirth and there are no other symptoms, it may not indicate any specific pathology but simply a temporary imbalance between Nutritive and Defensive Qi resulting from the strain of labour; this will not require treatment. A slight fever that appears 3 or 4 days after childbirth and in between breastfeeding sessions is called zheng ru, meaning ‘steaming breast’, and is not pathological: this will disappear after a few days. Thus, Fever after Childbirth can be defined as a temperature of at least 38°C (100°F) that is persistent, that does not abate on its own and that is accompanied by other symptoms and signs.
Aetiology and pathology After childbirth, the Upright Qi (Zheng Qi) is weakened, the Nutritive (Ying) and Defensive (Wei) Qi are out of balance with each other and the mother is therefore prone to invasions of Exterior pathogenic factors which may cause a fever. Internal factors such as deficiency of Blood or Yin may also cause a fever. Invasion of external toxins After childbirth the Upright Qi is weakened, resistance to disease is lowered, the Blood is exhausted and the blood vessels and channels are Empty and therefore prone to being invaded by external toxins. This concept corresponds to bacterial infections of the genital tract after childbirth. The fever is caused by the reaction of the Upright Qi against the external toxins. In the old times in China, this was a very frequent occurrence after childbirth due to poor hygienic procedures during and after labour. External invasion of Wind-Heat After childbirth the body’s Qi is weakened, the Nutritive and Defensive Qi are out of balance and the body is easily invaded by external Wind: the fight between the Upright Qi and the external Wind on the Exterior of the body causes a fever. Severe blood loss during labour Severe blood loss during labour causes exhaustion of Blood and/or Yin, Yang floats upwards and causes a fever: this is a fever of internal origin and is quite different in nature from the previous two. In the previous two cases the fever is due to the struggle between the Upright Qi and external pathogenic
factors; in the case of Blood/Yin deficiency, fever is caused by the floating upwards of Yang and it is a sign of weakness. Surgery, emotional problems Caesarian birth may cause stasis of Blood. Emotional problems before or after childbirth may cause stagnation of Qi which also leads to Blood stasis. If stagnant Blood generates Heat, this may cause a fever of internal origin. Retention of food A woman needs to eat nourishing and Blood-forming food after childbirth, but it should also be easily digestible because Spleen-Qi is weakened by the strain of labour. Eating too much after childbirth may therefore lead to retention of food: when food stagnates in the Stomach and Intestines, it gives rise to Heat and may cause a fever. This process, common in children, is usually rare in adults, except in women after childbirth due to the weakened state of their digestive system. When confronted with a feverish woman after childbirth, the first thing to establish is whether the fever is of external or internal origin. External fevers are due to invasion of either ‘toxins’ (corresponding to bacterial infections in Western medicine) or external Wind: in such cases, fever is due to the struggle between the Upright Qi and the pathogenic factors and it is a sign that the body is reacting. Of these two cases, invasion by external toxins is much more serious than that from external Wind. In internal fevers, the fever is the end result of a pathological process and it does not indicate that the body is reacting to any pathogenic factor. For example, fever from Blood/Yin deficiency is due to Yang floating to the surface and to its ‘detachment’ from Yin: this is a sign of weakness, not a sign of reaction of the persons’s Upright Qi. As for diagnosis, this must be based on the degree and timing of the fever, the character and appearance of the lochial discharge, the presence or
absence of abdominal pain, headache or bodyaches, any breast pathology, the tongue and the pulse. Thus, a fever of external origin is accompanied by shivers: if it is from external toxins, the fever may be high and the lochial discharge foul-smelling; if from invasion of external Wind, the fever will be low and accompanied by bodyaches, headache and stiff neck. Fevers from internal origin occur without shivers. If the fever is caused by stasis of Blood, the lochial discharge will be scanty with clots, or may not occur at all, and there will be abdominal pain. If the fever derives from Blood/Yin deficiency with Yang floating, it will be accompanied by prostration, exhaustion, sweating and dizziness. Clinical Note • Shivers, aversion to cold, low fever, bodyaches, headache, stiff neck: fever from external invasion of Wind • Shivers, aversion to cold, high fever, foul-smelling lochial discharge: fever from external toxins • Scanty lochial discharge, clots, abdominal pain: fever from Blood stasis • Prostration, exhaustion, night sweating, dizziness: fever from Yin deficiency
Identification of patterns and treatment The treatment principle depends entirely on the origin of the fever: in external fevers one must clear Heat or Wind-Heat, release the Exterior and harmonize the Nutritive and Defensive Qi. In internal fevers, one must clear Heat, and invigorate Blood or nourish Blood and Yin. The patterns discussed are: • invasion of external toxins • invasion of external Wind • Blood deficiency • Blood stasis • steaming breast • retention of food.
Invasion of external toxins
Clinical manifestations High fever after childbirth, hypogastric pain which is worse with pressure, scanty lochial discharge that is dark purple and smelling like soya sauce, mental restlessness, agitation, thirst, in severe cases delirium or even convulsions, scanty, dark urine, constipation. Tongue: Red with Red points and a thick, sticky, yellow coating. Pulse: Slippery, Overflowing, Rapid. Treatment principle Clear Heat, drain Fire, resolve Toxin, cool Blood, invigorate Blood, eliminate stasis. Acupuncture L.I.-11 Quchi, P-3 Quze, KI-2 Rangu, LIV-3 Taichong, SP-9 Yinlingquan, Du-14 Dazhui. All with reducing method, no moxa. Explanation
– L.I.-11 clears Heat and resolves Toxin. – P-3 cools Blood. – KI-2 and LIV-3, in combination, cool Blood. LIV-3 also invigorates Blood. – SP-9 helps to resolve Toxin.
– Du-14 clears Heat. Herbal treatment
a Prescription
– WU WEI XIAO DU YIN and SHI XIAO SAN – Five Ingredient Dissolving Toxin Decoction and Breaking into a Smile Powder Explanation The first five ingredients constitute the formula Wu Wei Xiao Du Yin, with all its ingredients resolving Toxic-Heat. – Pu Huang and Wu Ling Zhi invigorate Blood and eliminate stasis. b Prescription
– JIE DU HUO XUE TANG Variation – Expelling Toxin Invigorating Blood Decoction Variation Explanation The first eleven herbs constitute the formula Jie Du Huo Xue Tang which resolves Toxic-Heat and invigorates and cools Blood.
– Lian Qiao, Ge Gen, Chai Hu and Gan Cao clear Heat and resolve Toxic-Heat. – Sheng Di Huang, Chi Shao and Dang Gui cool and harmonize Blood. – Hong Hua and Tao Ren invigorate Blood and eliminate stasis. – Zhi Ke moves Qi to help to invigorate Blood. – Bai Shao pacifies the Liver and harmonizes Blood. Together with Gan Cao it also stops pain and moderates urgency. – Jin Yin Hua has been added to resolve Toxic-Heat. Compared with the previous formula, the present one has a stronger action in cooling Blood and clearing Empty-Heat: it is therefore suitable if the tongue coating is beginning to fall off and the tongue body is becoming peeled. c Prescription
– DA HUANG MU DAN TANG Variation – Rheum-Moutan Decoction Variation Explanation The first five herbs constitute the formula Da Huang Mu Dan Tang which resolves Toxic-Heat and cools Blood. Taken from the Discussion of Coldinduced Diseases, it is specific for intestinal abscess with high fever. It is therefore well suited to treat high fever after childbirth deriving from a genital infection. The tongue presentation appropriate to this formula is a Red body with Red points with a thick, yellow coating.
– Da Huang and Mang Xiao drain Fire, resolve Toxic-Heat and invigorate Blood. – Mu Dan Pi and Tao Ren invigorate and cool Blood. – Dong Gua Ren drains Damp-Heat and helps to resolve Toxic-Heat – Bai Jiang Cao and Hong Teng resolve Toxic-Heat. – Yi Yi Ren drains Damp-Heat and resolves Toxic-Heat. Compared with the previous two formulae, the present one is for a severe condition of genital infection after childbirth with a dark Red tongue and an Overflowing, Rapid pulse. It may be considered a variation of the prescription Tao He Cheng Qi Tang Persica Conducting Qi Decoction which is for Fire at the Qi level (within the Identification of Patterns according to the Four Levels) with stasis of Blood. Modifications
• If there are symptoms of Heat at the Qi level (Bright-Yang Channel pattern), such as profuse sweating, intense thirst, Big pulse and high fever, add Shi Gao Gypsum, Zhi Mu Rhizoma Anemarrhenae and Tian Hua Fen Radix Trichosanthis. • If there are symptoms of Fire at the Qi level (Bright-Yang Organ pattern), such as constipation and abdominal fullness and pain, add (or increase) Da Huang Radix et Rhizoma Rhei and Mang Xiao Sulfas Natrii. • If there are symptoms of Dampness, add (or increase) Yin Chen Hao Herba Artemisiae scopariae and Yi Yi Ren Semen Coicis. • If there are symptoms of Blood-Heat such as maculae and a Red tongue without coating, add or increase Mu Dan Pi Cortex Moutan, Chi Shao
Radix Paeoniae rubra, Sheng Di Huang Radix Rehmanniae and Xuan Shen Radix Scrophulariae. Table 51.1 compares and contrasts the above three formulae. Table 51.1 Comparison of three formulae for Fever after Childbirth from invasion of toxins
As can be seen from reading the modifications listed above, this pattern can be analysed in the light of the Identification of Patterns according to the Four Levels. In most cases, the pattern will be Heat at the Qi level which can manifest itself in two ways, i.e. Stomach-Heat (identical with the Bright-Yang Channel pattern in the Identification of Patterns according to the Six Stages) or Intestines Dry-Heat (identical with the Bright-Yang Organ pattern in that Identification). The Qi level is characterized by strong Heat but also by the reaction of the body against infection, hence the fever. A condition at the Qi level is never life-threatening. The treatment principle at the Qi level differs according to whether there is Heat (as in Stomach-Heat) or Fire (as in Dry-Heat in Stomach and Intestines): in the former case, one must clear Stomach-Heat with cold, pungent herbs (such as Shi Gao Gypsum) to push it outwards; in
the latter case, one must drain Fire by using bitter, cold herbs (such as Da Huang Radix et Rhizoma Rhei) that drain it downwards by purgation. At the Nutritive Qi level, the Heat penetrates deeper into the Interior and it burns the body fluids giving rise to some Yin deficiency. At the Blood level, the Heat is at its deepest; in the Blood portion, the Yin is injured and internal Wind may develop. The Nutritive Qi and Blood levels are similar in character but the Blood level is typically characterized by mental confusion, bleeding and maculae. The treatment principle at the Nutritive Qi level is to clear Ying and nourish Yin; at the Blood level, it is to clear Empty-Heat, cool Blood, nourish Yin, stop bleeding and extinguish Wind if necessary. Contrary to the Qi level, a condition at the Nutritive Qi and Blood level may be lifethreatening. Apart from the symptoms, the tongue is important in identifying the level: at the Qi level, the tongue is Red, with Red points and with a thick, dry, dark yellow or brown coating; at the Nutritive Qi level and the Blood level, it begins to lose its coating and becomes dark Red with Red points and dry. Table 51.2 will clarify the symptoms and formulae applicable at each level. Table 51.2 Symptoms and formulae for Qi, Nutritive Qi and Blood levels of the Four Levels
Summary Invasion of external toxins
Clinical manife stations
High fever after childbirth, hypogastric pain which is worse with pressure, scanty lochial discharge that is dark purple and smelling like soya sauce, mental restlessness, agitation, thirst, in severe cases delirium or even convulsions, scanty, dark urine, constipation. Tongue: Red with Red points and a thick, sticky, yellow coating. Pulse: Slippery, Overflowing, Rapid. Tre atme nt principle
Clear Heat, drain Fire, resolve Toxin, cool Blood, invigorate Blood, eliminate stasis. Acupuncture
L.I.-11 Quchi, P-3 Quze, KI-2 Rangu, LIV-3 Taichong, SP-9 Yinlingquan, Du-14 Dazhui. All with reducing method, no moxa. He rbal tre atme nt
Prescriptions
• WU WEI XIAO DU YIN and SHI XIAO SAN Five Ingredient Dissolving Toxin Decoction and Breaking into a Smile Powder • JIE DU HUO XUE TANG Variation Expelling Toxin Invigorating Blood Decoction Variation • DA HUANG MU DAN TANG Variation Rheum-Moutan Decoction Variation
Invasion of external Wind
Clinical manifestations Wind-Cold: fever after childbirth, shivers, headache, stiff neck, bodyaches, no sweating, runny nose, sneezing, cough. Tongue: thin, white coating. Pulse: Floating, Tight. Wind-Heat: fever after childbirth, sore throat, slight thirst, runny nose with yellow discharge, headache, shivers, slight sweating, cough. Tongue: slightly Red sides. Pulse: Floating, slightly Rapid. Treatment principle Nourish Blood, expel Wind-Cold or Wind-Heat, release the Exterior. Acupuncture LU-7 Lieque, L.I.-4 Hegu, T.B.-5 Waiguan, LU-11 Shaoshang, Du-14 Dazhui, BL-12 Fengmen, BL-17 Geshu. All with reducing method, except for Geshu which should be needled with reinforcing method. Explanation
– LU-7, L.I.-4 and T.B.-5 expel Wind and release the Exterior. – LU-11 expels Wind-Heat and eases the throat. – Du-14 expels Wind-Heat. – BL-12, with cupping, expels Wind.
– BL-17 nourishes Blood. Herbal treatment
a Prescription
– JING FANG SI WU TANG – Schizonepeta-Ledebouriella Four Substances Decoction Explanation The first four herbs constitute the formula Si Wu Tang which nourishes Blood. – Jing Jie, Fang Feng and Zi Su Ye expel Wind-Cold and release the Exterior. This formula is for Wind-Cold. b Prescription
– YIN QIAO SAN Variation – Lonicera-Forsythia Powder Variation Explanation The first nine herbs constitute the formula Yin Qiao San which expels WindHeat and releases the Exterior.
– Dang Gui and Bai Shao nourish Blood. This formula is for Wind-Heat. c Prescription
– GUI ZHI CHAI HU TANG1 – Ramulus Cinnamomi-Bupleurum Decoction Explanation
– Gui Zhi and Bai Shao harmonize Nutritive and Defensive Qi, ease the muscles, regulate the pores, stop sweating and expel Wind. – Sheng Jiang and Da Zao have the same function as above. – Chai Hu and Huang Qin harmonize the Lesser Yang. – Ban Xia and Dang Shen tonify Qi and harmonize the Centre. – Zhi Gan Cao harmonizes. This formula is a combination of Gui Zhi Tang Ramulus Cinnamomi Decoction and Xiao Chai Hu Tang Small Bupleurum Decoction: the former expels Wind by harmonizing Nutritive and Defensive Qi, regulating the pores and stopping sweating (it is therefore used if the patient is sweating slightly); the latter harmonizes the Lesser Yang and is indicated when the patient alternates between feeling cold and feeling hot. Modifications
• If there is a pronounced headache and stiff neck, add Qiang Huo Rhizoma seu Radix Notopterygii and Ge Gen Radix Puerariae. • If there are pronounced bodyaches, add Du Huo Radix Angelicae pubescentis. Three Treasures remedies
– EXPEL WIND-COLD This remedy expels Wind-Cold and releases the Exterior. The tongue presentation appropriate to this remedy is a thin, white coating. – EXPEL WIND-HEAT This remedy is a variation of the formula Yin Qiao San LoniceraForsythia Powder and it expels Wind-Heat and releases the Exterior. The tongue presentation appropriate to this remedy is a body that is slightly Red on the sides and/or front part. Summary Invasion of external Wind
Clinical manifestations
Wind-Cold: fever after childbirth, shivers, headache, stiff neck, bodyaches, no sweating, runny nose, sneezing, cough. Tongue: thin, white coating. Pulse: Floating, Tight. Wind-Heat: fever after childbirth, sore throat, slight thirst, runny nose with yellow discharge, headache, shivers, slight sweating, cough. Tongue: slightly Red sides. Pulse: Floating, slightly Rapid.
Treatment principle
Nourish Blood, expel Wind-Cold or Wind-Heat, release the Exterior. Acupuncture
LU-7 Lieque, L.I.-4 Hegu, T.B.-5 Waiguan, LU-11 Shaoshang, Du-14 Dazhui, BL-12 Fengmen, BL-17 Geshu. All with reducing method, except for Geshu which should be needled with reinforcing method. Herbal treatment
Pre scriptions
• JING FANG SI WU TANG Schizonepeta-Ledebouriella Four Substances Decoction • YIN QIAO SAN Variation Lonicera-Forsythia Powder Variation • GUI ZHI CHAI HU TANG Ramulus Cinnamomi-Bupleurum Decoction Three Treasures remedies
• EXPEL WIND-COLD • EXPEL WIND-HEAT
Blood deficiency
Clinical manifestations Continuous low-grade fever after childbirth, sweating, blurred vision, dizziness, exhaustion, palpitations, insomnia, malar flush, tingling in the limbs. Tongue: Pale and Thin. Pulse: Choppy. Treatment principle Tonify Qi, nourish Blood, subdue floating Yang. Acupuncture Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, LIV8 Ququan, BL-17 Geshu, T.B.-5 Waiguan. All with reinforcing method except for T.B.-5 which should be needled with reducing method. Explanation
– Ren-12, ST-36 and SP-6 tonify Qi and Blood. – Ren-4 nourishes Blood. – LIV-8 nourishes Liver-Blood. – BL-17 tonifies Blood. – T.B.-5 subdues the floating Yang.
Herbal treatment
a Prescription
– BA ZHEN TANG Variation – Eight Precious Decoction Variation Explanation The first seven herbs constitute Ba Zhen Tang (minus Chuan Xiong) which tonifies Qi and nourishes Blood. – Huang Qi is added to tonify Qi. Modifications
• If there is insomnia, anxiety and palpitations, add Bai Zi Ren Semen Platycladi, Suan Zao Ren Semen Ziziphi spinosae and Ye Jiao Teng Caulis Polygoni multiflori. • If there is sweating, add Fu Xiao Mai Fructus Tritici levis. • If Blood deficiency is turning into Yin deficiency (with malar flush, feeling of heat in the evening, five-palm heat and night sweating), add Sheng Di Huang Radix Rehmanniae, Gui Ban Plastrum Testudinis and Di Gu Pi Cortex Lycii. b Prescription
– YI GUAN JIAN Variation – One Linking Decoction Variation Explanation The first six herbs constitute the formula Yi Guan Jian which nourishes LiverYin. – Gui Ban nourishes Liver- and Kidney-Yin, nourishes the Directing and Penetrating Vessels and subdues floating Yang. – Qing Hao clears Empty-Heat. Modifications
• If there are pronounced symptoms of Empty-Heat, add Zhi Mu Rhizoma Anemarrhenae and Di Gu Pi Cortex Lycii. Three Treasures remedies
– BRIGHTEN THE EYES This remedy nourishes Blood and tonifies the Liver and Kidneys. It is particularly suited to treat low-grade fever deriving from Blood deficiency as it contains herbs that clear Heat on the superficial energetic layers. The tongue presentation appropriate to this remedy is a Pale and Thin body. – ROOT THE SPIRIT This remedy nourishes Liver- and Kidney-Yin, settles the Ethereal Soul
and promotes sleep. It is suited to treat low-grade fever from Yin deficiency as it nourishes Yin and sinks floating Yang. The tongue presentation appropriate to this remedy is a Red and peeled body. Women’s Treasure remedy
– PRECIOUS SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. It has been modified with the addition of Kidney tonics. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Blood deficiency
Clinical manifestations
Continuous low-grade fever after childbirth, sweating, blurred vision, dizziness, exhaustion, palpitations, insomnia, malar flush, tingling in the limbs. Tongue: Pale and Thin. Pulse: Choppy. Treatment principle
Tonify Qi, nourish Blood, subdue floating Yang. Acupuncture
Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, LIV8 Ququan, BL-17 Geshu, T.B.-5 Waiguan. All with reinforcing method
except for T.B.-5 which should be needled with reducing method. Herbal treatment
Pre scriptions
• BA ZHEN TANG Variation Eight Precious Decoction Variation • YI GUAN JIAN Variation One Linking Decoction Variation Three Treasures remedies
• BRIGHTEN THE EYES • ROOT THE SPIRIT Women’s Treasure remedy
• PRECIOUS SEA
Blood stasis
Clinical manifestations Fever after childbirth, feeling of heat, absence of lochial discharge or scanty, dark discharge with clots, lower abdominal pain which is worse with pressure, dry mouth with no desire to drink. Tongue: Reddish-Purple. Pulse: Wiry or Firm. Treatment principle Invigorate Blood, eliminate stasis, cool Blood. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, BL-17 Geshu, SP-6 Sanyinjiao, KI-14 Siman, ST-29 Guilai, LIV-3 Taichong, L.I.-11 Quchi. All with reducing or even method. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel and invigorate Blood. – SP-10 and BL-17 invigorate Blood and eliminate stasis. – SP-6 invigorates Blood. – KI-14, a point of the Penetrating Vessel, invigorates Blood and treats abdominal pain.
– ST-29 invigorates Blood and promotes the expulsion of lochia. – LIV-3 invigorates Blood. – L.I.-11 clears Heat and, in combination with SP-10, cools Blood. Herbal treatment
a Prescription
– SHENG HUA TANG Variation – Generating and Resolving Decoction Variation Explanation The first five herbs constitute the formula Sheng Hua Tang which invigorates Blood, eliminates stasis and promotes the discharge of lochia. – Dan Shen and Yi Mu Cao are added to increase the Blood-invigorating effect. – Mu Dan Pi invigorates and cools Blood and clears Empty-Heat. b Prescription
– DAN GUI HUO XUE TANG – Salvia-Angelica Invigorating Blood Decoction
Explanation
– Dan Shen, Chi Shao, Hong Hua, Chuan Xiong and Tao Ren invigorate Blood and eliminate stasis. – Dang Gui nourishes and invigorates Blood. – Gan Cao harmonizes. Three Treasures remedy
– STIR FIELD OF ELIXIR This remedy invigorates Blood and eliminates stasis in the Lower Burner. The tongue presentation appropriate to this remedy is a Purple body. Summary Blood stasis
Clinical manifestations
Fever after childbirth, feeling of heat, absence of lochial discharge or scanty, dark discharge with clots, lower abdominal pain which is worse with pressure, dry mouth with no desire to drink. Tongue: Reddish-Purple. Pulse: Wiry or Firm. Treatment principle
Invigorate Blood, eliminate stasis, cool Blood.
Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, BL-17 Geshu, SP-6 Sanyinjiao, KI-14 Siman, ST-29 Guilai, LIV-3 Taichong, L.I.-11 Quchi. All with reducing or even method. Herbal treatment
Pre scriptions
• SHENG HUA TANG Variation Generating and Resolving Decoction Variation • DAN GUI HUO XUE TANG Salvia-Angelica Invigorating Blood Decoction Three Treasures remedy
• STIR FIELD OF ELIXIR
Steaming breast
Clinical manifestations Low-grade fever 2 or 3 days after childbirth, breast milk which does not flow freely or no milk at all, distension, hardness and pain in the breasts which feel lumpy. Tongue: sticky coating. Pulse: Wiry. This pattern is due to stagnation of Qi and Damp-Heat affecting the breast and preventing a proper flow of milk. Treatment principle Move Qi, eliminate stagnation, remove obstructions from the Connecting channels, promote lactation. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), BL-51 Huangmen, G.B.-41 Zulinqi, T.B.-6 Zhigou, ST-18 Rugen, S.I.-1 Shaoze, LIV-3 Taichong. All with reducing or even method. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel and remove obstructions from the Connecting channels of the breasts. – BL-51 is the point that controls the exiting of the Triple Burner’s Qi from the space between the kidneys on its way upwards and that removes obstructions from the Connecting channels over the breasts.
– G.B.-41 drains Damp-Heat and affects the breasts. – T.B.-6 moves Qi and eliminates stagnation and affects the areas lateral to the breasts. – LIV-3 moves Qi and eliminates stagnation. – ST-18 is a local point for the breasts and promotes lactation. – S.I.-1 is an empirical point to promote lactation. Herbal treatment
Prescription
– TONG JING HUO LUO TANG – Penetrating the Menses and Invigorating the Connecting Channels Decoction Explanation
– Xiang Fu and Qing Pi move Qi and eliminate stagnation. – Si Gua Luo and Tong Cao remove obstructions from the Connecting channels and affect the breasts. They also promote lactation. – Gua Lou resolves Phlegm and affects the breasts. – Dang Gui nourishes Blood.
– Bian Dou drains Dampness and strengthens the Spleen. – Ju Luo moves Qi, resolves Dampness and removes obstructions from the Connecting channels. Modifications
• If there is pain and distension of the breasts, add Lou Lu Radix Rhapontici, Lu Lu Tong Fructus Liquidambaris and Wang Bu Liu Xing Semen Vaccariae. • If there is pain in the breasts and Heat symptoms, add Huang Qin Radix Scutellariae and Pu Gong Ying Herba Taraxaci. Summary Steaming breast
Clinical manife stations
Low-grade fever 2 or 3 days after childbirth, breast milk which does not flow freely or no milk at all, distension, hardness and pain in the breasts which feel lumpy. Tongue: sticky coating. Pulse: Wiry. Tre atme nt principle
Move Qi, eliminate stagnation, remove obstructions from the Connecting channels, promote lactation. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), BL-51 Huangmen, G.B.-41 Zulinqi, T.B.-6 Zhigou, ST-18 Rugen, S.I.-1 Shaoze,
LIV-3 Taichong. All with reducing or even method. He rbal tre atme nt
Prescription
• TONG JING HUO LUO TANG Penetrating the Menses and Invigorating the Connecting Channels Decoction
Retention of food
Clinical manifestations Low-grade fever 3 or 4 days after childbirth, fever higher in the afternoon, digestive upset after childbirth, a feeling of fullness and distension in the epigastrium, sour regurgitation, belching, foul breath. Tongue: thick, sticky, yellow coating. Pulse: Slippery. Treatment principle Dissolve food accumulation, clear Stomach-Heat. Acupuncture Ren-11 Jianli, Ren-10 Xiawan, ST-21 Liangmen, ST-19 Burong, L.I.-4 Hegu, ST-40 Fenglong, L.I.-11 Quchi, ST-44 Neiting, ST-34 Liangqiu. All with reducing or even method. No moxa. Explanation
– Ren-11 clears Stomach-Heat and dissolves food accumulation. – Ren-10 promotes the descending of Stomach-Qi. – ST-21 clears Stomach-Heat. – ST-19 dissolves food accumulation. – L.I.-4 harmonizes the ascending and descending of Stomach-Qi.
– ST-40, in combination with L.I.-4, harmonizes the ascending and descending of Stomach-Qi. – L.I.-11 is used if Heat is pronounced. – ST-44 clears Stomach-Heat. – ST-34, Accumulation point of the Stomach, dissolves food accumulation. Herbal treatment
Prescription
– BAO HE WAN – Preserving and Harmonizing Pill Explanation
– Lai Fu Zi, Shen Qu and Shan Zha promote the digestion of food and dissolve food accumulation. – Ban Xia, Fu Ling and Chen Pi resolve Dampness which helps to dissolve food accumulation. – Lian Qiao clears Stomach-Heat. Summary Retention of food
Clinical manife stations
Low-grade fever 3 or 4 days after childbirth, fever higher in the afternoon, digestive upset after childbirth, a feeling of fullness and distension in the epigastrium, sour regurgitation, belching, foul breath. Tongue: thick, sticky, yellow coating. Pulse: Slippery. Tre atme nt principle
Dissolve food accumulation, clear Stomach-Heat. Acupuncture
Ren-11 Jianli, Ren-10 Xiawan, ST-21 Liangmen, ST-19 Burong, L.I.-4 Hegu, ST-40 Fenglong, L.I.-11 Quchi, ST-44 Neiting, ST-34 Liangqiu. All with reducing or even method. No moxa. He rbal tre atme nt
Prescription
• BAO HE WAN Preserving and Harmonizing Pill
Prognosis and prevention Generally speaking, acupuncture and herbs give good results in Fever after Childbirth; herbal treatment is usually more effective than acupuncture, especially if there is a deficiency of Blood or Yin. The pattern from external invasions of toxins is the most difficult to treat and, in severe cases, the treatment should be combined with Western medicine with the administration of antibiotics (see below). A woman should take particular care after childbirth as the Blood is exhausted, the vessels and channels are devoid of Blood, the space between the skin and muscles is Empty and the woman is prone to invasions of pathogenic factors. It is therefore very important that she rests enough, that she eats well and that she is not exposed to cold, wind or dampness.
Western view The causes of pyrexia (fever) after childbirth are: • genital tract infection • urinary tract infection • breast infection • thrombophlebitis • respiratory tract infection. Genital tract infection Genital tract infection was the scourge of women in hospitals in the past. Before Western medicine gained an understanding of infection, this was transmitted by birth attendants to the mother through lack of hygiene. Genital tract infection is always a possibility after childbirth because, after delivery, where the placenta separates, the uterine wall has a raw area that is basically like a large, open wound: this is very prone to be attacked by bacteria. Other wounds may develop further down the birth canal resulting from delivery. The organisms invading the birth canal may be endogenous (present in the body) such as enterococci, or exogenous such as haemolytic streptococci and staphylococci. Infection may be classified as mild when it is restricted to the birth canal, moderate when it affects the tubes and peritoneum, and severe when it can cause blood septicaemia (this would be the equivalent of Toxic-Heat at the Blood level in Chinese medicine). The main symptom of genital tract infection is fever. From a Western perspective, a fever starting about 24 hours after delivery and persisting should always be assumed to be due to birth canal infection until proven otherwise. The treatment is based on the administration of antibiotics.
Urinary tract infection Infection of the urinary tract is the commonest cause of fever after childbirth: caused by infection with Escherichia coli, it presents with urinary symptoms such as burning on urination, difficulty and a dark urine. Breast infection The infecting organism is Staphylococcus aureus. There is pain in the breasts and a fever which may be as high as 40°C (104°F). Thrombophlebitis Fever from thrombophlebitis usually starts from the fourth to the tenth day after delivery. The fever is low grade. Respiratory tract infection In respiratory tract infection, the fever may be either low or high. There are respiratory infection symptoms such as cough, breathlessness and chest soreness. End note 1. Hu Xi Ming 1990 Great Treatise of Secret Formulae in Chinese Medicine (Zhong Guo Zhong Yi Mi Fang Da Quan
), Culture Publishing House, Shanghai, Vol. 2, p. 83..
CHAPTER 52 Joint Pain after Childbirth
AETIOLOGY 651 PATHOLOGY 651 IDENTIFICATION OF PATTERNS AND TREATMENT 652 Blood deficiency 652 Invasion of Wind 653 Blood stasis 654 Liver-Blood and Kidney-Yang deficiency 655 PROGNOSIS AND PREVENTION 656 Joint Pain after Childbirth includes pain, ache, soreness, numbness or feeling of heaviness in the joints, back or knees after childbirth. It pertains to the broad disease category of Painful Obstruction Syndrome but it has specific characteristics and pathology when it occurs after childbirth.
Aetiology
Severe blood loss during labour Profuse blood loss during labour leads to severe Blood deficiency after childbirth: the deficient Blood fails to nourish the channels and the sinews and this causes a dull ache of a deficient nature. Invasion of external Wind External Wind may invade the channels and settle in the joints causing Painful Obstruction Syndrome: a woman is more prone to such invasions after childbirth because the channels are in a weakened state due to Blood deficiency and the space between the skin and muscles is Empty due to Qi deficiency. Wind usually combines with either Cold or Dampness or both to cause joint pain. If Wind predominates, the ache will move from joint to joint. If Cold predominates, there is intense pain, and if Dampness predominates, there is numbness, tingling and a feeling of heaviness of the limbs. Emotional problems Emotional problems such as irritation, worry, frustration and resentment cause stagnation of Qi which, after childbirth, may easily lead to Blood stasis. Blood stagnating in the channels, especially in the joints, causes joint pain of a stabbing nature. Weak body condition If a woman suffers from a pre-existing weakness of the Kidneys and Liver,
this will be exacerbated after childbirth. The Kidneys influence the bones and the Liver the sinews, and these two tissues will lack nourishment: this will cause a dull pain of a deficient nature in the joints and especially in the lower back and knees.
Pathology The pathology of Joint Pain after Childbirth can be differentiated according to whether it is of an external or internal origin. When joint pain after childbirth is due to invasion of Wind, it is of external nature and its pathology is essentially the same as that of Painful Obstruction Syndrome. In the other cases of Blood deficiency and deficiency of Liver and Kidneys, the joint pain is caused by malnourishment of the channels, sinews and bones. Blood stasis, caused by stagnation of Qi and Blood in the channels, is always painful; the principle is that ‘obstruction causes pain’. From the point of view of deficiency/excess, the pain from invasion of Wind and from Blood stasis is of an excess nature, that from Blood deficiency and from Liver and Kidney deficiency is of a deficient nature. Pain of an excess nature is severe and stabbing if caused by Blood stasis; intense, fixed in one joint and cramping if caused by Cold; dull and with a feeling of heaviness if caused by Dampness; and dull and wandering from joint to joint if caused by Wind; it tends to improve with activity. Pain of a deficient nature is more like a dull ache and it improves with rest.
Identification of patterns and treatment The treatment principle must be clearly differentiated according to the pathology. In deficiency cases, the primary aim is to nourish Blood, tonify Liver and Kidneys and benefit sinews and bones; the secondary aim is to expel Wind, scatter Cold and resolve Dampness. In excess cases, the primary aim is to expel Wind, scatter Cold and resolve Dampness; the secondary aim is to nourish Blood. Even if the joint pain is from external Wind, it is important to nourish Blood after childbirth, because the deficiency of Blood renders the woman prone to invasions of Wind and because nourishing Blood helps to expel Wind from the channels. In cases of Blood stasis, the main treatment principle is to invigorate Blood and eliminate stasis. The patterns discussed are : • Blood deficiency • Invasion of Wind • Blood stasis • Liver-Blood and Kidney-Yang deficiency.
Blood deficiency
Clinical manifestations Dull ache in the joints after childbirth, numbness and tingling of limbs, dull complexion, dizziness, insomnia, blurred vision, tiredness. Tongue: Pale and Thin. Pulse: Choppy. Treatment principle Nourish Blood, tonify Qi, warm the channels, remove obstructions from the Connecting channels. Acupuncture ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, G.B.-34 Yanglingquan, L.I.-11 Quchi, T.B.-5 Waiguan, Ren-4 Guanyuan, BL-11 Dashu, BL-17 Geshu, BL-20 Pishu, BL-23 Shenshu. All with reinforcing method except for T.B.-5 which should be needled with even method. Moxa is applicable. Explanation
– ST-36 and SP-6 tonify Qi and Blood. – LIV-8 nourishes Liver-Blood. – G.B.-34, Gathering point for sinews, benefits the sinews. – L.I.-11 benefits the sinews.
– T.B.-5 expels Wind from the channels. – Ren-4, with moxa cones, nourishes Blood and strengthens the Original Qi. – BL-11, with moxa cones, nourishes Blood and expels Wind. It is the upper point of the Sea of Blood. – BL-17, with moxa cones, nourishes Blood. – BL-20 and BL-23 tonify Qi and Blood. Herbal treatment
Prescription
– HUANG QI GUI ZHI WU WU TANG Variation – Astragalus-Ramulus Cinnamomi Five Substances Decoction Variation Explanation
– Huang Qi tonifies Qi. – Bai Shao and Gui Zhi harmonize the Nutritive and Defensive Qi and regulate the space between the skin and muscles: by doing so, they promote the expulsion of any Wind that has invaded that space and prevent any further invasion.
– Sheng Jiang helps Gui Zhi to expel Wind from the space between skin and muscles and to harmonize Nutritive and Defensive Qi. – Da Zao helps Bai Shao to nourish the Nutritive Qi and regulate the space between skin and muscles. – Qin Jiao expels Wind from the channels. – Dang Gui nourishes Blood. – Ji Xue Teng nourishes Blood and benefits the sinews. Three Treasures remedy
– BROCADE SINEWS This remedy nourishes Blood and expels Wind-Dampness from the channels: it was formulated specifically for cases of Wind-Dampness in the joints occurring against a background of Blood deficiency. Summary Blood deficiency
Clinical manifestations
Dull ache in the joints after childbirth, numbness and tingling of limbs, dull complexion, dizziness, insomnia, blurred vision, tiredness. Tongue: Pale and Thin. Pulse: Choppy. Treatment principle
Nourish Blood, tonify Qi, warm the channels, remove obstructions from the Connecting channels. Acupuncture
ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, G.B.-34 Yanglingquan, L.I.-11 Quchi, T.B.-5 Waiguan, Ren-4 Guanyuan, BL-11 Dashu, BL-17 Geshu, BL-20 Pishu, BL-23 Shenshu. All with reinforcing method except for T.B.-5 which should be needled with even method. Moxa is applicable. Herbal treatment
Pre scription
• HUANG QI GUI ZHI WU WU TANG Variation Astragalus-Ramulus Cinnamomi Five Substances Decoction Variation Three Treasures remedy
• BROCADE SINEWS
Invasion of Wind
Clinical manifestations Pain in the joints with sudden onset, contractions of joints, pain relieved by movement. If Cold predominates, the pain is fixed in a joint, intense and ameliorated by the application of heat. If Wind predominates, the pain wanders from joint to joint. If Dampness predominates, the ache is dull and accompanied by a feeling of heaviness and tingling, and the joints are swollen. Tongue: no change. Pulse: no change. Treatment principle Nourish Blood, expel Wind, scatter Cold, resolve Dampness. Acupuncture LIV-8 Ququan, G.B.-34 Yanglingquan, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, BL-11 Dashu, Du-14 Dazhui, BL-12 Fengmen, T.B.-5 Waiguan, ST-43 Xiangu, BL-17 Geshu, SP-9 Yinlingquan, Ren-12 Zhongwan, Ren-6 Qihai. The points to nourish Blood with reinforcing method and those to expel Wind, Scatter Cold and resolve Dampness with reducing method. Explanation
– LIV-8, ST-36, SP-6, Ren-4 and BL-17 nourish Blood. – G.B.-34 benefits the sinews.
– BL-11, with moxa cones, nourishes Blood and expels Wind. – BL-12, with cupping, expels Wind. – Du-14 and T.B.-5 expel Wind. – ST-43 expels Wind. – SP-9 and Ren-12 resolve Dampness. – Ren-6, with moxa cones, expels Cold. Herbal treatment
Prescription
– DU HUO JI SHENG TANG – Angelica pubescens-Loranthus Decoction Explanation
– Du Huo and Sang Ji Sheng benefit the sinews and expel Wind. Sang Ji Sheng also nourishes Blood. – Xi Xin and Rou Gui scatter Cold. – Qin Jiao and Fang Feng expel Wind and resolve Dampness. – Niu Xi and Du Zhong tonify Liver and Kidneys and benefit sinews and bones.
– Dang Gui, Bai Shao, Chuan Xiong and Sheng Di Huang nourish Blood: this facilitates the expulsion of Wind. – Ren Shen, Fu Ling and Gan Cao tonify Qi. This prescription is warm in nature and it is more suitable if there is Cold in the joints and the tongue is Pale. Modifications
• If Dampness predominates, add Cang Zhu Rhizoma Atractylodis and Yi Yi Ren Semen Coicis. • If the symptoms of Cold are not pronounced and the tongue is Red, remove Rou Gui Cortex Cinnamomi and Xi Xin Herba Asari. • If the joint-aches are concentrated in the upper part of the body, replace Du Huo Radix Angelicae pubescentis with Qiang Huo Rhizoma seu Radix Notopterygii. Three Treasures remedy
– INVIGORATE THE ROOT This remedy is a variation of Du Huo Ji Sheng Tang above. Summary Invasion of Wind
Clinical manifestations
Pain in the joints with sudden onset, contractions of joints, pain relieved by movement. If Cold predominates, the pain is fixed in a joint, intense and ameliorated by the application of heat. If Wind predominates, the pain wanders from joint to joint. If Dampness predominates, the ache is dull and accompanied by a feeling of heaviness and tingling, and the joints are swollen. Tongue: no change. Pulse: no change. Treatment principle
Nourish Blood, expel Wind, scatter Cold, resolve Dampness. Acupuncture
LIV-8 Ququan, G.B.-34 Yanglingquan, ST-36 Zusanli, SP-6 Sanyinjiao, Ren-4 Guanyuan, BL-11 Dashu, Du-14 Dazhui, BL-12 Fengmen, T.B.-5 Waiguan, ST-43 Xiangu, BL-17 Geshu, SP-9 Yinlingquan, Ren-12 Zhongwan, Ren-6 Qihai. The points to nourish Blood with reinforcing method and those to expel Wind, Scatter Cold and resolve Dampness with reducing method. Herbal treatment
Pre scription
• DU HUO JI SHENG TANGAngelica pubescens-Loranthus Decoction Three Treasures remedy
• INVIGORATE THE ROOT
Blood stasis
Clinical manifestations Severe joint pain after childbirth, stiffness of joints, contraction of limbs, abdominal pain, scanty lochial discharge, dark complexion. Tongue: Purple. Pulse: Wiry or Firm. Treatment principle Move Qi, invigorate Blood, eliminate stasis. Acupuncture L.I.-11 Quchi, SP-10 Xuehai, BL-17 Geshu, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-6 Sanyinjiao, Du-8 Jinsuo, Ren-6 Qihai, T.B.-5 Waiguan, T.B.-6 Zhigou. All with reducing or even method. Explanation
– L.I.-11 benefits the sinews. – SP-10 and BL-17 invigorate Blood and eliminate stasis. – SP-4 and P-6 regulate the Penetrating Vessel and invigorate Blood. – SP-6 invigorates Blood. – Du-8 relaxes the sinews and relieves stiffness.
– Ren-6 moves Qi in the abdomen. – T.B.-5 treats Painful Obstruction Syndrome of the upper limbs. – T.B.-6 moves Qi. Herbal treatment
Prescription
– SHEN TONG ZHU YU TANG – Body-Aches Eliminating Stasis Decoction Explanation
– Qin Jiao and Qiang Huo expel Wind. – Chuan Xiong, Tao Ren, Hong Hua, Mo Yao, Wu Ling Zhi and Chuan Niu Xi invigorate Blood and eliminate stasis. – Dang Gui nourishes and invigorates Blood. – Xiang Fu moves Qi. – Di Long expels Wind from the channels and removes obstructions from the Connecting channels. – Gan Cao harmonizes. Summary
Blood stasis
Clinical manife stations
Severe joint pain after childbirth, stiffness of joints, contraction of limbs, abdominal pain, scanty lochial discharge, dark complexion. Tongue: Purple. Pulse: Wiry or Firm. Tre atme nt principle
Move Qi, invigorate Blood, eliminate stasis. Acupuncture
L.I.-11 Quchi, SP-10 Xuehai, BL-17 Geshu, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-6 Sanyinjiao, Du-8 Jinsuo, Ren-6 Qihai, T.B.-5 Waiguan, T.B.-6 Zhigou. All with reducing or even method. He rbal tre atme nt
Prescription
• SHEN TONG ZHU YU TANGBody-Aches Eliminating Stasis Decoction
Liver-Blood and Kidney-Yang deficiency
Clinical manifestations Dull joint-ache after childbirth especially in the knees and lower back, tiredness, dizziness, tinnitus, backache. Tongue: Pale and wet. Pulse: Deep, Weak. Treatment principle Tonify the Liver and Kidneys, remove obstructions from the Connecting channels, warm the channels and stop pain. Acupuncture BL-23 Shenshu, BL-18 Ganshu, Ren-4 Guanyuan, LIV-8 Ququan, KI-10 Yingu, LIV-7 Xiguan, G.B.-34 Yanglingquan, KI-3 Taixi, G.B.-39 Xuanzhong. All with reinforcing method; moxa is applicable. Explanation
– BL-23 and BL-18 tonify the Kidneys and Liver. – Ren-4 tonifies Liver and Kidneys and, with moxa cones, it tonifies Kidney-Yang. – LIV-8 nourishes Liver-Blood. – KI-10, with moxa cones, tonifies Kidney-Yang and benefits the knees.
– LIV-7 tonifies the Liver and benefits the knees. – G.B.-34 benefits the sinews. – KI-3 tonifies the Kidneys. – G.B.-39 benefits the bones and expels Wind. Herbal treatment
a Prescription
– YANG RONG ZHUANG SHEN TANG – Nourishing and Flourishing Strengthening the Kidneys Decoction Explanation The first eight herbs constitute the formula Yang Rong Zhuang Shen Tang. – Sang Ji Sheng and Dang Gui nourish Blood and expel Wind from the channels. – Xu Duan and Du Zhong tonify and warm Kidney-Yang. – Du Huo benefits the sinews and expels Wind from the channels, especially in the lower part of the body. – Fang Feng expels Wind. – Rou Gui and Sheng Jiang scatter Cold and warm the channels.
– Shu Di Huang nourishes Blood and tonifies the Kidneys. b Prescription
– EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan1 Explanation
– Yan Hu Suo, Tao Ren and Dang Gui nourish and invigorate Blood and stop pain. – Gui Zhi warms the channels and expels Cold. – Du Zhong and Xu Duan tonify Kidney-Yang. – Huai Niu Xi nourishes the Liver and Kidneys and benefits sinews and bones. – Rice wine expels Cold from the channels. Three Treasures remedy
– NOURISH THE ROOT AND CLEAR WIND This remedy nourishes Liver- and Kidney-Yin and benefits sinews and bones. The tongue presentation appropriate to this remedy is a Red body without coating. Summary
Liver-Blood and Kidney-Yang deficiency
Clinical manifestations
Dull joint-ache after childbirth especially in the knees and lower back, tiredness, dizziness, tinnitus, backache. Tongue: Pale and wet. Pulse: Deep, Weak. Treatment principle
Tonify the Liver and Kidneys, remove obstructions from the Connecting channels, warm the channels and stop pain. Acupuncture
BL-23 Shenshu, BL-18 Ganshu, Ren-4 Guanyuan, LIV-8 Ququan, KI-10 Yingu, LIV-7 Xiguan, G.B.-34 Yanglingquan, KI-3 Taixi, G.B.-39 Xuanzhong. All with reinforcing method; moxa is applicable. Herbal treatment
Pre scriptions
• YANG RONG ZHUANG SHEN TANGNourishing and Flourishing Strengthening the Kidneys Decoction • EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan Three Treasures remedy
• NOURISH THE ROOT AND CLEAR WIND
Prognosis and prevention Joint Pain after Childbirth reacts well to treatment with both acupuncture and herbs, but it may take some weeks to achieve an improvement. The sooner after childbirth the treatment is started, the better the results. The easiest pattern to treat is the one from Blood deficiency and the most difficult that from Blood stasis. Acupuncture is particularly useful in the treatment of this condition because it can treat the affected joints directly. As for prevention, it is very important for women to take extra care after childbirth and not be exposed to Cold, Wind or Dampness. They should also take enough rest so that Qi and Blood can recover from the strains of labour. There is no Western view of this condition. End note 1. Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 24. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang) and published in 1729..
CHAPTER 53 Breast Milk not Flowing (and Acute Mastitis)
AETIOLOGY 657 PATHOLOGY 657 IDENTIFICATION OF PATTERNS AND TREATMENT 658 Qi and Blood deficiency 658 Liver-Qi stagnation 660 Ancient acupuncture prescriptions for lack of milk 663 PROGNOSIS AND PREVENTION 663 WESTERN VIEW 663 APPENDIX: ACUTE MASTITIS 664 TREATMENT 665 This condition consists of scanty or absent breast milk after childbirth. I have preferred the term ‘Breast Milk not Flowing’ to ‘Insufficient Lactation’ or ‘Agalactia’ because the last two terms both imply a deficiency, a lack of a vital substance; lack of breast milk, however, may be due not to a deficiency of milk but to an obstruction or stagnation that prevents the flow of milk.
Aetiology
Severe blood loss during labour, long labour Profuse blood loss during labour leads to deficiency of Blood: since Blood is the source of breast milk, deficient lactation results. A long and difficult labour leads to depletion of Qi and this may result in insufficient lactation when there is not enough Qi to express the breast milk. Emotional problems Emotional problems such as worry, anger, frustration or resentment cause stagnation of Liver-Qi: the Liver influences the breast and controls the nipple, and stagnant Qi obstructs the Connecting channels of the breast so that the breast milk cannot flow.
Pathology The pathology of insufficient or absent lactation can be clearly differentiated between deficiency and excess: breast milk may be deficient because its source, Blood, is deficient; or there may be enough milk but it does not flow properly due to stagnation of Qi in the breast. Fu Qing Zhu places a special emphasis on distinguishing between the two main causes of insufficient lactation: a deficiency of Qi and Blood; or stagnation of Qi in the breast. He also places special emphasis on the role of Qi in lactation. To transform breast milk from Blood needs Qi’s action and to express it needs Qi’s power. This situation could be compared with that of water being pumped out of a reservoir: there may be plenty of water (breast milk) in the reservoir, but if the pump (Qi) is inefficient, the water will not flow. Fu Qing Zhu says: Breast milk is a product of the transformation of Qi and Blood. Milk cannot be generated without Blood, but it also cannot be generated without Qi … without Qi, breast milk cannot be transformed, without Blood it cannot be generated. Of the two, Blood is transformed into breast milk … In a woman after childbirth, Blood is exhausted … how can it be transformed into breast milk? It is due to the strength of Qi if Blood is transported and transformed into breast milk … if Qi is flourishing, milk is also flourishing, if Qi is depleted, milk is depleted.1 Breast milk is a product deriving from the transformation of menstrual Blood by the Directing and Penetrating Vessels (Ren and Chong Mai): these two vessels are the source of menstrual blood below, and of breast milk above. Zhang Jing Yue says in his Complete Works of Jing Yue (1624): Breast milk is a product of the transformation of the Qi and Blood of the Directing and Penetrating Vessels: downward movement of Qi and Blood produces the menses while upward movement produces milk. When there is insufficient lactation after childbirth, it is due to Qi
and Blood deficiency … which is due to the depletion of the Directing and Penetrating Vessels.2 The Stomach channel also plays a role in lactation as it controls the breast as a whole, while the Liver channel controls the nipple. Fu Qing Zhu says: “Breast milk is transformed from Yang Ming [channel] which pertains to Earth.”3 While the main Empty cause of insufficient lactation is deficiency of Qi and Blood, the main Full cause of insufficient lactation is stagnation of LiverQi. As mentioned above, the Liver controls the nipple and it easily overacts on the Bright-Yang Channels (Wood overacting on Earth). Lactation relies on the power of Qi to transform Blood into milk and to express the milk properly. When Liver-Qi stagnates, it may hinder the flow of Stomach-Qi in the breast and create stagnation there with symptoms of distension, pain and milk not flowing. Fu Qing Zhu emphasizes the role of stagnant Liver-Qi in hindering Stomach-Qi in the breast and it is significant that Dr Fu mentions “stagnation in the Bright Yang [Yang Ming]” rather than Liver-Qi stagnation. He says: Distension, fullness and pain in the breast show that [the breast] would like to transform the milk but cannot do so, what else beside stagnant Qi could cause this? The stagnation in Bright Yang is due to shame and resentment.4 Thus, Fu Qing Zhu clearly identifies emotional problems as the chief cause of stagnation of Liver-Qi. The Literati’s Care of their Parents (Ru Men Shi Qin) by Zhang Zi He (1156–1228) also says: “Crying, weeping, sadness, anger, depression, may all cause the breast vessels not to flow.”5 Thus, we can also see the pathology of Breast Milk not Flowing in terms of Qi and Blood, with the former either deficient or stagnant and the latter only deficient (see Figure 53.1).
Figure 53.1 Pathology of Breast Milk not Flowing. In terms of differential diagnosis, Breast Milk not Flowing should be distinguished from Breast Carbuncle (Ru Yong) which is also characterized by insufficient lactation but, in addition, by systemic signs such as shivers, fever, joint pain and a feeling of oppression of the chest: Breast Carbuncle corresponds to acute mastitis in Western medicine.
Identification of patterns and treatment The patterns discussed are: • Qi and Blood deficiency • Liver-Qi stagnation.
Qi and Blood deficiency
Clinical manifestations Insufficient or absent lactation after childbirth, watery milk, no feeling of distension of the breasts, sallow complexion, dry skin, poor appetite, tiredness. Tongue: Pale. Pulse: Choppy. Treatment principle Tonify Qi and Blood primarily: secondarily, remove obstructions from the breast Connecting channels. Acupuncture ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, G.B.-41 Zulinqi, ST-18 Rugen, ST-12 Quepen, Ren-4 Guanyuan, BL-20 Pishu, BL-23 Shenshu, S.I.-1 Shaoze, Ren-17 Shanzhong. All with reinforcing method. Moxa may be used. Explanation
– ST-36 and SP-6 tonify Qi and Blood. They are especially effective with warming needle. – LIV-8 nourishes Liver-Blood. – G.B.-41 removes obstructions from the breast Connecting channels. – ST-18 is a local point for the breast.
– ST-12 influences the breasts and stimulates the descending of StomachQi and the flow of milk. – Ren-4 nourishes Blood. – S.I.-1 is an empirical point for insufficient lactation. – BL-20 and BL-23 tonify Qi and Blood. – Ren-17 tonifies Qi in the chest which is necessary to express milk. Herbal treatment
a. Prescription
– TONG RU DAN – Penetrating the Breast Special Pill Explanation
– Ren Shen and Huang Qi tonify Qi. As explained above, Qi is necessary to express milk. – Dang Gui and Mai Men Dong nourish Blood and promote fluids. This is necessary because Blood is the source of milk. – Mu Tong removes obstructions from the breast Connecting channels. – Jie Geng acts as a messenger to direct the herbs to the Upper Burner.
– Pig’s trotter is a folk remedy to promote the production of breast milk. Traditionally in China the ‘seven-star pig’s trotter’ is used, which indicates a particularly fat pig. This formula is from Fu Qing Zhu’s Gynaecology and the dosages indicated above are those from the source text. They are interesting because of the very high quantities of the Qi and Blood tonics and the minute quantities of Mu Tong and Jie Geng. Modifications
• If there is a very dull complexion, dry skin, depression, exhaustion, and palpitations, add Shu Di Huang Radix Rehmanniae preparata, Bai Shao Radix Paeoniae alba, Chuan Xiong Rhizoma Chuanxiong and Shou Wu Radix Polygoni multiflori preparata. • If there is dizziness, palpitations, five-palm heat, dry mouth and throat, a feeling of heat in the afternoon, dry stools and a Red tongue without coating, add Sheng Di Huang Radix Rehmanniae, Tian Hua Fen Radix Trichosanthis and Zhi Mu Rhizoma Anemarrhenae. • If there is poor appetite and loose stools, add Shan Yao Radix Dioscoreae and Bian Dou Semen Lablab album. • If there is some Qi stagnation, add Chai Hu Radix Bupleuri and Fo Shou Fructus Citri sarcodactylis. b. Prescription
– EMPIRICAL PRESCRIPTION from Dr Cong Chun Yu Explanation
This formula is used if there is a condition of mixed deficiency and excess, with deficiency of Qi and Blood and some stasis of Blood, Heat and Phlegm in the breasts. Thus, in such a case, although the main problem is a deficiency of Qi and Blood, the breasts would be swollen, hot and tender. The tongue presentation appropriate to this formula is a Pale body but with slightly Red sides and Swollen with a sticky coating. – Dang Gui and Huang Qi tonify Blood and Qi respectively; the high dosage indicates that this is the primary aim of the formula. – Lou Lu resolves Toxic-Heat and promotes lactation. – Dong Kui Zi drains Dampness and promotes lactation. – Wang Bu Liu Xing and Chuan Xiong invigorate Blood and eliminate stasis. – Gua Lou resolves Phlegm and affects the breasts. – Tian Hua Fen and Bai Shao promote fluids and nourish Blood. – Tong Cao and Mu Tong remove obstructions from the breast Connecting channels. c. Prescription
– SI WU TANG Variation – Four Substances Decoction Variation Explanation
This variation is recommended by Wu Qian, author of the Golden Mirror of Medicine (1742).6 The first four herbs constitute the formula Si Wu Tang which nourishes Blood. – Tian Hua Fen promotes the generation of fluids and stimulates lactation. – Wang Bu Liu Xing invigorates Blood and stimulates lactation. – Mu Tong removes obstructions from the Connecting channels and stimulates lactation. Please note that this herb cannot be used and it should be replaced with Tong Cao Medulla Tetrapanacis. – Pig’s trotter stimulates lactation. Folk remedies
– Soup made with two pig’s trotters, salt and Tong Cao Medulla Tetrapanacis 5 g. – Carp soup with spring onions, ginger, salt and Tong Cao Medulla Tetrapanacis 5 g. – Eating Day Lily vegetables (Hemerocallis fulva) is beneficial in general after childbirth and promotes lactation. Women’s Treasure remedy
– PRECIOUS SEA This remedy tonifies Qi and nourishes Blood. The tongue presentation appropriate to this remedy is a Pale and Thin body.
Summary Qi and Blood deficiency
Clinical manifestations
Insufficient or absent lactation after childbirth, watery milk, no feeling of distension of the breasts, sallow complexion, dry skin, poor appetite, tiredness. Tongue: Pale. Pulse: Choppy. Treatment principle
Tonify Qi and Blood primarily: secondarily, remove obstructions from the breast Connecting channels. Acupuncture
ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, G.B.-41 Zulinqi, ST-18 Rugen, ST-12 Quepen, Ren-4 Guanyuan, BL-20 Pishu, BL-23 Shenshu, S.I.-1 Shaoze, Ren-17 Shanzhong. All with reinforcing method. Moxa may be used. Herbal treatment
Pre scriptions
• TONG RU DAN Penetrating the Breast Special Pill • EMPIRICAL PRESCRIPTION from Dr Cong Chun Yu • SI WU TANG Variation Four Substances Decoction Variation
Women’s Treasure remedy
• PRECIOUS SEA
Liver-Qi stagnation
Clinical manifestations Absent or scanty lactation, distension, hardness and pain of breasts, hypochondrial distension, irritability, epigastric distension. Tongue: slightly Red on the sides. Pulse: Wiry. Treatment principle Pacify the Liver, eliminate stagnation, move Qi, remove obstructions from the breast Connecting channels, promote lactation. Acupuncture T.B.-6 Zhigou, G.B.-41 Zulinqi, ST-18 Rugen, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), G.B.-34 Yanglingquan, LIV-3 Taichong, Ren17 Shanzhong, S.I.-1 Shaoze, T.B.-3 Zhongzhu, BL-51 Huangmen, LU-9 Taiyuan, LIV-4 Zhongfeng, G.B.-21 Jianjing. All with reducing or even method. Explanation
– T.B.-6 moves Qi and affects the sides of the breasts. – G.B.-41 removes obstructions from the breast Connecting channels. – ST-18 is a local point for the breast. – SP-4 and P-6 subdue rebellious Qi in the Penetrating Vessel and pacify
the Liver. The Penetrating Vessel flows over the breasts. – G.B.-34 and LIV-3 move Qi, eliminate stagnation and pacify the Liver. – Ren-17 moves Qi in the chest. – S.I.-1 is an empirical point to promote lactation. – T.B.-3 moves Qi and removes obstructions from the Upper Burner. – BL-51 moves Qi of the Triple Burner in the breast region and removes obstructions from the breast channels.7 – LU-9 is recommended for ‘jealous breast’ (also called ‘grudging milk’, see below) with pain in the breast and insufficient milk, by Huang Fu Mi in the ABC of Acupuncture (AD 259).8 – LIV-4 is also recommended by the ABC of Acupuncture for insufficient lactation with abdominal distension and a dry throat.9 – G.B.-21 moves Liver-Qi, makes Qi descend and affects the breasts. Herbal treatment
a. Prescription
– XIA RU YONG QUAN SAN – Promoting Lactation Gushing Spring Powder Explanation
– Dang Gui, Bai Shao and Chuan Xiong nourish and invigorate Blood. – Sheng Di Huang and Tian Hua Fen nourish fluids. Sheng Di Huang, in combination with the previous three remedies, forms a variation of Si Wu Tang Four Substances Decoction which nourishes and invigorates Blood. – Qing Pi and Chai Hu move Qi and eliminate stagnation. – Jie Geng acts as a messenger to direct the herbs to the Upper Burner. – Tong Cao removes obstructions from the breast Connecting channels. – Lou Lu resolves Toxic-Heat and promotes lactation. – Chuan Shan Jia and Wang Bu Liu Xing invigorate Blood and promote lactation. – Gan Cao harmonizes. Modifications
• If the breast feels hot and there are other signs of Heat, add Huang Qin Radix Scutellariae and Pu Gong Ying Herba Taraxaci. • If the breasts are distended, hot and painful, add Si Gua Luo Retinervus Luffae fructus, Lu Lu Tong Fructus Liquidambaris and Xia Ku Cao Spica Prunellae. • If there are signs of Phlegm and the breasts are very swollen, add Zhe Bei Mu Bulbus Fritillariae thunbergii and Gua Lou Fructus Trichosanthis.
b. Prescription
– YONG QUAN SAN – Gushing Spring Powder Explanation This prescription is recommended by Wu Qian, author of the Golden Mirror of Medicine.10 – Ding Xiang opens the Yang and frees the Connecting channels. – Wang Bu Liu Xing invigorates Blood and promotes lactation. – Tian Hua Fen generates fluids and promotes lactation. – Lou Lu resolves Toxic-Heat and causes milk to descend. – Jiang Can resolves Toxic-Heat and frees the Connecting channels. – Pig’s trotter promotes lactation. c Prescription
– TONG GAN SHENG RU TANG – Penetrating the Liver and Generating Milk Decoction Explanation
– Bai Shao, Dang Gui and Shu Di Huang nourish Liver-Blood and pacify the Liver. – Bai Zhu tonifies Spleen-Qi and strengthens the transforming action of Qi. – Gan Cao harmonizes. – Mai Men Dong helps to nourish Blood by nourishing Yin. – Tong Cao removes obstructions from the Connecting channels of the breast. – Chai Hu pacifies the Liver, moves Qi and eliminates stagnation. – Yuan Zhi calms the Mind. d. Prescription
– SHU GAN TONG RU TANG11 – Pacifying the Liver and Penetrating the Breast Decoction Explanation
– Chai Hu pacifies the Liver, moves Qi and eliminates stagnation. – Chuan Xiong, Lu Lu Tong, Wang Bu Liu Xing and Chuan Shan Jia invigorate Blood, eliminate stasis and promote lactation. Please note that the use of Chuan Shan Jia may be prohibited in certain countries.
– Mu Tong and Tong Cao remove obstructions from the Connecting channels of the breast and promote lactation. – Jie Geng directs the herbs to the Upper Burner to treat the breasts. – Lou Lu resolves Toxic-Heat and promotes lactation. – Dang Gui nourishes Liver-Blood and helps to pacify the Liver. e Prescription
– EMPIRICAL PRESCRIPTION from Dr Chen Jia Yuan12 Explanation
– Lou Lu, Zhu Di and Mu Tong resolve Toxic-Heat, remove obstructions from the Connecting channels and promote lactation. – Chen Pi and Wu Yao move Qi and eliminate stagnation. – Bai Zhi opens the orifices. – Shan Zha resolves food stagnation and dissolves masses. – Jie Geng directs the formula to the upper part of the body. – Chuan Xiong, Shu Di Huang, Dang Gui and Yi Mu Cao nourish and invigorate Blood. – Sheng Jiang and Gui Zhi warm the channels and expel Cold. – Gan Cao harmonizes.
Table 53.1 illustrates the differentiation between the five formulae for agalactia from Qi stagnation. Table 53.1 Differentiation of formulae for agalactia from Qi stagnation
External treatment
– Apply a decoction of Pu Gong Ying Herba Taraxaci and Chen Pi Pericarpium Citri reticulatae.
Folk remedy
– A soup made of Wang Bu Liu Xing Semen Vaccariae, Chuan Shan Jia Squama Manitis and Tong Cao Medulla Tetrapanacis. Three Treasures remedy
– FREEING THE MOON This remedy is a variation of Xiao Yao San Free and Easy Wanderer Powder which pacifies the Liver, moves Qi and eliminates stagnation. The formula has been modified in such a way (with more herbs that move Qi and affect the breast) that it is more suitable than Xiao Yao San for breast problems. The tongue presentation appropriate to this remedy is a body that is slightly Red on the sides. Women’s Treasure remedies
– FREEING CONSTRAINT This remedy is a variation of the formula Yue Ju Wan GardeniaLigusticum Pill: it pacifies the Liver, moves Qi, eliminates stagnation, calms the Mind and settles the Ethereal Soul. It differs from the previous remedy in so far as it is for ‘pure’ Liver-Qi stagnation without Liver-Blood deficiency. For this reason, the pulse indicating the use of this remedy is quite Wiry and Full on both right and left. The tongue presentation appropriate to this remedy is a body that is Red on the sides (Liver area). – PENETRATING VESSEL This remedy is specific to subdue rebellious Qi in the Penetrating Vessel: it is therefore indicated when there are symptoms and signs of rebellious Qi in
this vessel. As the Penetrating Vessel flows over the breasts, a stagnation of Qi in this channel may cause the breast milk not to flow. Other symptoms include abdominal pain, fullness and distension, a feeling of energy rising, a tightness of the chest, slight breathlessness, a feeling of lump in the throat and anxiety. This remedy subdues rebellious Qi in the Penetrating Vessel by nourishing Blood and the Kidneys within this vessel. Summary Liver-Qi stagnation
Clinical manifestations
Absent or scanty lactation, distension, hardness and pain of breasts, hypochondrial distension, irritability, epigastric distension. Tongue: slightly Red on the sides. Pulse: Wiry. Treatment principle
Pacify the Liver, eliminate stagnation, move Qi, remove obstructions from the breast Connecting channels, promote lactation. Acupuncture
T.B.-6 Zhigou, G.B.-41 Zulinqi, ST-18 Rugen, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), G.B.-34 Yanglingquan, LIV-3 Taichong, Ren17 Shanzhong, S.I.-1 Shaoze, T.B.-3 Zhongzhu, BL-51 Huangmen, LU-9 Taiyuan, LIV-4 Zhongfeng, G.B.-21 Jianjing. All with reducing or even method. Herbal treatment
Pre scriptions
• XIA RU YONG QUAN SAN Promoting Lactation Gushing Spring Powder • YONG QUAN SAN Gushing Spring Powder • TONG GAN SHENG RU TANG Penetrating the Liver and Generating Milk Decoction • SHU GAN TONG RU TANG Pacifying the Liver and Penetrating the Breast Decoction • EMPIRICAL PRESCRIPTION from Dr Chen Jia Yuan Three Treasures remedy
• FREEING THE MOON Women’s Treasure remedies
• FREEING CONSTRAINT • PENETRATING VESSEL
Ancient acupuncture prescriptions for lack of milk13
1. LIV-3 Taichong and KI-7 Fuliu (ABC of Acupuncture, Zhen Jiu Jia Yi Jing, AD 259). 2. For lack of milk, needle the lateral corner of the nail of the little finger (i.e. S.I.-1 Shaoze) 0.1 cun deep, T.B.-2 Yemen, 0.3 cun deep and T.B.-10 Tianjing 0.6 cun deep (Supplement to Thousand Golden Ducat Prescriptions, Zhen Jiu Yi Fang, 13th century). 3. S.I.-1 Shaoze, L.I.-4 Hegu and Ren-17 Shanzhong (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601). 4. Ren-17 Shanzhong (Prescriptions for Universal Relief, Pu Ji Fang, 15th century). 5. S.I.-2 Qiangu (Classic of Miraculous Moxibustion, Shen Jiu Jing Lun, 1851).
Prognosis and prevention Both acupuncture and herbs are effective for Breast Milk not Flowing and are the treatment of choice also considering that Western medicine has very little to offer. Herbs are probably more effective than acupuncture especially for treating deficiency of Qi and Blood. In fact, if lactation is insufficient because of a blockage due to Qi stagnation, acupuncture is good at clearing it; but if lactation is deficient because of lack of Blood, herbs are better at supplementing the deficiency. In deficiency cases, it is important that the nursing mother eats easily digestible but also nourishing foods and especially foods that nourish Blood such as beef or chicken. If the woman is vegetarian she should pay great care and attention to eating enough protein of vegetable origin. As mentioned above, in China, pig’s trotter is considered the best type of food for insufficient lactation from a deficiency of Blood; many women may find this type of food unappealing, but it is eaten quite frequently in Mediterranean countries. In insufficient lactation from stagnation of Qi, it is of course important that the woman avoids emotional problems and is, as far as possible, isolated from any source of irritation or worry.
Western view The problem of insufficient lactation from not enough milk (i.e. from a deficiency according to the Chinese perspective) is given only a cursory mention in obstetrics books, perhaps because although there are drugs to inhibit lactation, there is none to increase it. Obstetrics books do give, however, indications as to how to ascertain that there is not enough milk, and that is by weighing the baby before and after every feed for 24 hours. If the mother is not producing at least 60 ml per feed and the baby is not gaining weight, then milk production is insufficient. Western books simply advise that the mother should eat and drink more. The engorgement of the breast occurring a few days after childbirth roughly corresponds to the Full type of Breast Milk not Flowing from the Chinese point of view. If the baby does not empty the breasts sufficiently, they soon become engorged, distended, tender, hard and knotty. Once this condition is established, the congestion and pressure on the ducts prevent a proper flow of milk and the baby cannot empty the breasts: this clearly corresponds to Breast Milk not Flowing from Liver-Qi stagnation. From the Western point of view, manual expression of milk before each feed may help to relieve the congestion; alternatively, an electric breast pump may be used.
Appendix: acute mastitis Acute mastitis and breast abscess broadly correspond to the Chinese disease ‘Breast Carbuncle’ (Ru Yong): this is characterized by redness, swelling, heat and pain in the breast and by red nodules which, after some days, rupture with the discharge of sticky pus. Judging from the description of clinical manifestations of Breast Carbuncle, the initial stages correspond to acute mastitis, the later stage, with the discharging nodules, to breast abscess. Zhu Dan Xi describes the pathology and aetiology of Breast Carbuncle in some detail: The breast itself pertains to the Bright-Yang channels, while the nipple to the Terminal-Yin channels. If the nursing mother does not know the principles of good nutrition, or if she is affected by indignation and anger, Qi will rebel upwards, her emotions of depression and a feeling of oppression are repressed, heavy-todigest food brews inside, so that the Qi of the Terminal Yin [Liver] stagnates, the orifices are blocked and milk cannot come out. When the Bright-Yang Heat boils over, it transforms into pus. In some cases the feeding baby might have Phlegm stagnating in the diaphragm and his/her breath is burning hot; when this is blown on to the mother’s breast, hot Qi is blown which gives rises to nodules. Right at the beginning, one should overcome the pain and massage the nodules to soften them, thus when the baby sucks the milk flows and the nodules will be dispersed.14 Apart from the above-mentioned emotional causes, the ancient Chinese doctors differentiated two stages of breast problems after childbirth; the first, ‘Blow Breast’ (Chui Ru), was caused by the baby ‘blowing’ onto the breast and transmitting Heat to it; the second, Breast Carbuncle, developed from the first. The idea of the baby blowing onto the breast and transmitting its own Heat to the mother ties in remarkably well with modern medicine’s pathology of puerperal mastitis because, in most cases, this problem is due to
infection with Staphylococcus aureus, with the baby being the most frequent source of infection. Very often breast infections occur in association with skin infections or umbilical cord infections which the baby has. Bacteriological investigations carried out during epidemics of breast infection with S. aureus have shown that if one baby in a nursery has the organism in its nose or mouth, almost all the other babies will be affected and so spread infection to their mothers.15 Fu Qing Zhu gives a similar interpretation of Breast Carbuncle: The nipples pertain to the Terminal-Yin channels [Liver] and the breast itself to the Bright-Yang channels. A swelling of the breast with red nodules that after some days rupture and ooze a sticky pus which then heal, is due to Toxic Heat in Stomach and Gall-Bladder with stagnation of Qi and Blood and is called Breast Carbuncle which is easy to treat.16 There is yet another breast condition occurring after childbirth called ‘jealous breast’ or ‘envious breast’ (du ru), which could also be translated as ‘begrudging milk’ characterized by milk not flowing due to the baby’s inability to suck properly: the breast becomes engorged, hot, painful and hard, the milk does not flow, Qi and Blood stagnate, and the mother is thirsty and cannot bear the breasts being touched. According to the ancient doctors, this condition should be treated as soon as it appears by gently kneading the breast to disperse accumulation so that the milk flows and the baby can suck: if this is not done, Heat and pus may form and the condition develops into Breast Carbuncle. Figure 53.2 illustrates the various types of breast conditions after childbirth and their relationship with Western puerperal diseases.
Figure 53.2 Breast conditions occurring after childbirth and their modern equivalent.
Fu Qing Zhu then gives detailed treatment principles for Breast Carbuncle according to clinical manifestations. He says: If the breast is painful and hot and the woman feels hot and shivery, release the Exterior and expel pathogenic factors. If there is pain, pacify the Liver and clear the Stomach. If there is pus that does not flow out, expel it from within. If the flesh does not heal and watery pus flows continuously, tonify Stomach and Spleen. If pus flows and there are shivers and fever, tonify Qi and Blood. If there is inability to eat and vomiting, tonify Stomach-Qi.17
Treatment The pathology of Breast Carbuncle after childbirth is always one of Heat and Toxic-Heat affecting the Liver, Stomach and Gall Bladder channels. Thus, the treatment principle is to clear Heat, resolve toxins, pacify the Liver, clear Stomach-Heat and resolve pus. Acupuncture G.B.-41 Zulinqi, ST-44 Neiting, LIV-2 Xingjian, L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, ST-40 Fenglong, ST-18 Rugen, P-6 Neiguan, T.B.-6 Zhigou. All with reducing or even method. No moxa. Explanation
– G.B.-41 resolves Damp-Heat and specifically affects the breast. – ST-44 and LIV-2 are used to clear Stomach-Heat or Liver-Heat respectively. – L.I.-11 resolves Toxic-Heat. – SP-9, SP-6 and ST-40 drain Dampness and help to dissolve toxins and pus. – ST-18 is a local point for the breast. – P-6 and T.B.-6 pacify the Liver and move Qi in the chest and sides of the breast areas. Prescription from the Great Compendium of Acupuncture (1601)18
L.I.-8 Xialian, ST-36 Zusanli, G.B.-43 Xiaxi, LU-10 Yuji, BL-40 Weizhong, G.B.-41 Zulinqi, S.I.-1 Shaoze. Prescription from Dr Wang Feng Jin19
This prescription is for acute mastitis and, interestingly, places the emphasis of treatment on the Liver and Heart channels: Du-14 Dazhui, Du-12 Shenzhu, BL-15 Xinshu, BL-18 Ganshu, BL-17 Geshu, ST-15 Wuyi, G.B.-21 Jianjing, HE-1 Jiquan, P-6 Neiguan. Herbal treatment
a. Prescription
– GUA LOU SAN – Trichosanthes Powder Explanation
– Gua Lou resolves Phlegm and affects the breast. – Gan Cao and Jin Yin Hua resolve Toxic-Heat. – Dang Gui nourishes Blood. – Ru Xiang and Mo Yao invigorate Blood and eliminate stasis.
– Bai Zhi expels pus. – Qing Pi moves Qi and it specifically affects the breast. b. Prescription
– HUI MAI SAN – Rescuing the Pulse Powder Explanation This formula is used before the carbuncle ruptures: it uses Da Huang to dissolve toxin through defaecation. – Da Huang resolves toxins through defaecation and clears Heat. – Bai Zhi dissolves pus. – Ru Xiang, Mo Yao and Chuan Shan Jia invigorate Blood and eliminate stasis. – Ren Shen tonifies Qi and is used here to strengthen the body’s ability to dissolve pus and combat infection. – Mu Xiang moves Liver-Qi and eliminates stagnation. c. Prescription
– SHI QUAN DA BU TANG Variation
– Ten Complete Great Tonification Decoction Variation Explanation The first seven herbs constitute the formula Shi Quan Da Bu Tang minus Dang Gui, Bai Shao and Rou Gui. This formula tonifies Qi and Blood. – Jin Yin Hua is added to resolve Toxic-Heat. This prescription is used if there is Toxic-Heat against a background of Qi and Blood deficiency. d Prescription
– XIAN FANG HUO MING YIN – Immortal’s Formula Life-Saving Decoction Explanation
– Jin Yin Hua and Gan Cao resolve Toxic-Heat. – Bai Zhi expels pus. – Fang Feng releases the Exterior and expels Wind. – Dang Gui nourishes Blood. – Chen Pi resolves Dampness. – Zhe Bei Mu and Zhen Zhu Mu soften masses. – Tian Hua Fen nourishes Yin, resolves Phlegm, clears Heat, resolves
Toxic-Heat and expels pus. – Ru Xiang and Mo Yao invigorate Blood and eliminate stasis; they specifically affect the breast. – Zao Jiao Ci reduces swelling, expels pus, invigorates Blood and dissipates abscesses. This formula is used if there is an abscess in the breast. e. Prescription
– XIAO DU YIN – Dissolving Toxin Decoction Explanation
– Qing Pi and Chai Hu pacify the Liver, move Qi and eliminate stagnation. – Bai Zhi expels pus. – Dang Gui nourishes Liver-Blood which helps to pacify the Liver. – Zhe Bei Mu and Jiang Can clear Heat, resolve Phlegm and soften masses. – Tian Hua Fen nourishes Yin, resolve Phlegm, clears Heat, resolves Toxic-Heat and expels pus. – Jin Yin Hua and Gan Cao resolve Toxic-Heat. Modifications
• If there is pus, add Zao Jiao Ci Spina Gleditsiae. Table 53.2 illustrates the differences between the above formulae. Table 53.2 Comparison of formulae for Breast Carbuncle
Folk remedies
– The mother should eat a gruel made from Yi Yi Ren Semen Coicis every day.
– To stop the milk production, two treatments may be applied, one external, the other internal. Externally, the mother should apply powdered Mang Xiao to the breasts, tightly wrapped in gauze. This should be renewed every day and she should also drink less. Internally, she should take a decoction of 60 g of (Chao) Mai Ya Fructus Hordei germinatus (fried) and 60 g of Shan Zha Fructus Crataegi daily for 3 days. External use
– Apply a wash decocted from the following herbs: Dan Nan Xing Rhizoma Arisaematis preparatum, Ban Xia Rhizoma Pinelliae preparatum, Jiang Can Bombyx batryticatus, Bai Zhi Radix Angelicae dahuricae, Zao Jiao Ci Spina Gleditsiae. After decocting and straining, add fresh juice from 20 spring onions. Summary Treatment of acute mastitis
Acupuncture
G.B.-41 Zulinqi, ST-44 Neiting, LIV-2 Xingjian, L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, ST-40 Fenglong, ST-18 Rugen, P-6 Neiguan, T.B.-6 Zhigou. All with reducing or even method. No moxa. Herbal treatment
Pre scriptions
• GUA LOU SAN Trichosanthes Powder • HUI MAI SAN Rescuing the Pulse Powder • SHI QUAN DA BU TANG Variation Ten Complete Great Tonification Decoction Variation • XIAN FANG HUO MING YIN Immortal’s Formula Life-Saving Decoction • XIAO DU YIN Dissolving Toxin Decoction
End notes 1. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, pp 67–68. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
2. Zhang Jing Yue 1986 The Complete Works of Jing Yue (Jing Yue Quan Shu
), Shanghai Science and Technology Press, Shanghai, p. 678. First published in 1624..
3. Fu Qing Zhu’s Gynaecology, p. 68..
4. Ibid., pp 68–69..
5. Zhang Zi He 1217 The Literati’s Care of Their Parents (Ru Men Shi Qin), cited in Cong Chun Yu 1989 Chinese Medicine Gynaecology (Zhong Yi Fu Ke Xue
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 192..
6. Wu Qian 1977 The Golden Mirror of Medicine (Yi Zong Jin Jian
), People’s Health Publishing House, Beijing, Vol. 3, p. 104. First published in 1742..
7. The action of this point can be explained by reference to the Triple Burner’s function of being the ‘ambassador’ or ‘avenue’ of the Original Qi (Yuan Qi) as it emerges from between the Kidneys: this is described in Chapter 66 of the Classic of Difficulties (Nan Jing). The Classic of Difficulties says that the Original Qi spreads to the five Yin and six Yang Organs through the Triple Burner, it enters the twelve channels and emerges at the Source points. From this point of view, therefore, the Triple Burner is the agent through which the Original Qi performs its functions in different parts of the body, and a proper, smooth flow of Qi of the Triple Burner is essential to this function. Clavey (in Fluid Physiology and Pathology in Traditional Chinese Medicine, Churchill Livingstone, Edinburgh, 1995, p. 21) gives an interesting, slightly different interpretation of the role of the Triple Burner in relation to the Original Qi. He says that the Triple Burner separates the initially undifferentiated Original Qi and directs it into different channels and organs to perform its various functions. Thus, the point BL-51, level with BL-22 Sanjiaoshu which is the Back-Transporting point of the Triple Burner, is situated in the area of the Kidneys, from where the Original Qi emerges. Gaohuang in the name of BL-51 indicates the Gaohuang region between the heart and diaphragm, including the breast, while the character men, meaning ‘door’, indicates that Qi comes and goes
through this point or that this point is a crucial gateway for the passage of Qi. Thus, this point controls the entering and exiting of Qi of the Triple Burner in the breast region, hence its use to remove stagnation of Qi in this area. This point’s name should be seen in conjunction with that of BL-53 Baohuang; in fact, the Triple Burner penetrates upwards to the Gaohuang region (through the point BL-51 Huangmen) and downwards to the Baohuang region (through the point BL-52 Baohuang). ‘Baohuang’ indicates both the uterus and bladder..
8. Shandong College of Traditional Chinese Medicine 1980 An Explanation of the ABC of Acupuncture (Zhen Jiu Jia Yi Jing Jiao Shi
), People’s Health Publishing House, Beijing, p. 1478. The ABC of Acupuncture was written by Huang Fu Mi c. AD 259..
9. Ibid., p. 1480..
10. The Golden Mirror of Medicine, p. 104..
11. Hu Xi Ming 1990 Great Treatise of Secret Formulae in Chinese Medicine (Zhong Guo Zhong Yi Mi Fang Da Quan
), Culture Publishing House, Shanghai, Vol. 2, p. 74..
12. Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong
), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 26. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang) and published in 1729..
13. Wang Xue Tai 1995 Great Treatise of Chinese Acupuncture (Zhong Guo Zhen Jiu Da Quan
), Henan Science and Technology Publishing House, p. 496..
14. Han Bai Ling 1983 Bai Ling’s Gynaecology (Bai Ling Fu Ke
), Heilongjiang People’s Publishing House, pp 140–141..
15. Lewis T L T, Chamberlain G V P 1994 Obstetrics by Ten Teachers, Edward Arnold, London, p. 261..
16. Fu Qing Zhu’s Gynaecology, p. 120..
17. Ibid., p. 120..
18. Heilongjiang Province National Medical Research Group 1984 An Explanation of the Great Compendium of Acupuncture (Zhen Jiu Da Cheng Jiao Shi
), People’s Health Publishing House, Beijing, p. 1108. The Great Compendium of Acupuncture itself was published in 1601..
19. Wang Xue Tai (chief ed.) 1991 Medical Records of Famous Contemporary Chinese Acupuncturists (Zhong Guo Dang Dai Zhen Jiu Ming Jia Yi An
), Jilin Science and Technology Press, Jilin, p. 24..
CHAPTER 54 Spontaneous Flow of Milk
AETIOLOGY 669 PATHOLOGY 669 IDENTIFICATION OF PATTERNS AND TREATMENT 669 Spleen- and Stomach-Qi deficiency 669 Liver-Fire 670 PROGNOSIS AND PREVENTION 671 This condition consists of a spontaneous flow of milk not elicited by the suckling of the baby; it is called in Chinese lou ru, which means ‘trickling breast’.
Aetiology
Long labour, constitutional weakness The strain imposed on Qi by a long labour leads to Qi deficiency after childbirth, which may be more pronounced in women who have a preexisting Qi deficiency. Qi fails to hold fluids and the breast milk trickles out spontaneously. Emotional upset Ongoing emotional problems such as anger, frustration or resentment, or a sudden emotional upset may cause Liver-Qi stagnation and Liver-Fire; since the Liver controls the nipples, Liver-Fire ‘heats’ the breast milk which forces its way out of the breast.
Pathology The pathology of Spontaneous Flow of Milk is somewhat similar to that of Flooding and Trickling, i.e. either Qi fails to hold fluids and breast milk flows uninterrupted, or Liver-Fire agitates the breast milk and, since the Liver channel controls the nipples, milk is pushed out of the breasts. As for the organs involved, in the former case, a deficiency of Spleen- and Stomach-Qi is responsible for the trickling. The breast milk will have a different appearance according to the condition: in the case of Stomach-Qi deficiency, it is watery and dilute, while in the case of Liver-Fire it is dense and yellow.
Identification of patterns and treatment The treatment principle varies according to the condition; in the case of Spleen- and Stomach-Qi deficiency, it consists of tonifying Spleen- and Stomach-Qi to hold fluids; in the case of Liver-Fire, of pacifying the Liver, moving Qi and clearing Heat.
Spleen- and Stomach-Qi deficiency
Clinical manifestations Spontaneous flow of milk a few days after childbirth, scanty but constant flow of dilute, watery milk, the breasts are soft and not distended, pale complexion, tiredness, poor appetite. Tongue: Pale. Pulse: Weak. Treatment principle Tonify Qi, nourish Blood, firm fluids. Acupuncture Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu, ST-18 Rugen, Ren-6 Qihai. All with reinforcing method; moxa is applicable. Explanation
– Ren-12, ST-36, SP-6, BL-20 and BL-21 tonify Stomach and Spleen. – ST-18 is a local point for the breasts. – Ren-6 tonifies Qi in general. Herbal treatment
a Prescription
– BA ZHEN TANG – Eight Precious Decoction Explanation This formula, already explained, tonifies Qi and Blood. b. Prescription
– REN SHEN YANG RONG TANG – Ginseng Nourishing and Flourishing Decoction Explanation This formula, already explained, tonifies Qi, nourishes Blood, warms Yang and calms the Mind. More warming than the previous formula, it is therefore used if the patient’s tongue is particularly Pale. Because it contains Wu Wei Zi, which is astringent and therefore holds fluids, and Yuan Zhi, which calms the Mind, this formula is more suitable than the previous one. Modifications
– If the trickling of milk is profuse and difficult to stop, add (or increase) astringent herbs such as Wu Wei Zi Fructus Schisandrae (unless already in the formula) and Qian Shi Semen Euryales.
Women’s Treasure remedy
– PRECIOUS SEA This remedy tonifies Qi and nourishes Blood. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Spleen- and Stomach-Qi deficiency
Clinical manifestations
Spontaneous flow of milk a few days after childbirth, scanty but constant flow of dilute, watery milk, the breasts are soft and not distended, pale complexion, tiredness, poor appetite. Tongue: Pale. Pulse: Weak. Treatment principle
Tonify Qi, nourish Blood, firm fluids. Acupuncture
Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu, ST-18 Rugen, Ren-6 Qihai. All with reinforcing method; moxa is applicable. Herbal treatment
Pre scriptions
• BA ZHEN TANG Eight Precious Decoction • REN SHEN YANG RONG TANG Ginseng Nourishing and Flourishing Decoction Women’s Treasure remedy
• PRECIOUS SEA
Liver-Fire
Clinical manifestations Spontaneous trickling of milk after childbirth, dense milk, distension of breasts, hypochondrial distension, irritability, insomnia, headache, thirst, bitter taste, constipation. Tongue: Red, redder on the sides, yellow coating. Pulse: Wiry and Rapid. Treatment principle Pacify the Liver, drain Fire. Acupuncture LIV-2 Xingjian, G.B.-41 Zulinqi, ST-18 Rugen, P-7 Daling, T.B.-6 Zhigou, G.B.-34 Yanglingquan, Du-24 Shenting, Ren-15 Jiuwei, L.I.-11 Quchi. All with reducing or even method; no moxa. Explanation
– LIV-2 drains Liver-Fire. – G.B.-41 clears Heat and removes obstructions from the breast Connecting channels. – ST-18 is a local point for the breasts. – P-7 calms the Mind and pacifies the Liver.
– T.B.-6 pacifies the Liver and affects the sides of the breasts. – G.B.-34 pacifies the Liver. – Du-24 and Ren-15 calm the Mind. – L.I.-11 clears Heat. Herbal treatment
a. Prescription
– DAN ZHI XIAO YAO SAN – Moutan-Gardenia Free and Easy Wanderer Powder Explanation This formula, already explained, is specific to clear Liver-Heat when it derives from stagnation of Liver-Qi. The tongue presentation appropriate to this formula is a body with Red sides. In such a case, there are more manifestations of Liver-Qi stagnation than Liver-Fire, hence not so much thirst, bitter taste or constipation. b. Prescription
– LONG DAN XIE GAN TANG – Gentiana Draining the Liver Decoction
Explanation This formula, already explained, drains Liver-Fire. It is suitable to treat a spontaneous outbreak of Liver-Fire, rather than Liver-Heat deriving from stagnant Liver-Qi. The tongue presentation appropriate to this formula is a Red body with redder sides and a dry, yellow coating. Modifications
• If there is five-palm heat, add (or increase) Sheng Di Huang Radix Rehmanniae and Mai Men Dong Radix Ophiopogonis. • If the breasts are distended and lumpy, add Pu Gong Ying Herba Taraxaci and Xia Ku Cao Spica Prunellae. • If the breasts are swollen and hot and the woman has a fever, see under the category of Breast Carbuncle (see the Appendix to Ch. 53). Note If, for any reason, lactation needs to be suppressed, two treatments may be applied, one external, the other internal. Externally, the mother should apply powdered Mang Xiao Sulfas Natrii to the breasts, tightly wrapped in gauze. This should be renewed every day and she should also drink less. Internally, she should take a decoction of 60 g of (Chao) Mai Ya Fructus Hordei germinatus (fried) and 60 g of Shan Zha Fructus Crataegi daily for 3 days. Three Treasures remedy
– DRAIN FIRE
This remedy drains Liver-Fire. The tongue presentation appropriate to this remedy is a Red body, with redder sides and with a yellow, dry coating. Summary Liver-Fire
Clinical manifestations
Spontaneous trickling of milk after childbirth, dense milk, distension of breasts, hypochondrial distension, irritability, insomnia, headache, thirst, bitter taste, constipation. Tongue: Red, redder on the sides, yellow coating. Pulse: Wiry and Rapid. Treatment principle
Pacify the Liver, drain Fire. Acupuncture
LIV-2 Xingjian, G.B.-41 Zulinqi, ST-18 Rugen, P-7 Daling, T.B.-6 Zhigou, G.B.-34 Yanglingquan, Du-24 Shenting, Ren-15 Jiuwei, L.I.-11 Quchi. All with reducing or even method; no moxa. Herbal treatment
Pre scriptions
• DAN ZHI XIAO YAO SAN Moutan-Gardenia Free and Easy Wanderer Powder
• LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction Three Treasures remedy
• DRAIN FIRE
Prognosis and prevention Both acupuncture and herbal medicine are effective to stop spontaneous trickling from the breast. Herbs are more effective for the pattern of LiverFire. In most cases, trickling of milk should stop after a few days. There is no Western view of this problem.
CHAPTER 55 Collapse after Childbirth
AETIOLOGY 673 PATHOLOGY 673 IDENTIFICATION OF PATTERNS AND TREATMENT 674 Collapse of Qi with deficiency of Blood: Flaccid Syndrome 674 Blood stasis: Tense Syndrome 675 PROGNOSIS AND PREVENTION 676 WESTERN VIEW 677 Collapse after Childbirth indicates a condition characterized by severe dizziness with a sudden onset. The woman cannot stand or sit, she has blurred vision and a feeling of tightness of the chest, she suffers nausea and vomiting and, in extreme cases, may faint.
Aetiology
Severe blood loss during childbirth If there is a massive loss of blood during childbirth, Blood becomes exhausted and this induces a collapse of Qi. Since the Heart governs Blood and houses the Mind, a severe exhaustion of Blood will deprive the Mind of its residence and this causes the sudden dizziness and fainting. Exposure to cold during childbirth Exposure to cold during childbirth may lead to stasis of Blood after delivery. Stagnant Blood, taking advantage of exhaustion of Qi caused by childbirth, rises and harasses the Mind causing sudden dizziness and a feeling of tightness of the chest.
Pathology From the pathology point of view, there are two main conditions, both characterized by a deficiency of Qi: in one there is a severe deficiency of Blood, and in the other a stasis of Blood. The former pattern is characterized by profuse discharge of lochia and is called ‘Flaccid Syndrome’, the other by retention of lochia and is called ‘Tense Syndrome’. The distinction between Flaccid and Tense Syndromes is somewhat similar to that for Wind-stroke; they are differentiated on the basis of symptoms, pulse, tongue and uterine bleeding. In the Flaccid Syndrome, the situation is of collapse of Qi, with profuse discharge of lochia, pale complexion, palpitations, mental confusion, fainting, closed eyes, open mouth, cold limbs, and Deep and Fine pulse. In the Tense Syndrome, there is a scanty discharge of lochia or no discharge at all, dark complexion, chest and abdominal pain, fainting, closed mouth, clenched hands and a Full, Rapid pulse. It corresponds to the ‘Lung rebellion’ of the ‘three rebellions’ (san chong) mentioned at the beginning of this section, i.e. stagnant Blood in the Penetrating Vessel (Chong Mai) rising upward with rebellious Qi, and harassing the Lungs, causing the above symptoms. Clinical Note • Flaccid Syndrome: profuse discharge of lochia, pale complexion, palpitations, mental confusion, fainting, closed eyes, open mouth, cold limbs, and Deep and Fine pulse • Tense Syndrome: scanty discharge of lochia or no discharge at all, dark complexion, chest and abdominal pain, fainting, closed mouth, clenched hands, and a Full, Rapid pulse
The treatment of the Flaccid Syndrome is based on rescuing Qi from collapse and nourishing Blood, while that of the Tense Syndrome is based on
invigorating Blood, eliminating stasis and subduing rebellious Qi.
Identification of patterns and treatment
Collapse of Qi with deficiency of Blood: Flaccid Syndrome
Clinical manifestations Profuse bleeding after childbirth, sudden vertigo, pale, white complexion, palpitations, fainting, cold limbs, sweating. Tongue: Pale, Short. Pulse: Fine, Scattered. Treatment principle Rescue Qi, nourish Blood. Acupuncture Ren-4 Guanyuan, Ren-6 Qihai, Du-26 Renzhong. ST-36 Zusanli, SP-6 Sanyinjiao, Ren-8 Shenque, Du-4 Mingmen, BL-23 Shenshu. All with reinforcing method; moxa must be used. Explanation
– Ren-4, Ren-6 and Ren-8 with moxa cones (on salt in the case of Ren-8) rescue Qi and Yang from collapse. – Du-26 promotes resuscitation. – ST-36 and SP-6, with warm needle, tonify Qi and Blood. – Du-4 and BL-23 rescue Yang from collapse. These two are used if the symptoms of collapse of Yang are pronounced (such as cold limbs).
Herbal treatment
a Prescription
– DU SHEN TANG – Solitary Ginseng Decoction Explanation This formula is specific for collapse of Qi following loss of Blood. White Ginseng is used for Collapse of Qi and Red Ginseng for Collapse of Yang. – Ren Shen rescues Qi from collapse and tonifies the Original Qi. In such a case, a high dose must be used as indicated above (the original prescription actually recommended 60 g). – Da Zao harmonizes. b Prescription
– SHEN FU TANG – Ginseng-Aconitum Decoction Explanation This formula is specific for collapse of Yang and is therefore used if there are very cold limbs and profuse sweating.
– Ren Shen rescues Qi from collapse and tonifies the Original Qi. – Fu Zi rescues Yang from collapse. Modifications
• If there is profuse, continuous uterine bleeding, add toasted Sheng Jiang Rhizoma Zingiberis recens. c Prescription
– SHI QUAN DA BU TANG – Ten Complete Great Tonification Decoction Explanation The text Gynaecology in Chinese Medicine by the Nanjing College of Traditional Chinese Medicine recommends using the above formula, already explained, to tonify Qi and Blood, combined with powdered Du Shen Tang Solitary Ginseng Decoction or Shen Fu Tang Ginseng-Aconitum Decoction for collapse of Qi or Yang respectively. The above formula is a variation of Ba Zhen Tang Eight Precious Decoction with the addition of Huang Qi Radix Astragali and Rou Gui Cortex Cinnamomi. d Prescription
– QING HUN SAN
– Clearing the Ethereal Soul Powder Explanation This formula is recommended by Wu Qian is his Golden Mirror of Medicine (1742) for dizziness after childbirth from collapse of Qi.1 It should be chosen if the patient is unconscious with mouth closed, the limbs are cold and she is sweating profusely. – Jing Jie stops bleeding. – Ren Shen rescues Qi from collapse and tonifies the Original Qi. – Chuan Xiong and Ze Lan invigorate Blood. They are included in the formula to enter the Liver and specifically Liver-Blood so as to root the Ethereal Soul in it. – Gan Cao harmonizes. All the above formulae can be given in powder form if the patient is unconscious. Chinese books recommend mixing the powder with half a cup of warm rice wine or water and gently pouring the mixture into the patient’s mouth a little at a time. If there is lockjaw or unconsciousness, administer Gan Qi Resina Toxicodendri (lacquer) in powder form (0.06–0.1 g): to resuscitate the patient, some books also recommend burning lacquer in the room before taking it internally. Summary Collapse of Qi with deficiency of Blood: Flaccid Syndrome
Clinical manife stations
Profuse bleeding after childbirth, sudden vertigo, pale, white complexion,
palpitations, fainting, cold limbs, sweating. Tongue: Pale, Short. Pulse: Fine, Scattered. Tre atme nt principle
Rescue Qi, nourish Blood. Acupuncture
Ren-4 Guanyuan, Ren-6 Qihai, Du-26 Renzhong. ST-36 Zusanli, SP-6 Sanyinjiao, Ren-8 Shenque, Du-4 Mingmen, BL-23 Shenshu. All with reinforcing method; moxa must be used. He rbal tre atme nt
Prescription
• DU SHEN TANGSolitary Ginseng Decoction • SHEN FU TANGGinseng-Aconitum Decoction • SHI QUAN DA BU TANGTen Complete Great Tonification Decoction • QING HUN SANClearing the Ethereal Soul Powder
Blood stasis: Tense Syndrome
Clinical manifestations Retention of lochia or scanty lochia after childbirth, abdominal pain that is worse with pressure, a feeling of fullness under the heart, chest pain, cough, fainting, mouth closed, dark complexion. Tongue: Purple. Pulse: Wiry. This pattern is due to rebellious Qi within the Penetrating Vessel (Chong Mai): since this vessel is also the Sea of Blood, stagnant Blood rebels upwards with Qi harassing the Heart, to which this vessel flows, and the Lungs. As the Heart houses the Mind and governs Blood, stagnant Blood clouds the Mind’s orifices and causes fainting. Treatment principle Invigorate Blood, eliminate stasis, pacify the Penetrating Vessel, subdue rebellious Qi. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, KI-14 Siman, Ren-14 Juque, Du-26 Renzhong, SP-6 Sanyinjiao, BL-17 Geshu. All with reducing or even method. No moxa. Explanation
– SP-4 and P-6 pacify the Penetrating Vessel, subdue rebellious Qi and invigorate Blood.
– SP-10, SP-6 and BL-17 invigorate Blood and eliminate stasis. – KI-14, a point of the Penetrating Vessel, moves Qi and invigorates Blood in the lower abdomen. – Ren-14 invigorates Heart-Blood and restores consciousness. – Du-26 promotes resuscitation. Herbal treatment
Prescription
– DUO MING WAN and FO SHOU SAN – Seizing Life Powder and Buddha’s Hand Powder Explanation
– Mu Dan Pi, Tao Ren, Chi Shao, Pu Huang and Chuan Xiong invigorate Blood and eliminate stasis. – Dang Gui nourishes and invigorates Blood. – Gui Zhi enters the blood vessels, helping to invigorate Blood. – Fu Ling resolves Dampness and balances the other herbs. Modifications
• Common additions to the above formula are Chuan Niu Xi Radix Cyathulae to invigorate Blood and conduct rebellious Qi downward and Ze Lan Herba Lycopi to invigorate Blood. • If there are symptoms of Cold, add Pao Jiang Rhizoma Zingiberis preparatum (toasted), Rou Gui Cortex Cinnamomi and Pu Huang Pollen Typhae. Table 55.1 relates the conditions that may appear in Collapse after Childbirth to their Western and Chinese treatment principles. Table 55.1 Bleeding after childbirth: Western and Chinese treatment principles
Summary Blood stasis - Tense Syndrome
Clinical manife stations
Retention of lochia or scanty lochia after childbirth, abdominal pain that is worse with pressure, a feeling of fullness under the heart, chest pain, cough, fainting, mouth closed, dark complexion. Tongue: Purple. Pulse: Wiry. Tre atme nt principle
Invigorate Blood, eliminate stasis, pacify the Penetrating Vessel, subdue rebellious Qi. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, KI-14 Siman, Ren-14 Juque, Du-26 Renzhong, SP-6 Sanyinjiao, BL-17 Geshu. All with reducing or even method. No moxa. He rbal tre atme nt
Prescription
• DUO MING WAN and FO SHOU SANSeizing Life Powder and Buddha’s Hand Powder
Prognosis and prevention Collapse after Childbirth is a serious condition that requires urgent treatment, usually in an intensive care unit: thus, most practitioners will never see such a condition. Even in China, herbal treatment is seldom used. More appropriate from our perspective is the prevention of such a condition. As, from the Chinese point of view, this condition is due either to collapse of Qi following heavy blood loss or to stasis of Blood, it is important for us, if we are called upon to treat a woman soon after childbirth, to recognize the early signs of collapse of Qi, such as sweating, especially on the forehead, cold limbs, dizziness, confusion, extreme debility, a Pale and Short tongue and a Fine or Scattered pulse. In the presence of such symptoms, it is advisable to treat the woman straightaway with one of the above formulae and/or acupuncture points to prevent collapse of Qi, or to invigorate Blood and eliminate stasis. We must also make a clear distinction between the two possible cases of collapse of Qi or stasis of Blood on the basis of the lochia discharge, the tongue colour and other manifestations as indicated above.
Western view From the Western point of view, Collapse after Childbirth could correspond either to shock following a massive haemorrhage or to septic shock which may follow a puerperal infection: septic shock causes severe circulatory failure due to the toxins of bacteria. Initially, there may be an increase in heart rate; in the second phase there is circulatory failure with the patient becoming comatose and with cold hands and feet. The blood pressure and pulse become almost imperceptible. This condition requires urgent and specialized help in an intensive care unit. Treatment is based on antibiotics, catecholamines to increase cardiac output, often plasma transfusion, sometimes ventilation through an endotracheal tube and vasodilators. End note 1. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian
), People’s Health Publishing House, Beijing, Vol. 3, p. 75. First published in 1742..
CHAPTER 56 Convulsions after Childbirth
AETIOLOGY 679 PATHOLOGY 679 DIFFERENTIAL DIAGNOSIS 679 IDENTIFICATION OF PATTERNS AND TREATMENT 680 Blood and Yin deficiency with Empty-Wind 680 Exterior invasion of Toxin 681 PROGNOSIS AND PREVENTION 682 WESTERN VIEW 682 Convulsions after Childbirth is characterized by rigidity of the spine, tremor of limbs, lockjaw and opisthotonos (a spasm in which the head and heels are bent backwards and the body bowed forward). If only the first two signs are present, the condition is considered not too severe; if there is also lockjaw and opisthotonos, the condition is serious; if, in addition, the woman sweats on the forehead, with the sweat being like beads, the limbs are cold and the breathing is inaudible, then the condition is dangerous.
Aetiology
Severe loss of blood during childbirth Profuse bleeding during childbirth leads to Blood and Yin deficiency: LiverBlood and Liver-Yin fail to nourish and moisten the sinews and internal Wind develops from the Yin deficiency. The rigidity of the spine, tremors, lockjaw and opisthotonos are typical manifestations of internal Wind contracting the sinews. Invasion of external Toxin During and after childbirth, the channels and blood vessels are empty of Blood and very prone to invasions of exterior pathogenic factors. If sanitary conditions during and after childbirth are not good, external ‘Poisons’ (or Toxin) may invade the body and cause Toxic-Heat and internal Wind.
Pathology There are two main conditions causing convulsions after childbirth, one caused by deficiency, the other by excess. A deficiency of Liver-Blood and Liver-Yin may lead to the development of internal Wind: this is an Empty type of Wind as it derives from a deficiency. An invasion of external Toxin during or after childbirth causes the development of Toxic-Heat and internal Wind may develop from Fire: this is a Full type of Wind. In the Empty type of Wind, there will be manifestations of deficiency such as a Fine pulse, a tongue without coating, a pale complexion and only a slight tremor of the limbs. In the Full type of Wind, there will be manifestations of Fullness such as a Wiry and Full pulse, a Red tongue with thick, yellow coating and Red points, severe convulsions, a red face, lockjaw and opisthotonos.
Differential diagnosis Convulsions after Childbirth should be differentiated by the following conditions: • Wind-stroke • Convulsions in Pregnancy • Epilepsy • Breakdown Syndrome (Jue Zheng). Wind-stroke is characterized by sudden unconsciousness (in the severe type), deviation of the mouth and eye, and hemiplegia. There are tremors, convulsions, lockjaw or opisthotonos. Convulsions in Pregnancy (see Ch. 36), corresponding to eclampsia, is characterized by convulsions but not opisthotonos. It occurs before childbirth although it may also occur within 24 hours of delivery. Epilepsy is characterized by convulsions, foaming at the mouth and unconsciousness. There is no opisthotonos or lockjaw and, most of all, after the seizure, the patient is normal. There is a history of epilepsy. Breakdown Syndrome is characterized by sudden unconsciousness which, in Chinese medicine, may be due to a variety of causes such as pain, loss of blood, high fever, Cold, Summer-Heat, etc. There is unconsciousness, cold limbs and pale face, but no tremors or opisthotonos.
Identification of patterns and treatment
Blood and Yin deficiency with Empty-Wind
Clinical manifestations Profuse loss of blood during childbirth, tremor of limbs, rigidity of spine, pale complexion or malar flush. Tongue: without coating. Pulse: Choppy or Floating-Empty and slightly Wiry on the left. Treatment principle Nourish Blood and Yin, strengthen the Liver, extinguish Wind. Acupuncture LIV-8 Ququan, BL-18 Ganshu, KI-3 Taixi, SP-6 Sanyinjiao, Ren-4 Guanyuan, LIV-3 Taichong, Du-16 Fengfu, G.B.-20 Fengchi, S.I.-3 Houxi (on the right) and BL-62 Shenmai (on the left), Du-8 Jinsuo. LIV-8, BL-18, KI-3, SP-6 and Ren-4 with reinforcing method; all the others with reducing method. Explanation
– LIV-8, BL-18, KI-3, SP-6 and Ren-4 nourish Liver-Blood and LiverYin. – LIV-3 extinguishes Liver-Wind. – Du-16 and G.B.-20 extinguish Wind. – S.I.-3 and BL-62 regulate the Governing Vessel and extinguish internal
Wind. They also treat the spine and will relieve rigidity of the spine. – Du-8 relaxes the sinews and relieves rigidity of the spine. Herbal treatment
Prescription
– SAN JIA FU MAI TANG – Three-Shell Restoring the Pulse Decoction Explanation This formula, already explained in Chapter 36 on convulsions in pregnancy, nourishes Blood and Yin and extinguishes Wind. It is specific for EmptyWind deriving from Liver-Blood and Liver-Yin deficiency. Modifications
• If the symptoms of Wind are pronounced, add Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus Uncariae cum Uncis and Shi Jue Ming Concha Haliotidis. • If there is unconsciousness, add Shi Chang Pu Rhizoma Acori tatarinowii. • If there is profuse sweating, add Fu Xiao Mai Semen Tritici levis, Wu Wei Zi Fructus Schisandrae and Shan Zhu Yu Fructus Corni.
• If the complexion is white, add Dang Shen Radix Codonopsis, Huang Qi Radix Astragali and Shu Di Huang Radix Rehmanniae preparata. • If there are symptoms of Phlegm, add Zhu Ru Caulis Bambusae in Taeniam and Ban Xia Rhizoma Pinelliae preparatum. • If there is persistent uterine bleeding, add Dang Shen Radix Codonopsis, Huang Qi Radix Astragali and Han Lian Cao Herba Ecliptae. Summary Blood and Yin deficiency with Empty-Wind
Clinical manife stations
Profuse loss of blood during childbirth, tremor of limbs, rigidity of spine, pale complexion or malar flush. Tongue: without coating. Pulse: Choppy or Floating-Empty and slightly Wiry on the left. Tre atme nt principle
Nourish Blood and Yin, strengthen the Liver, extinguish Wind. Acupuncture
LIV-8 Ququan, BL-18 Ganshu, KI-3 Taixi, SP-6 Sanyinjiao, Ren-4 Guanyuan, LIV-3 Taichong, Du-16 Fengfu, G.B.-20 Fengchi, S.I.-3 Houxi (on the right) and BL-62 Shenmai (on the left), Du-8 Jinsuo. LIV-8, BL-18, KI-3, SP-6 and Ren-4 with reinforcing method; all the others with reducing method. He rbal tre atme nt
Prescription
• SAN JIA FU MAI TANG Three-Shell Restoring the Pulse Decoction
Exterior invasion of Toxin
Clinical manifestations Shivering and fever soon after childbirth, headache, stiff neck, rigidity of spine, lockjaw, convulsions, opisthotonos in severe cases. Tongue: Red with thick, sticky, yellow coating. Pulse: Wiry, Full. Treatment principle Resolve Toxin, drain Fire, extinguish Wind, invigorate Blood. Acupuncture L.I.-11 Quchi, SP-10 Xuehai, LIV-3 Taichong, LIV-2 Xingjian, Du-16 Fengfu, G.B.-20 Fengchi, Du-8 Jinsuo, Du-14 Dazhui, SP-9 Yinlingquan. All with reducing method, no moxa. Explanation
– L.I.-11 clears Heat, cools Blood and resolves Toxin. – SP-10 invigorates Blood and, in conjunction with L.I.-11, cools Blood. – LIV-3 extinguishes Liver-Wind. – LIV-2 drains Liver-Fire. – Du-16 and G.B.-20 extinguish Wind.
– Du-8 relaxes the sinews and relieves rigidity of the spine. – Du-14 clears Heat and extinguishes Wind. – SP-9 helps to clear Heat and resolve Toxin. Herbal treatment
Prescription
– QING WEN BAI DU YIN Variation – Clearing Warm Disease and Expelling Toxin Decoction Variation Explanation
– Shi Gao, Zhi Mu and Zhu Ye clear Heat. – Gan Cao, Huang Lian, Huang Qin, Lian Qiao, Shan Zhi Zi and Xuan Shen resolve Toxic-Heat. – Shui Niu Jiao opens the Mind’s orifices. – Sheng Di Huang, Mu Dan Pi and Chi Shao cool Blood. – Shan Zhi Zi clears Heat and resolves Damp-Heat. – Jie Geng directs the formula to the Upper Burner. – Tian Ma, Gou Teng and Jiang Can extinguish Wind.
Summary Exterior invasion of Toxin
Clinical manife stations
Shivering and fever soon after childbirth, headache, stiff neck, rigidity of spine, lockjaw, convulsions, opisthotonos in severe cases. Tongue: Red with thick, sticky, yellow coating. Pulse: Wiry, Full. Tre atme nt principle
Resolve Toxin, drain Fire, extinguish Wind, invigorate Blood. Acupuncture
L.I.-11 Quchi, SP-10 Xuehai, LIV-3 Taichong, LIV-2 Xingjian, Du-16 Fengfu, G.B.-20 Fengchi, Du-8 Jinsuo, Du-14 Dazhui, SP-9 Yinlingquan. All with reducing method, no moxa. He rbal tre atme nt
Prescription
• QING WEN BAI DU YIN Variation Clearing Warm Disease and Expelling Toxin Decoction Variation
Prognosis and prevention Most practitioners are unlikely to be treating Convulsions in Pregnancy, first of all because it is a rare condition in the West and second because a woman with this condition requires urgent Western treatment. The main cause of this condition is infection during or after childbirth through lack of hygiene.
Western view Convulsions after Childbirth corresponds to tetanus infection in Western medicine: this is now a very rare occurrence after childbirth. In the past, it was due to poor hygienic conditions during and after delivery.
SECTION 8 Miscellaneous Diseases
Introduction 57. INFERTILITY 685 58. MENOPAUSAL SYNDROME 735 59. BREAST LUMPS 769 60. ABDOMINAL MASSES 793 61. EXCESSIVE VAGINAL DISCHARGE 813 62. VAGINAL ITCHING (AND TRICHOMONAS AND CANDIDA INFECTIONS AND GENITAL ECZEMA) 827 63. PROLAPSE OF THE UTERUS 835 64. VULVAR SORES 841 65. ENDOMETRIOSIS 849 66. POLYCYSTIC OVARY SYNDROME 889 67. MYOMA 923
In this section, miscellaneous gynecological diseases that fall outside the sope of the previous sections are discussed. The term ‘miscellaneous’ perhaps does not do them justice as this section includes some of the most important and most frequently seen gynecological conditions. Chapters 57 to 64 are Chinese disease-symptoms derived from Chinese books while Chapters 65 to 67 are Western-defined gynecological diseases.
Chapter 57 Infertility
AETIOLOGY 685 PATHOLOGY 686 Full versus Empty causes of infertility 686 The Directing and Penetrating Vessels in infertility 688 The cervical secretion 689 The basal body temperature 689 Connections with biomedical causes of infertility 689 Patterns of infertility 689 IDENTIFICATION OF PATTERNS AND TREATMENT 689 EMPTY CONDITIONS 693 Kidney-Yang deficiency 693 Kidney-Yin deficiency 697 Blood deficiency 699 FULL CONDITIONS 701 Cold in the Uterus 701 Dampness in the Lower Burner 704 Blood-Heat 708 Stagnation of Qi 709 Stasis of Blood 712 Damp-Phlegm 714 COMBINED PATTERNS 715
Kidney-Yang deficiency with Damp-Phlegm in the Uterus 715 Kidney-Yang deficiency with Dampness 715 Kidney-Yang deficiency with Blood stasis 716 Kidney-Yang deficiency with Blood stasis and Dampness 716 ANCIENT ACUPUNCTURE PRESCRIPTIONS FOR INFERTILITY 716 MODERN ACUPUNCTURE PRESCRIPTION FOR RETROVERT UTERUS 717 EMPIRICAL PRESCRIPTIONS BY DR XIA GUI CHENG 717 EMPIRICAL PRESCRIPTIONS BY DR LIAN FANG AND DR SUN NING QUAN 718 EMPIRICAL PRESCRIPTIONS BY DR ZHU NAN SUN 719 EMPIRICAL FORMULAE ACCORDING TO WESTERN CONDITION BY DR SHAN DAO WEI 720 EMPIRICAL PRESCRIPTIONS BY THE SHANGHAI COLLEGE OF TRADITIONAL CHINESE MEDICINE 720 PROGNOSIS AND PREVENTION 721 WESTERN VIEW 722 CLINICAL TRIALS 725 Acupuncture 725 Herbal treatment 728 APPENDIX: MALE STERILITY 733 Infertility is defined as the inability to produce offspring in a woman who
has been trying for 2 years with a normal sexual life and, of course, the reproductive function of whose partner is normal.
Aetiology
Constitutional weakness Constitutional weakness of the Kidney-Essence is an important cause of infertility. Such weakness may be due to the woman’s mother having been too old when conceiving her, the parents’ constitution being not good, the parents’ health being not good at the time of conception, etc. Because the Kidney-Essence is the basis for the Tian Gui, the woman cannot conceive. Overwork Overwork in the sense of working long hours without adequate rest and with irregular diet for years is a major cause of Kidney-Yin deficiency. KidneyYin is the basis for menstrual blood and the uterus and when it is deficient there may be infertility. Excessive physical work Excessive physical work or strenuous exercise and sports weaken the Spleen- and Kidney-Yang, especially at puberty time when a young girl’s uterus is in a vulnerable state. At this age, excessive physical work may take the form of playing too much sport, training too hard at ballet or gymnastics, working on a farm, etc. Sexual activity at too early an age Sexual activity at too early an age (i.e. before and during puberty and up to about 18) is an important and increasingly frequent cause of disease in
Western countries. It seriously weakens the Kidneys and damages the Directing and Penetrating Vessels (Ren and Chong Mai) and may therefore cause infertility later in life. Invasion of Cold Invasion of Cold is a very common cause of infertility in young women – indeed, probably the most common cause of primary infertility in young women. If a girl undergoing puberty is exposed to cold and dampness (especially during her period) when exercising or playing sports, Cold invades the Uterus, turns into internal Cold and obstructs the Uterus and the Directing and Penetrating Vessels, preventing fertilization. Irregular diet Excessive consumption of cold, iced foods and drinks also leads to Cold in the Uterus as above. Excessive consumption of greasy foods and dairy products leads to the formation of Dampness in the Lower Burner which also prevents fertilization. Dampness in the Lower Burner easily turns into DampPhlegm which may obstruct the Uterus preventing implantation of the ovum. Blockage of the fallopian tubes is usually due to their obstruction by DampPhlegm; however, it is important to note that Damp-Phlegm obstructing the Uterus may cause infertility whether the tubes are blocked or not.
Pathology When discussing the pathology of infertility, there are various aspects to consider: • Full versus Empty causes of infertility. • The Directing and Penetrating Vessels in infertility. • The cervical secretion. • The basal body temperature. • Connections with biomedical causes of infertility. • Patterns of infertility.
Full versus Empty causes of infertility When diagnosing infertility, we should differentiate clearly between deficiency and excess: this is the most important aspect to clarify. We must diagnose clearly whether the woman cannot conceive because of a lack of Blood and/or Essence (in its Yin or Yang aspect) or because there is a pathogenic factor obstructing the Uterus. On the basis of this diagnosis, we must therefore establish whether we need to tonify and nourish the body’s Qi or to eliminate pathogenic factors. Empty conditions In case of Empty conditions, infertility is due to a lack of the vital substances that are essential for conception, i.e. Blood and/or Essence. The two main deficiencies are those of Blood or of Kidneys (which may be Kidney-Yin or Kidney-Yang). Whether it is a deficiency of Kidney-Yin or Kidney-Yang, the KidneyEssence is always involved in its Yin or Yang aspect. As discussed in Chapter 2 on physiology, the menstrual function and the Uterus rely on the Yin aspect (which is Post-Natal) and on the Yang aspect of the Essence (which is Pre-Natal). The Yang aspect of the Essence is the Fire of the Gate of Life, also called the Minister Fire, that is formed at conception. As we have seen in Chapter 2, the Minister Fire is of a special type: a ‘formless’ Fire, it can actually generate Water (rather than drying it up). For fertilization to occur, the Yin and Yang aspects of the Essence need to be perfectly balanced: the Yin in the form of Water, Essence and Blood is the substantial basis for conception to occur, but the Yin needs the warming and fertilizing action of Yang, in the form of Minister Fire. If the Water, i.e. the Yin aspect, is deficient, there is not enough nourishment to support the fertilized egg (or to produce an egg at all); if the Minister Fire is deficient, there is no ‘spark’ to transform and activate the Water, which therefore cannot fertilize or nourish an egg. Vice versa, if the
Minister Fire is excessive and pathological, the Blood in the Uterus may become hot and this creates adverse conditions for the fertilization or support of an egg. Figures 57.1 and 57.2 illustrate these concepts.
Figure 57.1 Yin and Yang aspects of the Essence in relation to the Uterus.
Figure 57.2 Pathological conditions of Yin and Yang aspects of the Essence.
Full conditions In the case of Full conditions, fertilization cannot occur because pathogenic factors obstruct the Uterus and the Directing and Penetrating Vessels (Ren
and Chong Mai). Such pathogenic factors may be Cold (very common in cold and damp countries), Blood-Heat, Dampness, stagnation of Qi, stasis of Blood and Phlegm. Fertilization is a very delicate process fraught with difficulties and any of the above pathogenic factors may prevent it. Cold is a very frequent cause of infertility: it prevents conception by obstructing the Uterus and its channels. As we have just seen, the Fire of the Gate of Life is essential for the fertilization of the egg: the Essence, in its Yin aspect, provides the basis for conception by producing the eggs, but the Fire of the Gate of Life is essential for the transformation of the egg into a fetus. Cold obstructs the Uterus and dampens the Fire of the Gate of Life, preventing fertilization. Cold can be of the Full or Empty type, depending on how much Kidney-Yang deficiency there is. One of the most important diagnostic factors differentiating Full- from Empty-Cold is the pulse: in FullCold the pulse will be Full and Tight, while in Empty-Cold it will be Weak on the whole (although it may also be slightly Tight on the left Rear position). Blood-Heat also causes infertility, but in the opposite way. Blood and Essence are the basis for conception (the Uterus is also called the Blood Chamber). Thus, if the Blood is hot it may create adverse conditions for the fertilization of the egg. The influence of Cold and Blood-Heat can be compared with a bird’s incubation of an egg; the temperature should be steady, warm, neither too cold nor too hot. Dampness, to which women are particularly prone, invades the body from the Lower Burner. It prevents the proper movement of Qi and Blood and may therefore lead to stagnation of Qi and/or stasis of Blood. Unable to function properly, the Directing and Penetrating Vessels (Ren and Chong Mai) cannot gather the Essence for the woman to conceive. From a channel perspective, this may due also to a pathology of the Girdle Vessel (Dai Mai) affecting the Directing Vessel (see Ch. 7). From a Western perspective, Damp-Heat often corresponds to pelvic or tubal inflammation. Liver-Qi stagnation is mentioned in Chinese books as a possible pathology of infertility. In my opinion, it is unlikely that Qi stagnation on its own would cause infertility because Qi is non-substantial and it is unlikely to cause an obstruction such as to lead to infertility. Nevertheless, I will discuss
its treatment below. Blood stasis is a frequent cause of infertility: stagnant Blood obstructs the Uterus and its channels and it prevents the proper functioning of the Directing and Penetrating Vessels so that conception cannot occur. If Blood stasis is severe and longstanding, stagnant Blood can give rise to abdominal masses, endometriosis, ovarian cysts or myomas. In endometriosis, a major factor in infertility, there is always Blood stasis. Phlegm may cause infertility by obstructing the Uterus and its channels so that the Directing and Penetrating Vessels cannot function properly and the Essence cannot be gathered. Zhu Dan Xi (1281–1358) says in his The Heart and Essence Dan Xi’s Methods of Treatment: “Inability to conceive in fat women is caused by the Fat [i.e. Phlegm] within the body blocking the Uterus.”1 This is an interesting statement because polycystic ovary syndrome, a major cause of infertility, often occurs in obese women. Modern Chinese doctors relate obesity to Phlegm. Damp-Phlegm is nearly always the main pathogenic factor in polycystic ovary syndrome.
The Directing and Penetrating Vessels in infertility No matter whether the condition is Full or Empty, in infertility the Uterus and the Directing and Penetrating Vessels (Ren and Chong Mai) are obviously always involved. In case of deficiency, the Uterus and the Directing and Penetrating Vessels lack the necessary nourishment to nurture the fertilized egg or to produce an egg at all; in the case of excess, pathogenic factors obstruct these structures and prevent their proper Qi, Blood and Essence transformation so that fertilization or implantation cannot occur (Fig. 57.3).
Figure 57.3 Causes of infertility. Treatment of the Penetrating and Directing Vessels is essential in infertility whether in a Full or Empty condition. In Empty conditions, Ren-4 Guanyuan is the best point to use: it nourish Blood, tonifies the Kidneys (both
Yin and Yang), nourishes the Essence, strengthens the Original Qi (Yuan Qi); finally, it strengthens both the Directing and the Penetrating Vessels because the latter connects with it internally. In Empty conditions, I often combine Ren-4 with KI-13 Qixue (a point of the Penetrating Vessel). In Full conditions, the best points to use are Ren-3 Zhongji and KI-14 Siman (a point of the Penetrating Vessel). Clinical Note In Empty conditions, Ren-4 Guanyuan is the best point to use: I often combine Ren-4 with KI-13 Qixue (a point of the Penetrating Vessel). In Full conditions, the best points to use are Ren-3 Zhongji and KI-14 Siman (a point of the Penetrating Vessel).
The cervical secretion When treating infertility, one must always take into consideration the cervical secretion that occurs just before ovulation and that indicates fertility. As discussed in Chapter 2, the cervical secretion is a direct manifestation of Kidney-Essence and its absence (or short duration of 1 day only) indicates a deficiency of Kidney-Essence and a weakness of the proliferative phase. Therefore, one must always ask a woman seeking treatment for infertility to check the cervical secretion every month.
The basal body temperature The second sign that one must consider is the basal body temperature (BBT) also discussed in Chapter 2. Although the BBT does not give us indications for treatment as the spike in temperature occurs after ovulation, it is important to chart the temperature every month to monitor the progress (or lack of it) of the treatment. If a previously flat chart starts to develop the typical biphasic shape, it is obviously a very good sign. It is also very encouraging for the patients to see the objective improvement in the chart for themselves.
Connections with biomedical causes of infertility Although it is not possible to make direct connections between Western pathologies and Chinese medicine patterns, modern Chinese books and journals make such an endeavour. Although one should keep an open mind and rely on a Chinese diagnosis and identification of patterns for treatment, such connections can give broad guidelines. According to such modern connection, absence or irregularity of ovulation often corresponds to a Kidney deficiency; blockage of the fallopian tubes to Damp-Heat, possibly with Toxic-Heat and stasis of Blood; uterine myomas and endometriosis to stasis of Blood, possibly with Phlegm; and pelvic adhesions to Dampness with stasis of Blood.
Patterns of infertility To get an idea of the statistical incidence of each type, we may refer to a study of 257 cases of infertility reported in Beijing’s Journal of Chinese Medicine.2 Of these 257 cases, the following were the proportions of various patterns: • Kidney-Yang deficiency: 27.63%. • Spleen- and Kidney-Yang deficiency: 12.84%. • Liver- and Kidney-Yin deficiency: 11.67%. • Kidney-Yin deficiency with Empty-Heat: 5.06%. • Liver-Qi stagnation: 7.39%. • Blood stasis: 29.57%. • Phlegm: 3.11%. • Cold-Dampness: 2.73%. As can be seen, if we total up all the various types of Kidney deficiency we obtain a total percentage of 57.20% of Kidney-Deficiency cases, by far the highest one. However, these figures are related to Chinese conditions and may not be exactly the same in other countries. For example, one might infer that the percentage of cases due to Cold and Dampness would be higher not only in cold and damp climates but also in relatively warm countries due to the consumption of iced drinks, especially by young people. Also, in my experience, the percentage of cases of infertility due to Phlegm would be considerably higher.
Identification of patterns and treatment Infertility is frequently treated in China according to the four phases of the menstrual cycle as described in Chapter 2, i.e. the period, the postmenstrual, the inter-menstrual and the pre-menstrual phases. The treatment principles in each phase are as follows: • Period phase: regulate menstruation (i.e. stop bleeding if period is heavy or invigorate Blood if it is scanty). • Post-menstrual phase: nourish Blood and tonify the Kidneys. • Inter-menstrual phase: tonify the Kidneys and consolidate the Directing and Penetrating Vessels. If necessary, resolve Dampness or Phlegm. • Pre-menstrual phase: tonify Yang and move Liver-Qi. If necessary, resolve Phlegm, invigorate Blood, expel Cold. In relation to infertility in particular, the treatment principle can be slightly different because the emphasis is always put on the treatment of the Kidneys (especially in deficiency conditions). Also, the phases are sometimes slightly different, being defined more according to Western physiology. For example, Dr Li Xiang Yun defines the following four phases: 1. Follicular development phase: this starts from about the fourth or fifth day after the beginning of the period. 2. Follicular maturity and ovulation phase: this is the inter-menstrual phase when the follicle matures and ovulation occurs. 3. Luteal phase: this is the pre-menstrual phase when the corpus luteum develops and secretes progesterone. 4. Atrophy of corpus luteum phase: this is the period time.3
Dr Li recommends the following treatment principles for the above four phases: 1. Follicular development phase: tonify the Kidneys and nourish Blood. 2. Follicular maturity and ovulation phase: nourish and invigorate Blood. 3. Luteal phase: tonify the Kidneys and consolidate the Directing and Penetrating Vessels. 4. Atrophy of corpus luteum phase: invigorate Blood and regulate menstruation. The treatment of infertility according to the four phases is always based principally on treating the Kidneys because the phases are a result of the waxing and waning of Kidney-Yin and Kidney-Yang and because the Kidneys are the source of the Tian Gui which is the basis for reproduction. Thus, from a Western perspective, the follicle maturation, ovulation, the ova and the corpus luteum are all manifestations of the fluctuation of Kidney-Yin and Kidney-Yang during the menstrual cycle. For this reason, several of the prescriptions mentioned in this chapter are based on four different formulae according to the above four phases of the menstrual cycle and they are all aimed at establishing a regular menstrual cycle and ovulation by tonifying different aspects of the Kidneys at each different phase. From an acupuncture perspective, the Governing, Directing and Penetrating Vessels (Du, Ren and Chong Mai) are the basis for follicle maturation, ovulation and corpus luteum development and these channels should therefore always be used to treat infertility. The Directing and Penetrating Vessels are Yin in nature and represent the biological basis for the follicles, ova and corpus luteum, while the Governing Vessel, Yang in nature, is the force of transformation that assists the biological processes involved in fertilization, i.e. the maturation of follicles, the expulsion of the ova and the maturation of the corpus luteum. The patterns discussed are as follows:
Empty
• Kidney-Yang deficiency. • Kidney-Yin deficiency. • Blood deficiency. Full
• Cold in the Uterus. • Dampness in the Lower Burner. • Blood-Heat. • Stagnation of Qi. • Stasis of Blood. • Damp-Phlegm. Combined patterns
• Kidney-Yang deficiency with Damp-Phlegm in the Uterus. • Kidney-Yang deficiency with Dampness. • Kidney-Yang deficiency with Blood stasis. • Kidney-Yang deficiency with Blood stasis and Dampness.
Please note that although the patterns are discussed individually, in practice they will always occur in combination. For example, it is very common for a woman with infertility to suffer from Kidney-Yang deficiency and Dampness (or Damp-Phlegm). It is precisely in these situations that treatment according to the four phases is particularly important. In the example above of Kidney-Yang deficiency with Dampness, it would be appropriate to tonify Kidney-Yang in phases 2 and 3 and resolve Dampness in phase 4 (or tonify Kidney-Yang in phase 2 and resolve Dampness in phases 3 and 4). For this reason, after discussing individual patterns, I will also discuss some examples of combinations and their treatment. Please note that the patterns given (all with Kidney-Yang deficiency) are only examples: in each case, the woman may be suffering from Kidney-Yin rather than Kidney-Yang deficiency. Herbs that nourish the Kidney-Essence Before discussing the differentiation and treatment of infertility, it is useful to review the herbs that nourish the Kidney-Essence. There is no separate category for Essence-nourishing herbs and they can be found in various categories. Most of them are in the Kidney-Yang tonics category. Some of them ‘stabilize’ the Essence rather than nourish it but they are often combined with Essence-nourishing herbs: for example, Bu Gu Zhi Fructus Psoraleae or Yi Zhi Ren Fructus Alpiniae oxyphyllae. ‘Stabilizing’ the Essence implies an astringent action that is used with symptoms such as nocturnal emissions or spermatorrhoea in men and chronic vaginal discharge in women. A list of herbs that nourish the Essence by category is given in Table 57.1 Table 57.1 Herbs that nourish the Essence by category
Nourishing the Essence is essential in infertility, especially of the deficient kind, and particularly that from Kidney deficiency. The majority of these cases of infertility are due to an ovulatory dysfunction and ovulation is an expression of the transformation of the Kidney-Essence into ova. Thus, to promote ovulation, it is necessary to nourish the Essence. Nourishing the Essence transcends tonification of Yin or Yang as the Essence itself has a Yin and a Yang aspect. Its Yang aspect is the Minister Fire which is present from conception, and its Yin aspect is the Essence itself that, at puberty, crystallizes into menstrual Blood and the ova (see Fig. 4.3). Given the importance of the role of the Minister Fire in transforming the Tian Gui into menstrual blood and ova, it is interesting to note that the majority of herbs that nourish the Essence are in the Kidney-Yang tonics category. Some of the herbs listed in Table 57.1 deserve particular comment. Lu Rong Cornu Cervi pantotrichum, Lu Jiao Cornu Cervi, Lu Jiao Jiao Colla Cornu Cervi and Lu Jiao Shuang Cornu Cervi degelatinatum
These are excellent substances to nourish the Essence because they nourish Yang without drying and nourish the Essence at the same time. They also strengthen the Governing Vessel and therefore activate the Minister Fire that promotes the transformation of Kidney-Essence into menstrual blood and ova. Lu Jiao Jiao is particularly indicated for women as it also nourishes Blood, while Lu Jiao Shuang would be indicated when there is excessive menstrual bleeding. Tu Si Zi Semen Cuscutae This herb is very frequently used to nourish the Essence and promote ovulation in infertility. Its advantage lies in its rather neutral quality as, although it does tonify Kidney-Yang, its action is rather mild and it can be used to nourish Kidney-Yin. Zi He Che Placenta hominis Being human placenta, this is the substance that is closest to actual Essence. It tonifies Yang and nourishes Blood and the Kidney-Essence. Herb combinations for infertility Some herb combinations are used particularly frequently in infertility. Combinations for deficiency conditions
Tu Si Zi Semen Cuscutae and Gou Qi Zi Fructus Lycii These are important herbs for Kidney deficiency. The combination is perfectly balanced, being neither too warm or too drying, and it tonifies
without cloying. Although this combination tonifies both Yin and Yang, it is primarily for Kidney-Yin deficiency. Shu Di Huang Radix Rehmannia preparata and Bai Shao Radix Paeoniae alba This combination tonifies Liver- and Kidney-Yin: it also ‘calms’ and protects the Yin. ‘Calming’ the Yin implies the capacity to stop bleeding from EmptyHeat; ‘protecting’ indicates an ability to prevent leakages of Yin such as occur in persistent vaginal discharges. This combination nourishes Water and irrigates Wood, i.e. it nourishes Kidney-Yin and Liver-Blood. Shan Yao Rhizoma Dioscoreae and Shan Zhu Yu Fructus Corni This combination tonifies Liver- and Kidney-Yin: it nourishes also the Kidney-Essence. Neither too hot nor too drying, it tonifies without creating stagnation: it can tonify as well as astringe. Rou Cong Rong Herba Cistanches and Ba Ji Tian Radix Morindae officinalis This is an important combination for infertility from deficiency. These two herbs in combination enter the Governing Vessel and they are often combined with Qi and Blood tonics when there is Kidney-Yang deficiency. The characteristic of this combination is to promote transformation by the warming action of Yang but, at the same time, to nourish the Essence. These two herbs are often combined with Yin tonics to nourish the Yin and Yang aspect of the Essence and promote fertility. In such a case, Bai Zi Ren Semen Platycladi is often added to the Yin tonics to nourish Yin, tonify Blood and moisten the Intestines. Fu Pen Zi Fructus Rubi and Zi Shi Ying Fluoritum
This combination is often used in deficiency-type infertility: it warms without drying and it tonifies Yin within Yang. It tonifies the Kidneys and the Essence. Zi He Che Placenta hominis and Lu Jiao Cornu Cervi This combination tonifies Spleen- and Kidney-Yang and nourishes the Essence. Both animal products, they are used according to the two principles that ‘animal products have feeling’ and ‘animal products nourish the Governing, Directing and Penetrating Vessels’. The combination is sweet, salty, warming and nourishing, it strengthens the Uterus and nourishes the Governing, Directing and Penetrating Vessels. Ba Ji Tian Radix Morindae officinalis and Lu Jiao Cornu Cervi This combination tonifies Spleen- and Kidney-Yang. Like the above combination, it nourishes the Governing, Directing and Penetrating Vessels; it warms and tonifies the Directing and Penetrating Vessels, nourishes the Kidneys and benefits Yang. Xian Mao Rhizoma Curculiginis and Yin Yang Huo Herba Epimedii This combination is pungent and hot and it tonifies the Fire of the Gate of Life. It is frequently used for infertility from pronounced Kidney-Yang deficiency with ovulatory irregularity. Obviously it should not be used in Yin deficiency as both herbs are very hot. Dang Shen Radix Codonopsis and Huang Qi Radix Astragali This combination tonifies and raises Qi. Apart from its use in prolapse, it is used for corpus luteum defect. These two herbs are often combined with
Kidney-Yang tonics. Fu Zi Radix Aconiti lateralis preparata and Rou Gui Cortex Cinnamomi This combination is used for infertility from Kidney-Yang deficiency. These two herbs are hot and pungent: the former moving, the latter ‘calming’. They warm the Uterus and stoke up the Fire of the Gate of Life. Combinations for excess conditions
Chai Hu Radix Bupleuri and Yan Hu Suo Rhizoma Corydalis This combination is used for pelvic inflammation and fallopian tube obstruction. These two herbs in combination pacify the Liver, move Qi, eliminate stagnation and stop pain. They are specific to remove or prevent obstructions. Pu Gong Ying Herba Taraxaci and Hong Teng Caulis Sargentodoxae This combination can treat acute pelvic inflammation and tubal obstruction. Bitter and cold, these herbs clear Heat, resolve Toxic-Heat, dissipate nodules and dissolve swelling. They are often combined with Bai Jiang Cao Herba Patriniae to enhance their stasis-eliminating and nodule-dissipating effect. Chuan Lian Zi Fructus Toosendan and Lu Lu Tong Fructus Liquidambaris
This combination can be used for tubal obstruction: it moves Liver-Qi and invigorates Blood. Lu Lu Tong Fructus Liquidambaris and Di Long Pheretima This combination can be used for tubal obstruction and hydrosalpinx (accumulation of watery fluid in the fallopian tubes). The herbs clear Heat, transform Water and remove obstructions from the Connecting channels. Ma Bian Cao Herba Verbenae and Wang Bu Liu Xing Semen Vaccariae This combination can also be used for hydrosalpinx: it invigorates Blood, removes obstruction from the Connecting channels and transforms Water. These herbs are often combined with Shi Jian Chuan Herba Salviae chinensis. Xiao Hui Xiang Fructus Foeniculi and Chen Xiang Lignum Aquilariae resinatum This combination can be used for tubal obstruction occurring against a background of Cold. The herbs move Qi, remove obstructions from the Connecting channels, warm the Kidneys and scatter Cold. Pungent and warm, they may therefore injure Yin: for this reason, they should not be used for longer than 5 days at a time. Shi Chang Pu Rhizoma Acori tatarinowii and Dan Nan Xing Rhizoma Arisaematis preparatum This combination can be used for infertility from Dampness and Phlegm. These two herbs resolve Phlegm, open the orifices, arouse the brain and remove Dampness and Phlegm from the Connecting channels. If there is a
pronounced Cold condition, these herbs are often combined with Shi Nan Ye Folia Photiniae serrulatae. Shi Jian Chuan Herba Salviae chinensis and Liu Ji Nu Herba Artemisiae anomalae This combination can be used for pathological changes of the endometrium and ovarian cysts. The herbs clear Heat, transform Water, remove obstructions from the Connecting channels and dissipate nodules. Pu Huang Pollen Typhae and Chi Shao Radix Paeoniae rubra This combination can be used for pathological changes of the endometrium: the herbs invigorate Blood, eliminate stasis and cool Blood. San Leng Rhizoma Sparganii and E Zhu Rhizoma Curcumae This combination can be used for pathological changes of the endometrium. These herbs ‘break’ Blood, eliminate stasis, move Qi and stop pain. Since they ‘break’ Blood, they may injure the Original Qi and should therefore be used sparingly. Ru Xiang Olibanum and Mo Yao Myrrha This combination can be used for pathological changes of the endometrium. These herbs invigorate Blood, eliminate stasis, dissolve swelling and stop pain: they affect both Qi and Blood. Xue Jie Resina Daemonoropis and San Qi Radix Notoginseng This combination can be used for pathological changes of the endometrium. These herbs both remove obstruction and stop fluid and blood leakage; they
invigorate Blood, eliminate stasis, stop pain and arrest bleeding. Sang Ji Sheng Ramulus Sangjisheng and Si Gua Luo Retinervus Luffae fructus This combination can be used for obstruction of the Fallopian tubes. The herbs tonify Liver and Kidneys but also remove obstructions from the Connecting channels. They are often combined with Sang Zhi. Zhi Mu Rhizoma Anemarrhenae and Huang Bo Cortex Phellodendri This combination can be used for pelvic inflammation from Damp-Heat occurring against a background of Kidney-Yin deficiency. The herbs clear Heat and resolve Dampness in the Lower Burner, nourish the Kidneys and clear Empty-Heat.
Empty conditions
Kidney-Yang deficiency
Clinical manifestations Prolonged menstrual cycle, the period could be either scanty or heavy, backache, dizziness, feeling cold, depression, frequent urination. Tongue: Pale, wet. Pulse: Deep, Weak. Treatment principle Tonify and warm Kidney-Yang, stoke up the Fire of the Gate of Life, strengthen the Uterus. Acupuncture KI-13 Qixue, KI-3 Taixi, BL-23 Shenshu, BL-52 Zhishi, Ren-4 Guanyuan, Du-4 Mingmen, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-8 Shenque-Baomen, Zihu. All with reinforcing method; moxa should be used. Explanation
– KI-13, a point of the Penetrating Vessel, nourishes this vessel and also the Directing Vessel, tonifies the Kidneys and strengthens the Uterus. – KI-3, BL-23 and BL-52 tonify the Kidneys, especially Kidney-Yang. BL-52 also nourishes the Essence. – Ren-4, with direct moxa cones, strengthens the Uterus and tonifies the
Kidneys. – Du-4, with direct moxa cones, stokes up the Fire of the Gate of Life. – LU-7 and KI-6 regulate the Directing Vessel and strengthen the Uterus and Kidneys. – Ren-8 with moxibustion with a moxa stick after filling the navel with salt warms the Kidneys and the Essence. It is recommended by Huang Fu Mi in his ABC of Acupuncture where he says: “For infertility, moxa the centre of the navel and conception will result.”4 – Baomen and Zihu are two points located two cun from Ren-4 Guanyuan, Baomen on the right and Zihu on the left. They are sometimes described as extra points although they coincide with ST-28 Shuidao. They are empirical points with a long history of use for infertility. For example, the Thousand Golden Ducat Prescriptions says: In women suffering from infertility, abdominal pain and red vaginal discharge, moxa Baomen with 50 cones: it is situated two cun on the left of Ren-4 Guanyuan. On the right, it is called Zihu.5 – These points can be used also for other types of infertility and especially that from Damp-Phlegm. Special moxibustion prescription
A special moxibustion method for infertility from Kidney-Yang deficiency consists in using moxa on Ren-8 Shenque. The method is as follows: take 2.5 g of moxa wool and add 1 g each of powdered Chuan Jiao Pericarpium Zanthoxyli and Xi Xin Herba Asari, and wet the mixture with a saline solution. Make into a paste. Place this paste in the umbilicus, cover with a thin slice of fresh ginger and apply moxibustion to it with a moxa stick for 30
minutes. After that, leave the paste in the umbilicus, cover with a plaster and remove after 24 hours. Repeat the same procedure for 10 successive days.6 Herbal treatment
a. Prescription
– YU LIN ZHU Variation – Fertility Pearl Variation Explanation The first 12 herbs constitute the formula Yu Lin Zhu which tonifies KidneyYang and promotes fertility. The unicorn is a symbol of fertility, hence the name of the formula which means ‘giving birth to the unicorn pearl’. It is from the Complete Works of Jing Yue (Jing Yue Quan Shu, 1624). – Ren Shen, Bai Zhu and Fu Ling tonify Qi. Ren Shen also tonifies the Original Qi. – Bai Shao, Chuan Xiong, Dang Gui and Shu Di Huang nourish and invigorate Blood (they form the formula Si Wu Tang Four Substances Decoction). – Tu Si Zi, Du Zhong, Lu Jiao Shuang and Chuan Jiao tonify Kidney-Yang and nourish the Governing, Directing and Penetrating Vessels. – Zi He Che nourishes Blood and the Essence. – Dan Shen and Xiang Fu invigorate Blood and move Qi to
counterbalance all the tonics in the formula. – Zhi Gan Cao harmonizes. b. Prescription
– BA ZHEN YI MU TANG Variation – Leonorus Eight Precious Decoction Variation Explanation The first nine herbs constitute the formula Ba Zhen Yi Mu Tang which tonifies Qi and Blood and invigorates Blood. This formula is particularly indicated if, in addition to a deficiency of Kidney-Yang, there is a pronounced deficiency of Blood. – Xiang Fu and Hong Hua are added to move Qi and invigorate Blood to counterbalance all the tonic herbs in the formula. – Fu Pen Zi and Yin Yang Huo tonify and warm Kidney-Yang. c. Prescription
– EMPIRICAL PRESCRIPTION by Dr Shang Xian Min7 Explanation
– Yin Yang Huo, Ba Ji Tian, Tu Si Zi and Fu Pen Zi tonify Kidney-Yang.
– Shu Di Huang, Dang Gui, Bai Shao and Chuan Xiong form the Si Wu Tang Four Substances Decoction which nourishes and invigorates Blood. – Zi He Che, Gou Qi Zi and Wu Wei Zi nourish the Blood and Essence. – Yi Mu Cao invigorates Blood and is added to counterbalance the tonic herbs in the formula. This formula is particularly indicated if there is a pronounced deficiency of Kidney-Essence: with regard to infertility, this would manifest with absent or irregular ovulation. d. Prescription
– ZHU YUN YU LIN FANG – Aiding Pregnancy and Giving Birth to Unicorn Formula This prescription consists of two formulae, one to be taken for 7 days after the period and the other for 8 days during ovulation. Formula I (for 7 days after the period)
– Shu Di Huang and Gui Ban tonify the Kidneys, strengthen the Uterus and nourish the Directing and Penetrating Vessels. – Yin Yang Huo tonifies and warms Kidney-Yang. – Shi Nan Ye tonifies the Kidneys and also removes obstructions from the channels. It can therefore also eliminate any pathogenic factors from the Uterus (such as Dampness or Cold). – Huang Jing, apart from tonifying Qi, nourishes the Kidney-Essence.
– Ding Xiang and Gui Zhi warm the channels and the Uterus. Ding Xiang has also a tonifying action on the Kidneys. – Chuan Niu Xi nourishes the Liver and Kidneys and invigorates Blood. – Fu Ling drains Dampness. Formula II (for 8 days during ovulation)
– Shu Di Huang tonifies the Kidneys. – Shi Nan Ye tonifies the Kidneys and also removes obstructions from the channels. It can therefore also eliminate any pathogenic factors from the Uterus (such as Dampness or Cold). – Yin Yang Huo, Gou Ji, Rou Cong Rong, Xian Mao and Hu Lu Ba tonify and warm Kidney-Yang. – Nu Zhen Zi nourishes Kidney-Yin. Notice that this herb is included in the formula for the 8 days during ovulation because, to promote fertility and stimulate the production of ova, it is necessary to nourish Yin and the Essence. The ova are a direct manifestation of the Kidney-Essence in women, just as sperm is a direct manifestation of the Kidney-Essence in men. – Lu Jiao Shuang tonifies the Kidneys, nourishes Blood and strengthens the Directing and Penetrating Vessels. – Zi Shi Ying warms the Uterus and is used for infertility from Empty-Cold. It also calms the Mind and subdues rebellious Qi. – Fu Ling drains Dampness. Table 57.2 compares and contrasts the formulae for infertility from Kidney-Yang deficiency.
Table 57.2 Comparison of formulae for infertility from Kidney-Yang deficiency
Women’s Treasure remedy
– UNICORN PEARL This remedy tonifies Kidney-Yang, nourishes Blood and Essence and strengthens the Governing Vessel. The tongue presentation appropriate to this remedy is a Pale and wet tongue. Summary Kidney-Yang deficiency
Clinical manifestations
Prolonged menstrual cycle, the period could be either scanty or heavy, backache, dizziness, feeling cold, depression, frequent urination. Tongue: Pale, wet. Pulse: Deep, Weak. Treatment principle
Tonify and warm Kidney-Yang, stoke up the Fire of the Gate of Life, strengthen the Uterus. Acupuncture
KI-13 Qixue, KI-3 Taixi, BL-23 Shenshu, BL-52 Zhishi, Ren-4 Guanyuan, Du-4 Mingmen, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-8 Shenque-Baomen, Zihu. All with reinforcing method; moxa should be used. Herbal treatment
Pre scriptions
• YU LIN ZHU Variation Fertility Pearl Variation • BA ZHEN YI MU TANG Variation Leonorus Eight Precious Decoction Variation • EMPIRICAL PRESCRIPTION by Dr Shang Xian Min • ZHU YUN YU LIN FANG Aiding Pregnancy and Giving Birth to Unicorn Formula Women’s Treasure remedy
• UNICORN PEARL
Case history A 35-year-old woman had been trying to conceive for 2 years. Her periods were regular but scanty, lasting only 2 days. The menstrual blood was bright red and there were no clots. She also complained of dull headaches on the vertex, floaters and dizziness. On interrogation, it transpired that she had also suffered from allergic rhinitis since the age of 17, manifesting with sneezing attacks and a clear, watery nasal discharge. She also complained of backache, occasional tinnitus, feeling cold in general and cold feet. Her tongue was slightly Pale and Swollen with a Heart crack, and her pulse was Weak on both Rear positions and slightly Choppy in general. Her complexion was dull and pale. Diagnosis There are two main patterns: one is Blood deficiency and the other KidneyYang deficiency. The symptoms of Blood deficiency are dull and pale complexion, floaters, scanty periods, dull headaches on the vertex, Choppy pulse and Pale tongue. The manifestations of Kidney-Yang deficiency are feeling cold, cold feet, occasional tinnitus, Weak Kidney pulses and Swollen tongue. I relate allergic rhinitis also to a Kidney-Yang deficiency and specifically a deficiency of what I call ‘Kidney Defensive Qi system’ (see Ch. 6 of the Practice of Chinese Medicine8 ). From a channel point of view, allergic rhinitis also involves a weakness of the Governing Vessel, which is consistent with a deficiency of Kidney-Yang. On the other hand, the Blood and Kidney-Yang deficiency involves a deficiency of the Directing and Penetrating Vessels: thus, in her case, there is a deficiency of the three main Extraordinary Vessels that control fertility, conception and pregnancy. Treatment principle
This patient was already receiving acupuncture and had been referred by her acupuncturist: I therefore treated her only with herbs. I used a variation of Yu Lin Zhu Fertility Pearl: • Ren Shen Radix Ginseng 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Bai Shao Radix Paeoniae alba 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Dang Gui Radix Angelicae sinensis 9 g • Shu Di Huang Radix Rehmannia preparata 9 g • Tu Si Zi Semen Cuscutae 6 g • Du Zhong Cortex Eucommiae 6 g • Lu Jiao Jiao Colla Cornu Cervi 6 g • Gui Ban Plastrum Testudinis 9 g • Dan Shen Radix Salviae miltiorrhizae 4.5 g • Qiang Huo Rhizoma seu Radix Notopterygii 3 g
Explanation
• Ren Shen, Bai Zhu and Fu Ling tonify Qi. Ren Shen also tonifies the Original Qi. • Chuan Xiong, Bai Shao, Dang Gui and Shu Di Huang constitute the formula Si Wu Tang Four Substances Decoction which nourishes Blood.
• Tu Si Zi, Du Zhong and Lu Jiao Jiao tonify Kidney-Yang. Lu Jiao Jiao also nourishes Blood and strengthens the Governing Vessel, which should help her allergic rhinitis, as well as promoting fertility. Tu Si Zi also nourishes the Essence. • Gui Ban nourishes the Kidneys and strengthens the Directing and Penetrating Vessels. • Dan Shen invigorates Blood and calms the Mind. This was added because of the Heart crack on the tongue. • Qiang Huo was added as a herb that enters the Governing Vessel and expels Wind, to treat the allergic rhinitis. • Zhi Gan Cao harmonizes.
After one course of this prescription (1 month) she felt better in general and the rhinitis got better as well. I continued treating her with similar prescriptions for 7 months after which she became pregnant. As she had quite a severe deficiency of Blood and Kidney-Yang, I treated her during the first few months of pregnancy to prevent miscarriage with a simple formula to tonify Kidney-Yang and ‘calm the fetus’: • Tu Si Zi to tonify Kidney-Yang and calm the fetus. • Sang Ji Sheng and E Jiao to nourish Blood and calm the fetus.
Because I usually prefer not to give herbs in the first 3 months of pregnancy at all, I kept the number to a minimum. I chose the above three herbs, using 6 g each, because they would address her two main deficiencies and calm the fetus, i.e. prevent miscarriage. After 9 months, she gave birth to a healthy baby. Case history A 35-year-old woman had been trying to conceive for 2 years. She had conceived but miscarried 3 months previously. Her periods were regular, they lasted 4–5 days and the menstrual blood’s colour was normal. She often felt cold, especially in her feet. She also tired easily and occasionally suffered
from headaches. Her tongue was of a normal colour, except for being Red on the tip and sides, and the tongue body was Thin. Her pulse was Weak on both Rear positions and relatively Overflowing on the left Front position. Diagnosis Although there are few symptoms, we can diagnose a Kidney-Yang deficiency from the general cold feeling, cold feet, tiredness, the infertility itself, the miscarriage and the Weak pulse on both Kidney positions. The Kidney deficiency has given rise to some Liver-Yang rising (headaches and Red sides of the tongue) and Heart-Fire (Red tip of the tongue and Overflowing Heart pulse). Treatment principle The treatment principle adopted was to tonify and warm Kidney-Yang, promote fertility and clear Heart-Fire. I treated her with acupuncture and a prepared remedy first, then a decoction. Acupuncture
The acupuncture was very simple and the points selected were: • ST-36 Zusanli and SP-6 Sanyinjiao with warm needle, to tonify Qi and Yang in general. • KI-3 Taixi and BL-23 Shenshu, with warm needle to tonify Kidney-Yang. • P-7 Daling to clear Heart-Fire and calm the Mind. Herbal treatment
I first gave her the herbal remedy You Gui Wan Restoring the Right [Kidney] Pill which tonifies Kidney-Yang. I later prescribed a decoction for
her using a variation of the formula from Dr Shang Xian Min: • Yin Yang Huo Herba Epimedii 6 g • Ba Ji Tian Radix Morindae officinalis 6 g • Tu Si Zi Semen Cuscutae 6 g • Shu Di Huang Radix Rehmannia preparata 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Bai Shao Radix Paeoniae alba 6 g • Yi Mu Cao Herba Leonuri 4.5 g • Gou Qi Zi Fructus Lycii 6 g • Wu Wei Zi Fructus Schisandrae 3 g • Huang Qin Radix Scutellariae 4.5 g • Yuan Zhi Radix Polygalae 6 g • Mu Dan Pi Cortex Moutan 6 g
Explanation The first 10 herbs constitute the original formula by Dr Shang Xian Min, minus Zi He Che Placenta hominis and Fu Pen Zi Fructus Rubi. • Huang Qin and Yuan Zhi were added to clear Heart-Fire and calm the Mind. • Mu Dan Pi was added to clear Liver-Heat.
I treated her for 4 months with this formula, at the end of which she became pregnant. Since she had had a miscarriage, I treated her during the first 3 months with the following herbs which prevent miscarriage:
• Huang Qin Radix Scutellariae 4.5 g • Du Zhong Cortex Eucommiae 6 g • Zi Su Ye Folium Perillae 4.5 g • Sha Ren Fructus Amomi 3 g
I chose Huang Qin among the fetus-calming herbs because of her preexisting Heart-Fire and Du Zhong because of the Kidney-Yang deficiency. The other two herbs also calm the fetus to prevent miscarriages. After 9 months, she gave birth to a healthy baby.
Kidney-Yin deficiency
Clinical manifestations Long-term infertility, periods early, scanty, with light-coloured blood, fivepalm heat, night sweating, dizziness, tinnitus. Tongue: without coating; also Red if there is Empty-Heat. Pulse: Floating-Empty or Rapid-Fine (in case of Empty-Heat). Treatment principle Nourish Kidney-Yin and Kidney-Essence. Acupuncture Ren-4 Guanyuan, Ren-7 Yinjiao, KI-3 Taixi, KI-13 Qixue, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), BL-52 Zhishi. All with reinforcing method; generally speaking, no moxa should be used. However, if the tongue is not Red or only slightly Red and the pulse is very Fine, a small amount of moxa (as a warm needle) on KI-3 is beneficial to increase the tonifying effect. Explanation
– Ren-4 tonifies the Kidneys, nourishes Yin, strengthens the Uterus and the Directing and Penetrating Vessels. – Ren-7 nourishes Yin.
– KI-3 and SP-6 nourish Kidney-Yin. – KI-13, a Penetrating Vessel point, tonifies the Kidneys, strengthens the Uterus and nourishes the Penetrating Vessel. – LU-7 and KI-6 regulate the Directing Vessel and nourish the Kidneys. – BL-52 nourishes the Kidney-Essence. Herbal treatment
a Prescription
– YANG JING ZHONG YU TANG Variation – Nourishing the Essence and Growing Jade Decoction Variation Explanation The first four herbs constitute the formula Yang Jing Zhong Yu Tang which tonifies the Kidneys, nourishes the Essence and Blood and promotes fertility. ‘Jade’ has the double meaning of ‘child’, hence the name of the formula. – Nu Zhen Zi and Han Lian Cao constitute the formula Er Zhi Wan Two Solstices Pill which nourishes Kidney-Yin and clears Empty-Heat. b Prescription
– EMPIRICAL PRESCRIPTION by Dr Shan Dao Wei
Explanation
– Sheng Di Huang, Bai Shao, Xuan Shen and Mai Men Dong nourish Yin. Xuan Shen also clears Empty-Heat and cools Blood. – Di Gu Pi and Qing Hao clear Empty-Heat. – Gou Qi Zi nourishes Blood, Yin and Essence. – Dan Shen invigorates Blood and calms the Mind. – Yi Mu Cao invigorates Blood. Compared with the previous formula, the present one is better at clearing the Empty-Heat that arises from Yin deficiency: it is therefore suitable when the tongue is particularly Red. c. Prescription
– EMPIRICAL PRESCRIPTION by Dr Zhu Nan Sun9 Explanation
– Dang Gui, Bai Shao and Bai Zi Ren nourish Blood. – Dan Shen and Chuan Xiong invigorate Blood and eliminate stasis. – Sheng Di Huang, Shu Di Huang, Xuan Shen, Bei Sha Shen, Mai Men Dong and Shan Zhu Yu tonify Liver and Kidneys and nourish Yin. – Zi He Che nourishes Blood and the Essence.
– Shan Yao tonifies the Spleen and Kidneys. – Rou Cong Rong and Ba Ji Tian tonify Kidney-Yang. Dr Zhu Nan Sun places the emphasis very much on Kidney-Yang for the treatment of infertility and he therefore uses Kidney-Yang tonics even in Yin-nourishing formulae. The formula reflects this approach with the inclusion of Rou Cong Rong and Ba Ji Tian. Compared with the previous two formulae, the present one is better when there is a combined deficiency of Kidney-Yin and Kidney-Yang, albeit with a predominance of Kidney-Yin deficiency. Women’s Treasure remedy
– GROWING JADE This remedy nourishes Kidney-Yin, Kidney-Essence and Blood and strengthens the Directing and Penetrating Vessels. The tongue presentation appropriate to this remedy is a Red body without coating. Summary Kidney-Yin deficiency
Clinical manifestations
Long-term infertility, periods early, scanty, with light-coloured blood, fivepalm heat, night sweating, dizziness, tinnitus. Tongue: without coating; also Red if there is Empty-Heat. Pulse: Floating-Empty or Rapid-Fine (in case of Empty-Heat). Treatment principle
Nourish Kidney-Yin and Kidney-Essence. Acupuncture
Ren-4 Guanyuan, Ren-7 Yinjiao, KI-3 Taixi, KI-13 Qixue, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), BL-52 Zhishi. All with reinforcing method; generally speaking, no moxa should be used. However, if the tongue is not Red or only slightly Red and the pulse is very Fine, a small amount of moxa (as a warm needle) on KI-3 is beneficial to increase the tonifying effect. Herbal treatment
Pre scriptions
• YANG JING ZHONG YU TANG Variation Nourishing the Essence and Growing Jade Decoction Variation • EMPIRICAL PRESCRIPTION by Dr Shan Dao Wei • EMPIRICAL PRESCRIPTION by Dr Zhu Nan Sun Women’s Treasure remedy
• GROWING JADE
Blood deficiency
Clinical manifestations Scanty periods, pale blood, delayed cycle, tiredness, depression, dizziness, pale complexion, blurred vision. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle Nourish Blood and the Essence, strengthen the Liver and Kidneys. Acupuncture Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-13 Qixue, BL-20 Pishu, BL-23 Shenshu, BL-17 Geshu, abdomen Zi Gong (three cun lateral to Ren-3). All with reinforcing method; moxa is applicable. Explanation
– Ren-4 nourishes Blood and strengthens the Uterus. – ST-36 and SP-6 nourish Blood. – KI-13, a point of the Penetrating Vessel, tonifies the Kidneys and strengthens the Uterus. – BL-20 and BL-23 tonify the Spleen and Kidneys to nourish Blood. – BL-17, with direct moxa cones, nourishes Blood.
– Zi Gong nourishes the Essence, strengthens the Uterus and promotes fertility. Herbal treatment
Prescription
– BA ZHEN TANG – Eight Precious Decoction Explanation This formula, which has already been explained, nourishes Blood. Women’s Treasure remedies
– PRECIOUS SEA This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood. The tongue presentation appropriate to this remedy is a Pale and Thin body. Summary Blood deficiency
Clinical manifestations
Scanty periods, pale blood, delayed cycle, tiredness, depression, dizziness, pale complexion, blurred vision. Tongue: Pale and Thin. Pulse: Choppy or Fine. Treatment principle
Nourish Blood and the Essence, strengthen the Liver and Kidneys. Acupuncture
Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-13 Qixue, BL-20 Pishu, BL-23 Shenshu, BL-17 Geshu, abdomen Zi Gong (three cun lateral to Ren-3). All with reinforcing method; moxa is applicable. Herbal treatment
Pre scription
• BA ZHEN TANG Eight Precious Decoction Women’s Treasure remedy
• PRECIOUS SEA
Case history A 33-year-old woman had been trying to conceive for 4 years. She had been told that her failure to conceive was due to an ovarian irregularity. She had had IVF treatment twice but both times she miscarried (at 10 and 12 weeks). After her second miscarriage her period did not come for 6 months. Her periods were regular but scanty, lasting only 2 days, with bright red
blood. She also complained of constipation and anaemia. Her tongue was Pale and Short and her pulse was Choppy. Diagnosis This is a very clear case of Blood deficiency as evidenced by the Choppy pulse, Pale tongue, scanty period and infertility itself. The tongue is Short because the Blood deficiency deprives it of fluids: this makes it less supple and therefore it does not protrude as far as usual. The shortness of the tongue indicates that the Blood deficiency is severe. The fact that the periods did not come for 6 months after her second miscarriage also indicates Blood deficiency. Treatment principle I treated this patient only with herbs and used my own prescription as follows: – Shu Di Huang Radix Rehmannia preparata 9 g – Bai Shao Radix Paeoniae alba 6 g – Dang Gui Radix Angelicae sinensis 6 g – Shan Zhu Yu Fructus Corni 6 g – Gou Qi Zi Fructus Lycii 6 g – Shou Wu Radix Polygoni multiflori preparata 6 g – Tu Si Zi Semen Cuscutae 6 g – Huang Jing Rhizoma Polygonati 6 g – Nu Zhen Zi Fructus Ligustri lucidi 6 g – Sang Ji Sheng Herba Taxilli 6 g
– Ji Xue Teng Caulis Spatholobi 6 g – Zhi Gan Cao Radix Glycyrrhizae preparata 3 g
Explanation
• Shu Di Huang, Bai Shao, Dang Gui, Gou Qi Zi, Shou Wu and Sang Ji Sheng nourish Blood. Shu Di Huang, Gou Qi Zi and Shou Wu also nourish the Essence. • Huang Jing tonifies Qi and Blood and nourishes the Essence. • Shan Zhu Yu nourishes the Liver and Kidneys and the Essence. • Tu Si Zi nourishes the Essence and promotes ovulation. • Nu Zhen Zi nourishes Liver- and Kidney-Yin and promotes ovulation.
I added a Yin tonic (apart from Gou Qi Zi which is also a Yin tonic) for two reasons: first of all, ‘promoting ovulation’ implies nourishing the Essence and especially its Yin aspect; second, the shortness of her tongue shows that the deficiency of Blood is very severe and is bordering on Yin deficiency. • Ji Xue Teng nourishes and invigorates Blood. • Zhi Gan Cao harmonizes.
I treated her with variations of this formula for nearly a year, after which she became pregnant and later gave birth to a healthy baby. Case history A 32-year-old woman had been trying to conceive for 2 years. She had become pregnant 2 years previously but had a miscarriage at 26 weeks. Her periods were regular and rather heavy, lasting 1 week. There was no pain and the blood was bright red. She also suffered from dizziness and blurred vision. Her tongue was Pale and Swollen and her pulse was Rapid and Empty.
Diagnosis This is a clear case of Qi and Blood deficiency even though she has few symptoms. Qi deficiency causes her periods to be heavy, the tongue Swollen and the pulse Empty. The Blood deficiency is evidenced by the Pale tongue, dizziness and blurred vision. I interpreted the Rapid pulse as being due to shock: this was apparent also from the look of her eyes which were dull and rather unstable. Treatment principle I treated this patient with acupuncture and herbs. The acupuncture was very simple and the points used were selected from the following: • ST-36 Zusanli and SP-6 Sanyinjiao to tonify Qi and nourish Blood. • HE-7 Shenmen to calm the Mind after the shock. • Ren-4 Guanyuan to nourish Blood.
I used a variation of the formula Ba Zhen Tang Eight Precious Decoction: • Dang Gui Radix Angelicae sinensis 9 g • Shu Di Huang Radix Rehmannia preparata 6 g • Bai Shao Radix Paeoniae alba 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Dang Shen Radix Codonopsis 6 g • Fu Ling Poria 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g
• Shou Wu Radix Polygoni multiflori preparata 6 g • Gou Qi Zi Fructus Lycii 6 g • Suan Zao Ren Semen Ziziphi spinosae 4.5 g
Explanation The first eight herbs constitute the formula Ba Zhen Tang Eight Precious Decoction which tonifies Qi and nourishes Blood. • Shou Wu and Gou Qi Zi nourish Blood and the Essence. • Suan Zao Ren nourishes and calms the Mind.
After 9 months of this treatment she became pregnant and gave birth to a healthy baby.
Full conditions
Cold in the Uterus
Clinical manifestations Primary infertility, delayed cycle, scanty period, small clots, painful period, better with heat, feeling colder during period, pale face, feeling cold, sore back. Tongue: Pale with thick, white coating. Pulse: Weak, Tight. This is a condition of Empty-Cold in the Uterus from Kidney-Yang deficiency: it is more common in young women or young girls. Treatment principle Warm and tonify Kidney-Yang, warm the Uterus, scatter Cold. Acupuncture Ren-2 Qugu, Ren-4 Guanyuan, Du-4 Mingmen, KI-7 Fuliu, BL-23 Shenshu, Ren-7 Yinjiao (Ren-7 and Du-4 make a combination). All with reinforcing method; moxa should be used. Explanation
– Ren-2, with direct moxa cones, scatters Cold in the Uterus. – Ren-4, with direct moxa cones, warms Kidney-Yang and tonifies the Uterus. – Du-4, with direct moxa cones, warms the Fire of the Gate of Life and strengthens the Governing Vessel.
– KI-7 and BL-23 tonify Kidney-Yang. – Ren-7, nourishes the Kidneys and strengthens the Uterus. Ren-7 and Du-4 in combination warm the Uterus and the Kidneys and scatter Cold from the Uterus. Herbal treatment
a. Prescription
– AI FU NUAN GONG WAN and JU HE WAN – Artemisia-Cyperus Warming the Uterus Pill and Semen Citri reticulatae Pill Explanation The first 10 herbs constitute the formula Ai Fu Nuan Gong Wan which nourishes Blood, tonifies Kidney-Yang and expels Cold from the Uterus. The last three herbs constitute the formula Ju He Wan which warms the Uterus and scatters Cold. b. Prescription
– EMPIRICAL PRESCRIPTION by Dr Shang Xian Min10 Explanation
– Xiao Hui Xiang, Rou Gui, Wu Zhu Yu and Gan Jiang warm the Kidneys and the Uterus and expel Cold. – Wu Yao moves Qi and expels Cold. – Yin Yang Huo tonifies and warms Kidney-Yang. – Dang Gui, Chuan Xiong and Chi Shao nourish and invigorate Blood. – Pu Huang, Wu Ling Zhi and Yan Hu Suo invigorate Blood and eliminate stasis. – Cang Zhu resolves Dampness. Compared with the previous formula, this prescription is more warming and its Cold-expelling effect is much stronger. Another difference is that it addresses the stasis of Blood that might derive from Cold. The tongue presentation appropriate to this formula is therefore a Bluish-Purple body. This formula is also suitable if there is obstruction of the fallopian tubes. c. Prescription
– WEN JING TANG – Warming the Menses Decoction Explanation
– Wu Zhu Yu, Gui Zhi and Sheng Jiang warm the Uterus and expel Cold. – Dang Gui, Chuan Xiong, Bai Shao and E Jiao nourish and invigorate Blood.
– Dang Shen tonifies Qi to nourish Blood. – Mai Men Dong nourishes Yin to help to nourish Blood. – Mu Dan Pi clears any Empty-Heat that might arise from Blood deficiency. For this reason, although this formula is for Cold in the Uterus, one of its symptoms is a feeling of heat in the face. – Ban Xia regulates the Penetrating Vessel: it does so because of the close relationship between the Stomach channel (which Ban Xia affects) and this vessel through the point ST-30 Qichong. – Zhi Gan Cao harmonizes. Table 57.3 compares and contrasts the above three prescriptions. Table 57.3 Comparison of formulae for infertility from Cold
Women’s Treasure remedy
– WARM THE MANSION
This remedy is a variation of the formula Ai Fu Nuan Gong Wan Artemisia-Cyperus Warming the Uterus Pill which expels Cold and warms the Uterus. The tongue presentation appropriate to this remedy is a Pale and wet body. Summary Cold in Uterus
Clinical manifestations
Primary infertility, delayed cycle, scanty period, small clots, painful period, better with heat, feeling colder during period, pale face, feeling cold, sore back. Tongue: Pale with thick, white coating. Pulse: Weak, Tight. Treatment principle
Warm and tonify Kidney-Yang, warm the Uterus, scatter Cold. Acupuncture
Ren-2 Qugu, Ren-4 Guanyuan, Du-4 Mingmen, KI-7 Fuliu, BL-23 Shenshu, Ren-7 Yinjiao (Ren-7 and Du-4 make a combination). All with reinforcing method; moxa should be used. Herbal treatment
Pre scriptions
• AI FU NUAN GONG WAN and JU HE WAN Artemisia-Cyperus Warming the Uterus Pill and Semen Citri reticulatae Pill
• EMPIRICAL PRESCRIPTION by Dr Shang Xian Min • WEN JING TANG Warming the Menses Decoction Women’s Treasure remedies
• WARM THE MANSION
Case history A 28-year-old woman had been trying to conceive for 3 years. She had not had a normal ovulation since 16 years old and, without hormonal treatment, she had no menstrual cycle. She did not have many symptoms apart from a pronounced cold feeling, and a liking for very hot baths. She did, however, also experience a feeling of heat in the face occasionally. Her tongue was Pale and her pulse was Tight and Full. Diagnosis In this case, infertility is clearly due to obstruction of the Uterus by Cold. Although there are few symptoms, the pronounced cold feeling, the Pale tongue and the Full-Tight pulse indicate Cold. Given that she had had no normal ovulation since the age of 16, presumably external Cold had invaded the Uterus, perhaps through her playing school sports in shorts in the cold and damp environment of the British isles: these are extremely common aetiological factors in young women in Britain, causing infertility or dysmenorrhoea. The diagnosis of Cold, and therefore of a Full condition, was also somewhat confirmed by the fact that she had already had Chinese herbs from another practitioner and they made her feel very tired and heavy. I enquired of the practitioner and he confirmed that he had prescribed a Kidney tonic formula: I therefore deduced that she felt tired and heavy after it because she needed the elimination of pathogenic factors rather than
tonifying. However, my prognosis was not good as I felt that, since she had not had normal ovulation since the age of 16, it might be difficult to adjust this. Treatment principle I prescribed a variation of Wen Jing Tang Warming the Menses Decoction: • Wu Zhu Yu Fructus Evodiae 9 g • Gui Zhi Ramulus Cinnamomi 9 g • Sheng Jiang Rhizoma Zingiberis recens 6 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Bai Shao Radix Paeoniae alba 9 g • Dang Shen Radix Codonopsis 12 g • Mai Men Dong Radix Ophiopogonis 6 g • E Jiao Colla Corii asini 9 g • Mu Dan Pi Cortex Moutan 4.5 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Rou Gui Cortex Cinnamomi 1.5 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Yi Mu Cao Herba Leonuri 6 g
Explanation
The first 12 herbs constitute the formula Wen Jing Tang which has been explained above. It seemed to fit her case very well considering that she even had some hot flushes from Blood deficiency (for which the formula uses Mu Dan Pi). • Rou Gui was added to warm the Uterus and expel Cold. • Nu Zhen Zi nourishes the Liver and Kidneys and the Essence and promotes ovulation. Although this is a Yin tonic, I added it because to promote ovulation it is necessary to nourish the Yin aspect of the Essence. • Yi Mu Cao invigorates Blood.
I treated her for 6 months with variations of this formula without results, after which she discontinued the treatment. It is difficult to establish whether the treatment might have been successful if she had continued but my feeling is that it probably would not have been. Case history A 34-year-old woman had been trying to conceive for 5 years. Her periods were regular but very scanty, lasting only 2 days. The blood was of a normal red colour and had small, dark clots. Tests revealed that she had an anovulatory cycle with a flat temperature chart. She was constipated, having a bowel movement every 2 days. The skin on her scalp was dry and scaly and her feet and hands were always very cold. Her tongue was Pale-Purple with a few Purple spots on the sides (Plate 8), and her pulse was Slow, Tight and Weak on both Rear positions. Diagnosis This was a clear case of Empty-Cold in the Uterus against a background of Kidney-Yang and Blood deficiency. The symptoms of Cold in the Uterus are the small, dark clots, the Pale-Purple tongue and the Tight and Slow pulse.
Symptoms of Blood deficiency are scanty period, dry scalp and Pale tongue. The symptoms of Kidney-Yang deficiency are cold hands and feet, Pale tongue, scanty period and the Weak pulse on both Rear positions. All her three main patterns (Cold, Kidney-Yang deficiency and Blood deficiency) may cause constipation. Treatment principle I treated this patient only with herbal medicine and prescribed a variation of Wen Jing Tang Warming the Menses Decoction: • Wu Zhu Yu Fructus Evodiae 3 g • Gui Zhi Ramulus Cinnamomi 4.5 g • Sheng Jiang Rhizoma Zingiberis recens 6 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Bai Shao Radix Paeoniae alba 9 g • Dang Shen Radix Codonopsis 6 g • Mai Men Dong Radix Ophiopogonis 6 g • E Jiao Colla Corii Asini 6 g • Mu Dan Pi Cortex Moutan 4.5 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Fu Zi Radix Aconiti lateralis preparata 1.5 g
Explanation The first 12 herbs constitute the formula Wen Jing Tang which scatters Cold, strengthens the Uterus and nourishes Blood. This formula does not tonify Kidney-Yang as its main emphasis is to expel Cold from the Uterus. • Shu Di Huang was added to tonify the Kidneys and nourish Blood. • Fu Zi was added to expel Cold from the Uterus.
I used slight variations of this formula for 3 months during which her tongue became less Pale and less Purple. She then became pregnant but had a miscarriage during the second month. I then used the same formula Wen Jing Tang but with the addition of some Kidney-Yang tonics which also prevent miscarriage, such as Tu Si Zi Semen Cuscutae, Xu Duan Radix Dipsaci and Du Zhong Cortex Eucommiae. After 3 months, she conceived and later gave birth to a healthy girl.
Dampness in the Lower Burner
Clinical manifestations Irregular periods, delayed cycle, mid-cycle pain, vaginal discharge, long-term infertility, adhesions, obesity, feeling of heaviness. Tongue: sticky coating. Pulse: Slippery. Treatment principle Resolve Dampness, remove obstructions from the Directing and Penetrating Vessels. Acupuncture Ren-3 Zhongji, Zigong, ST-28 Shuidao, SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-9 Shuifen, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), ST-30 Qichong, KI-14 Siman, BL-32 Ciliao. All with reducing or even method. No moxa. For Damp-Heat in the Lower Burner with other Girdle Vessel symptoms use G.B.-41 Zulinqi (on the right) and T.B.-5 Waiguan (on the left), plus G.B.-26 Daimai, BL-32 Ciliao and Ren-4 Guanyuan, in combination, with electrical stimulation. Explanation
– Ren-3 strengthens the Uterus and resolves Dampness. – Zigong, an extra point three cun from Ren-3, removes obstructions from the Uterus and Fallopian tubes. It is often used in combination with Ren-3.
– ST-28, SP-9, SP-6 and Ren-9 resolve Dampness. – LU-7 and KI-6 regulate the Directing Vessel and strengthen the Uterus. – ST-30, a point of the Penetrating Vessel, regulates the Penetrating Vessel and invigorates Blood. By invigorating Blood in this vessel, it helps to transform Water. – KI-14, a point of the Penetrating Vessel, eliminates stagnation of Water. – BL-32 drains Dampness from the genital system. – G.B.-41 (on the right) and T.B.-5 (on the left) regulate the Girdle Vessel and drain Dampness. They are used instead of LU-7 and KI-6 if there are symptoms of the Girdle Vessel which include Damp-Heat in the genital system, vaginal discharge, a feeling of heaviness of the abdomen, an abdominal pain that extends to the loins and a pulse that is Wiry on both Middle positions. – G.B.-26 is a Girdle Vessel point that resolves Damp-Heat in the genital system. It should be used in conjunction with the opening points G.B.-41 and T.B.-5. – BL-32 (electric stimulation with negative pole) and Ren-4 (electric stimulation with positive pole), in combination, is a modern treatment which is used specifically for obstruction of the Fallopian tubes. For this treatment, the patient needs to lie on her side. Herbal treatment
a. Prescription
– QI GONG WAN – Arousing the Uterus Pill Explanation
– Ban Xia, Cang Zhu, Chen Pi and Fu Ling resolve Dampness. – Xiang Fu moves Qi, which helps to resolve Dampness. – Shen Qu resolves accumulation of Food, which helps to resolve Dampness. – Chuan Xiong invigorates Blood: this also helps to resolve Dampness. The main emphasis of this formula is in resolving Dampness. The tongue presentation appropriate to this formula is a thick, sticky, white coating. b. Prescription
– EMPIRICAL PRESCRIPTION (I) by Dr Shang Xian Min11 Explanation
– Shan Zha resolves food accumulation which helps to resolve Dampness. – Xian Mao, Yin Yang Huo, Tu Si Zi and Fu Pen Zi tonify and warm Kidney-Yang. – Dan Nan Xing, Ban Xia, Fu Ling and Bai Zhu tonify Qi and resolve Dampness and Phlegm.
– Xiang Fu and Zhi Ke move Qi, which helps to resolve Dampness. – Chuan Xiong and Ze Lan invigorate Blood and eliminate stasis, which helps to resolve Dampness. This formula resolves Cold-Dampness and tonifies Kidney-Yang. The tongue presentation appropriate to this formula is therefore a Pale body with a thick, sticky, white coating. c. Prescription
– EMPIRICAL PRESCRIPTION (II) by Dr Shang Xian Min12 Explanation
– Chai Hu, Chuan Lian Zi and Zhi Shi move Qi: this helps to resolve Dampness. – Chi Shao, Yan Hu Suo and Lu Lu Tong invigorate Blood and eliminate stasis. Lu Lu Tong also resolves Dampness and removes obstructions from the channels: it is specific for ovarian cysts. – Hong Teng, Bai Jiang Cao and Da Huang resolve Toxic-Heat. These herbs are included to deal with any inflammatory obstructions of the fallopian tubes. – Bi Xie resolves Dampness. – Gan Cao harmonizes. This formula is for Damp-Heat with stasis of Blood manifesting with abdominal pain, pelvic inflammation and salpingitis.
d. Prescription
– EMPIRICAL PRESCRIPTION by Dr Shan Dao Wei Explanation This formula consists of two prescriptions, one to be used for 6 days after the end of the period and the other for 6 days at mid-cycle starting from the twelfth day after the beginning of the period. They are for obstruction of the Lower Burner by Dampness together with deficiency of the Kidneys and stasis of Blood (a common occurrence). Since the second prescription strongly invigorates Blood and eliminates stasis, they should be used only when there is an obvious stasis of Blood (in addition to Dampness and Kidney deficiency): thus, the tongue presentation appropriate to this formula is a Pale-Purple body with a sticky coating. Prescription I (after the end of the period for 6 days) This prescription tonifies Qi and Kidney-Yang and resolves Dampness. – Yin Yang Huo, Ba Ji Tian, Lu Jiao and Tu Si Zi tonify Kidney-Yang. Lu Jiao also strengthens the Governing Vessel. – Shan Yao and Bai Zhu tonify Spleen-Qi and help to resolve Dampness. – Cang Zhu and Dan Nan Xing resolve Dampness and Phlegm. – Bai Jie Zi is a hot herb that resolves Cold Phlegm. – Xiang Fu moves Qi, which helps to resolve Dampness. – Dang Gui nourishes Blood.
– Shi Chang Pu opens the orifices, which helps to resolve Dampness and Phlegm. – Hai Zao softens and resolves masses: in combination with Phlegmresolving herbs (such as Cang Zhu and Dan Nan Xing above) it helps to dissolve masses, in this case ovarian cysts or inflammatory obstructions of the fallopian tubes. – Yi Mu Cao invigorates Blood and eliminates stasis, which helps also to resolve Dampness. Prescription II (mid-cycle, from 12th day after the first day of the period, for 6 days) This formula nourishes and invigorates Blood and eliminates stasis. – Dang Gui and Ji Xue Teng nourish and invigorate Blood. – Dan Shen, Chuan Xiong, Chi Shao, Liu Ji Nu, Ze Lan, Yi Mu Cao and Hong Hua invigorate Blood and eliminate stasis. Ze Lan ‘breaks’ Blood and resolves Dampness. – Xiang Fu moves Qi, which helps to invigorate Blood. – Rou Gui warms the Fire of the Gate of Life and expels Cold. – Zao Jiao resolves Phlegm and opens the orifices. e. Prescription
– SAN QI HONG TENG TANG – Notoginseng-Sargentodoxa Decoction
This formula consists of three prescriptions: counting day 1 as the first day of the period, the first prescription is to be taken from day 1 to 10, the second from day 11 to 20 and the third from day 21 to 28. The three formulae together are for complex conditions of infertility caused by Dampness, Heat, stasis of Blood and Toxic-Heat. The tongue presentation appropriate to this formula is a Reddish-Purple body with a sticky, yellow coating. In Western medicine, this often corresponds to conditions of fallopian tube infection or ovarian cysts. Three months constitute one course and the prescriptions should be taken for at least two courses. Prescription I
– Hong Teng, Jin Yin Hua and Yi Yi Ren resolve Toxic-Heat. Yi Yi Ren also drains Dampness. – San Qi, Dang Gui, Chuan Xiong and Tao Ren invigorate Blood and eliminate stasis. – Xiang Fu moves Qi, which helps to invigorate Blood. – Mai Men Dong nourishes Yin: this is added to prevent injury of Yin from the other herbs in the formula. Prescription II
– Dang Gui, Chi Shao, Dan Shen, E Zhu, Wu Ling Zhi, San Qi and Shui Zhi invigorate Blood and eliminate stasis. – Hong Teng and Pu Gong Ying resolve Toxic-Heat. – Gui Ban and Xuan Shen nourish Yin: this is necessary to protect the Yin from injury by the many pungent herbs in the formula. Gui Ban also nourishes
the Directing and Penetrating Vessels. Prescription III
– Jin Yin Hua, Bai Jiang Cao and Da Qing Ye resolve Toxic-Heat. – Xiang Fu and Chuan Lian Zi move Qi, which helps to invigorate Blood. – Qian Cao Gen, Yi Mu Cao, Yan Hu Suo, San Qi and Ji Xue Teng invigorate Blood and eliminate stasis. – Jin Ying Zi, an astringent herb, nourishes and stabilizes the Essence. f. Prescription
– SI MIAO SAN – Four Wonderful Powder Explanation This formula drains Damp-Heat from the Lower Burner and the genital system. The tongue presentation appropriate to this formula is a sticky, yellow coating. – Cang Zhu and Huang Bo resolve Dampness from the Lower Burner: they form the Er Miao San Two Wonderful Powder. – Niu Xi directs the herbs to the Lower Burner. – Yi Yi Ren drains Dampness, resolves Toxic-Heat and eliminates pus.
Together with the others, it makes the formula suitable for inflammatory pathologies of the genital system (such as salpingitis or pelvic inflammatory disease). g. Prescription
– EMPIRICAL PRESCRIPTION by Dr Zhu Nan Sun Explanation
– Sheng Di Huang and Mu Dan Pi cool Blood. – Pu Gong Ying, Hong Teng, Bai Jiang Cao and Zi Hua Di Ding resolve Toxic-Heat. – Yu Jin, Yan Hu Suo and Liu Ji Nu invigorate Blood and eliminate stasis. – Chai Hu moves Qi and eliminates stagnation. – Zhi Mu and Huang Bo resolve Damp-Heat in the Lower Burner and clear Empty-Heat. Compared with the previous formulae, this prescription places the emphasis on resolving Toxic-Heat more than on Damp-Heat. It also invigorates Blood and moves Qi. It therefore has the strongest action in resolving Toxic-Heat. Table 57.4 compares and contrasts the above seven formulae for infertility from Dampness. Table 57.4 Comparison of formulae for infertility from Dampness
Women’s Treasure remedy
– DRAIN REDNESS This remedy clears Heat and resolves Dampness from the Uterus. The tongue presentation appropriate to this remedy is a sticky, yellow coating on the root. Summary Dampness in the Lower Burner
Clinical manifestations
Irregular periods, delayed cycle, mid-cycle pain, vaginal discharge, long-term infertility, adhesions, obesity, feeling of heaviness. Tongue: sticky coating. Pulse: Slippery. Treatment principle
Resolve Dampness, remove obstructions from the Directing and Penetrating Vessels. Acupuncture
Ren-3 Zhongji, Zigong, ST-28 Shuidao, SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-9 Shuifen, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), ST-30 Qichong, KI-14 Siman, BL-32 Ciliao. All with reducing or even method. No moxa. Herbal treatment
Pre scriptions
• QI GONG WAN Arousing the Uterus Pill • EMPIRICAL PRESCRIPTION (I) by Dr Shang Xian Min • EMPIRICAL PRESCRIPTION (II) by Dr Shang Xian Min • EMPIRICAL PRESCRIPTION by Dr Shan Dao Wei • SAN QI HONG TENG TANG Notoginseng-Sargentodoxa Decoction • SI MIAO SAN Four Wonderful Powder • EMPIRICAL PRESCRIPTION by Dr Zhu Nan Sun Women’s Treasure remedy
• DRAIN REDNESS
Case history A 33-year-old woman had been trying to conceive for 2 years. She had earlier borne two children, now aged 6 and 8. Her periods had a long cycle (35 days), they lasted 5 days and the blood was dark at the beginning and brown, mucus towards the end. She had had cysts on her ovaries, one removed 13 years before and the other treated by laser 2 years previously. She also suffered from epigastric fullness and distension, loose stools, tiredness, a feeling of heaviness, backache, dizziness and, occasionally, tinnitus. Her tongue was Pale with a sticky, white coating. Her Pulse was Weak, especially on both Rear positions, and slightly Slippery. Diagnosis
This patient’s conditions was characterized by Dampness (mucus menstrual blood, epigastric fullness and distension, feeling of heaviness, sticky tongue coating and Slippery pulse), and a deficiency of the Spleen (tiredness, loose stools) and Kidney-Yang (Pale tongue, backache, dizziness, tinnitus, Weak pulse on both Rear positions). Treatment principle I decided, as I often do, to expel pathogenic factors before tonifying the Spleen and Kidneys. I therefore prescribed a variation of the formulae for infertility from Dampness by Dr Shan Dao Wei. Prescription I (after the end of the period for 6 days)
• Yin Yang Huo Herba Epimedii 3 g • Ba Ji Tian Radix Morindae officinalis 6 g • Lu Jiao Cornu Cervi 6 g • Tu Si Zi Semen Cuscutae 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Cang Zhu Rhizoma Atractylodis 6 g • Bai Jie Zi Semen Sinapis 1 g • Xiang Fu Rhizoma Cyperi 6 g • Dang Gui Radix Angelicae sinensis 6 g • Shi Chang Pu Rhizoma Acori tatarinowii 4.5 g • Dan Nan Xing Rhizoma Arisaematis preparatum 4.5 g
• Hai Zao Sargassum 6 g • Yi Mu Cao Herba Leonuri 4.5 g Prescription II (mid-cycle, from 12th day after the first day of the period, for 6 days)
• Dang Gui Radix Angelicae sinensis 6 g • Dan Shen Radix Salviae miltiorrhizae 4 g • Chuan Xiong Rhizoma Chuanxiong 4 g • Chi Shao Radix Paeoniae rubra 6 g • Ji Xue Teng Caulis Spatholobi 6 g • Ze Lan Herba Lycopi 3 g • Xiang Fu Rhizoma Cyperi 6 g • Yi Mu Cao Herba Leonuri 6 g • Hong Hua Flos Carthami 6 g • Rou Gui Cortex Cinnamomi 1.5 g • Zao Jiao Fructus Gleditsiae 6 g
Explanation These prescriptions have already been described above: I used them unchanged apart from reducing the dosages and removing the herb Liu Ji Nu. After taking these two decoctions for three menstrual cycles, she conceived and later gave birth to a healthy girl.
Blood-Heat
Clinical manifestations Early periods (short cycle) up to twice a month, heavy flow, feeling hot during period, thirst, mental restlessness. Tongue: Red with yellow coating. Pulse: Rapid, Overflowing. Treatment principle Cool Blood, regulate the periods. Acupuncture L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, LIV-3 Taichong, SP-6 Sanyinjiao, P-3 Quze, BL-17 Geshu, Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left). All with reducing or even method; no moxa. Explanation
– L.I.-11 and SP-10 cool Blood. – KI-2 and LIV-3, in combination, cool Blood. – SP-6 and P-3 cool Blood. – BL-17 cools Blood. – Ren-4 strengthens the Uterus and nourishes Blood.
– LU-7 and KI-6 regulate the Directing Vessel and nourish Yin. Herbal treatment
Prescription
– QING JING SAN Variation – Clearing the Menses Powder Variation Explanation
– Mu Dan Pi, Sheng Di Huang and Di Gu Pi cool Blood. – Bai Shao nourishes Yin. – Qing Hao and Huang Bo clear Empty-Heat. – Fu Ling resolves Dampness to counteract the cloying nature of some of the ingredients. – Huang Qin clears Heat and resolves Dampness. – Qu Mai resolves Damp-Heat, ‘penetrates’ the menses and invigorates Blood. – Che Qian Zi conducts Heat downwards and away through urination. Women’s Treasure remedy
– COOL THE MENSES Summary Blood-Heat
Clinical manifestations
Early periods (short cycle) up to twice a month, heavy flow, feeling hot during period, thirst, mental restlessness. Tongue: Red with yellow coating. Pulse: Rapid, Overflowing. Treatment principle
Cool Blood, regulate the periods. Acupuncture
L.I.-11 Quchi, SP-10 Xuehai, KI-2 Rangu, LIV-3 Taichong, SP-6 Sanyinjiao, P-3 Quze, BL-17 Geshu, Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left). All with reducing or even method; no moxa. Herbal treatment
Pre scription
• QING JING SAN Variation Clearing the Menses Powder Variation Women’s Treasure remedy
• COOL THE MENSES
This remedy cools the Blood and clears Heat from the Uterus.
Stagnation of Qi
Clinical manifestations Irregular periods, pre-menstrual tension, painful periods, breast distention, irritability. Tongue: normal colour or slightly Red on the sides; if stagnation of Qi arises from Blood deficiency, the sides might be Pale. Pulse: Wiry; if Qi stagnation arises from Blood deficiency, the pulse may be Choppy or Fine in general and slightly Wiry on the left. Treatment principle Move Qi, eliminate stagnation, pacify the Liver, regulate the periods. Acupuncture LIV-3 Taichong, G.B.-34 Yanglingquan, T.B.-6 Zhigou, P-6 Neiguan, Ren-6 Qihai, Ren-4 Guanyuan, KI-14 Siman, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left). All with reducing or even method. Explanation
– LIV-3, G.B.-34 and T.B.-6 move Qi, pacify the Liver, settle the Ethereal Soul and eliminate stagnation. – P-6 pacifies the Liver, moves Qi and eliminates stagnation. – Ren-4 strengthens the Uterus. – Ren-6 moves Qi in the Lower Burner.
– KI-14, a Penetrating Vessel point, moves Qi in the lower abdomen. – SP-4 and P-6 regulate the Penetrating Vessel and subdue rebellious Qi. Herbal treatment
a. Prescription
– KAI YU ZHONG YU TANG – Opening Stagnation and Growing Jade Decoction Explanation This formula is essentially a variation of Xiao Yao San Free and Easy Wanderer Powder. – Dang Gui and Bai Shao nourish Liver-Blood and pacify the Liver. – Bai Zhu and Fu Ling tonify Spleen-Qi. – Mu Dan Pi clears Liver-Heat: this herb is added because long-term stagnation of Liver-Qi often generates Heat. – Xiang Fu moves Qi, pacifies the Liver and eliminates stagnation. – Tian Hua Fen nourishes Yin. b. Prescription
– EMPIRICAL PRESCRIPTION by Dr Shang Xian Min13 Explanation
– Chai Hu, Xiang Fu and He Huan Pi move Qi, pacify the Liver, eliminate stagnation, calm the Mind and settle the Ethereal Soul. – Dang Gui, Chuan Xiong, Bai Shao and Shu Di Huang form the Si Wu Tang which nourishes and invigorates Blood. Nourishing Liver-Blood helps to pacify the Liver and eliminate stagnation. – Dan Shen and Yue Ji Hua invigorate Blood and eliminate stasis. – Chen Pi and Ju He move Qi and eliminate stagnation. c. Prescription
– ZHU YUN TANG – Aiding Pregnancy Decoction Explanation
– Mu Xiang, Chai Hu and Xiang Fu move Qi, eliminate stagnation and pacify the Liver. – Dang Gui and Bai Shao nourish Liver-Blood and pacify the Liver to eliminate stagnation. – Zi He Che nourishes Blood and Essence and promotes fertility. As an
animal product, it nourishes the Governing, Directing and Penetrating Vessels. – Yi Mu Cao invigorates Blood and eliminates stasis. – Qiang Huo enters the Qi of Blood in the channels to remove obstructions: this action helps to move Qi and eliminate stagnation. This prescription is more nourishing than the previous formula and its Blood- and Essence-strengthening effect is stronger. Modifications These modification apply to all the above formulae. • If there is pronounced distension, add (or increase if already in the formula) Qing Pi Pericarpium Citri reticulatae viride, Xiang Fu Rhizoma Cyperi and Mei Gui Hua Flos Rosae rugosae. • If Liver-Qi stagnation occurs against a background of Liver and Kidney deficiency (a very common occurrence), add Shu Di Huang Radix Rehmanniae preparata and Shan Zhu Yu Fructus Corni. d. Prescription
– EMPIRICAL PRESCRIPTION (I) by Dr Zhu Nan Sun Explanation
– Dan Shen, Mu Dan Pi, Wang Bu Liu Xing Lu Lu Tong and Chi Shao invigorate Blood and eliminate stasis. – Xiang Fu, Chai Hu, Suo Luo Zi and Chuan Lian Zi move Qi and
eliminate stagnation. – Di Long removes obstructions from the Connecting channels. This substance and Lu Lu Tong combine well to treat obstruction of the tubes. – Shi Chang Pu opens the orifices and helps to resolve Dampness. This formula moves Qi, invigorates Blood, eliminates stasis, clears Heat and removes obstructions from the Connecting channels. Dr Zhu uses two formulae for infertility from Qi stagnation, this one being cold in nature, and the following one hot. e. Prescription
– EMPIRICAL PRESCRIPTION (II) by Dr Zhu Nan Sun Explanation
– Chai Hu, Chuan Lian Zi, Xiang Fu, Chen Xiang and Suo Luo Zi move Qi and eliminate stagnation. – Wang Bu Liu Xing, and Lu Lu Tong invigorate Blood and eliminate stasis. – Di Long eliminates obstruction from the Connecting channels. It combines with Lu Lu Tong to treat obstruction of the tubes. – Shi Chang Pu opens the orifices, which helps to eliminate obstructions. – Xiao Hui Xiang warms the Uterus and expels Cold. This formula moves Qi and eliminates obstructions by warming. Table 57.5 compares and contrasts the five formulae for infertility from Qi stagnation.
Table 57.5 Comparison of formulae for infertility from Qi stagnation
Three Treasures remedies
– FREEING THE MOON This remedy is a variation of the formula Xiao Yao San Free and Easy Wanderer Powder: it moves Qi, pacifies the Liver, eliminates stagnation, nourishes Liver-Blood, calms the Mind and settles the Ethereal Soul. The tongue presentation appropriate to this remedy is a normal-coloured or even
Pale body. The pulse presentation appropriate to this remedy is a Choppy or Fine pulse which may be only slightly Wiry on one side. – RELEASE CONSTRAINT This remedy is a variation of the formula Yue Ju Wan GardeniaLigusticum Pill which moves Qi, pacifies the Liver, eliminates stagnation and settles the Ethereal Soul. The tongue presentation appropriate to this remedy is a body that is Red on the sides. The pulse presentation appropriate to this remedy is a Full and Wiry pulse all over. Please note the pulse and tongue differences between this remedy and the previous one, Freeing the Moon. Women’s Treasure remedy
– FREEING CONSTRAINT This remedy is a variation of the same formula Yue Ju Wan GardeniaLigusticum Pill: it pacifies the Liver, moves Qi, eliminates stagnation, invigorates Blood, eliminates stasis, calms the Mind and settles the Ethereal Soul. Compared with the previous one, it is indicated when there is also some stasis of Blood. The tongue presentation appropriate to this remedy is a Purple body. Summary Stagnation of Qi
Clinical manifestations
Irregular periods, pre-menstrual tension, painful periods, breast distention, irritability. Tongue: normal colour or slightly Red on the sides; if stagnation of Qi arises from Blood deficiency, the sides might be Pale. Pulse: Wiry; if Qi
stagnation arises from Blood deficiency, the pulse may be Choppy or Fine in general and slightly Wiry on the left. Treatment principle
Move Qi, eliminate stagnation, pacify the Liver, regulate the periods. Acupuncture
LIV-3 Taichong, G.B.-34 Yanglingquan, T.B.-6 Zhigou, P-6 Neiguan, Ren-6 Qihai, Ren-4 Guanyuan, KI-14 Siman, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left). All with reducing or even method. Herbal treatment
Pre scriptions
• KAI YU ZHONG YU TANG Opening Stagnation and Growing Jade Decoction • EMPIRICAL PRESCRIPTION by Dr Shang Xian Min • ZHU YUN TANG Aiding Pregnancy Decoction • EMPIRICAL PRESCRIPTION (I) by Dr Zhu Nan Sun • EMPIRICAL PRESCRIPTION (II) by Dr Zhu Nan Sun Three Treasures remedies
• FREEING THE MOON • RELEASE CONSTRAINT Women’s Treasure remedies
• FREEING CONSTRAINT
Stasis of Blood
Clinical manifestations Irregular and painful periods, dark blood with clots, irritability, mental restlessness, abdominal pain. Tongue: Purple. Pulse: Wiry or Choppy. Treatment principle Invigorate Blood, eliminate stasis, pacify the Liver and the Penetrating Vessel, regulate the periods. Acupuncture LIV-3 Taichong, G.B.-34 Yanglingquan, BL-17 Geshu, SP-10 Xuehai, SP-6 Sanyinjiao, P-6 Neiguan, T.B.-6 Zhigou, Ren-6 Qihai, Ren-4 Guanyuan, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), KI-14 Siman, ST-29 Guilai, KI-6 Zhaohai (on the right) and LU-7 Lieque (on the left). All with reducing or even method. Explanation
– LIV-3 and G.B.-34 pacify the Liver, invigorate Blood and eliminate stasis. – BL-17, SP-10, SP-6 and P-6 invigorate Blood and eliminate stasis. – T.B.-6 and Ren-6 move Qi, which helps to invigorate Blood. – Ren-4 strengthens the Uterus. The ABC of Acupuncture by Huang Fu
Mi (AD 259) says: “For infertility with stasis of Blood, use Ren-4 Guanyuan.”14 – SP-4 and P-6 regulate the Penetrating Vessel, invigorate Blood and subdue rebellious Qi. – KI-14, a point of the Penetrating Vessel, invigorates Blood in the lower abdomen. – ST-29 invigorates Blood. – KI-6 (on the right) and LU-7 (on the left) regulate the Yin Stepping Vessel and remove obstructions from the lower abdomen. The repeated use of this vessel in successive sessions is effective in treating adhesions. Herbal treatment
a. Prescription
– SHAO FU ZHU YU TANG – Lower Abdomen Eliminating Stasis Decoction Explanation This formula, already explained, invigorates Blood, eliminates stasis and expels Cold: it therefore eliminates stasis of Blood when this is caused by Cold in the Uterus. The tongue presentation appropriate to this formula is therefore a Bluish-Purple body. b. Prescription
– EMPIRICAL PRESCRIPTION by Dr Shang Xian Min15 This formula is for obstruction of tubes from stagnation of Qi and Blood. Compared with the previous formula, in addition to invigorating Blood, it also resolves Toxic-Heat and softens masses. Explanation
– Dang Gui nourishes and invigorates Blood. – Chuan Xiong, Dan Shen, Tao Ren, Chuan Shan Jia, Xue Jie and Lu Lu Tong invigorate Blood and eliminate stasis. – Zao Jiao resolves Phlegm and opens the orifices. – Hai Zao softens masses. – Mu Xiang and Chai Hu move Qi, which helps to invigorate Blood. c. Prescription
– EMPIRICAL PRESCRIPTION by Dr Zhu Nan Sun Explanation
– Dan Shen, Chi Shao, Mu Dan Pi, Yan Hu Suo, Pu Huang, San Leng, E Zhu, Shi Jian Chuan, Liu Ji Nu, Ru Xiang and Xue Jie invigorate Blood and eliminate stasis. – Chai Hu and Chuan Lian Zi move Qi and eliminate stagnation.
– Di Long removes obstructions from the Connecting channels Compared with the previous formulae, this is the strongest. Please note that it contains many herbs that ‘break’ Blood and should therefore be used with caution, possibly reducing the above dosages, and in any case for no longer than 3 months at a stretch. Women’s Treasure remedies
– STIR FIELD OF ELIXIR This remedy is a variation of the formula Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction which invigorates Blood and eliminates stasis. The tongue presentation appropriate to this remedy is a Purple body. Summary Stasis of Blood
Clinical manifestations
Irregular and painful periods, dark blood with clots, irritability, mental restlessness, abdominal pain. Tongue: Purple. Pulse: Wiry or Choppy. Treatment principle
Invigorate Blood, eliminate stasis, pacify the Liver and the Penetrating Vessel, regulate the periods. Acupuncture
LIV-3 Taichong, G.B.-34 Yanglingquan, BL-17 Geshu, SP-10 Xuehai, SP-6 Sanyinjiao, P-6 Neiguan, T.B.-6 Zhigou, Ren-6 Qihai, Ren-4 Guanyuan, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), KI-14 Siman, ST-29 Guilai, KI-6 Zhaohai (on the right) and LU-7 Lieque (on the left). All with reducing or even method. Herbal treatment
Pre scriptions
• SHAO FU ZHU YU TANG Lower Abdomen Eliminating Stasis Decoction • EMPIRICAL PRESCRIPTION by Dr Shang Xian Min • EMPIRICAL PRESCRIPTION by Dr Zhu Nan Sun Women’s Treasure remedy
• STIR FIELD OF ELIXIR
Case history A 40-year-old woman presented with primary infertility (she had never previously conceived): she had been trying to conceive for 15 years. Her periods cycle was regular, the periods were not painful but the blood was dark with clots, and the period lasted 3 days. She sweated at night and the glands in her neck were always swollen. Her main presenting symptom was a persistent pain in both groins on mid-cycle: the pain was sharp and stabbing in character and it was better with pressure and worse with the application of a hot-water bottle. Her tongue was Reddish-Purple and her pulse was Weak in general but practically non-existent on both Rear positions. Her face had a purplish hue.
Diagnosis There are clear symptoms and signs of Blood stasis: purple complexion, Purple tongue and groin pain of a stabbing character. Besides this, there is an obvious Kidney deficiency as her pulse and night sweating show. There are a few anomalies, however. First, given that the Kidney pulse is extremely Weak and Deep, there are hardly any Kidney symptoms – in fact, only one, the night sweating. When there is stasis in the Uterus, the obstruction in this organ may be reflected in a very Weak pulse on the Kidney position (the Kidney channel is connected to the Uterus and shares the same position on the pulse). I therefore considered that the weakness of the Kidney pulse could be partially due to the stasis of Blood. Second, it was difficult to make sense of the swollen glands in the neck. As there was no sign of Phlegm, and as they were obviously not due to an acute illness, I concluded that the swelling was probably due to stagnation in the Yin Stepping Vessel. This vessel is heavily involved in stagnation in the Lower Burner and I felt this was the main problem. There was a further discrepancy in the character of the groin pain since it was better with pressure, which indicates a deficiency, and worse with a hot-water bottle, which indicates a Fullness. This is due to the simultaneous occurrence of a Kidney deficiency and an excess in the form of Blood stasis. I therefore concluded that Blood stasis (in the Liver channel) was the cause of the groin pain and the main cause of infertility. Treatment principle I decided to invigorate Blood and eliminate stasis first, without tonifying the Kidneys, and to observe how the Kidney pulse would react so as to establish how much of its weakness was due to stasis and how much to an actual deficiency. I treated her only with acupuncture as she did not want herbal treatment. Acupuncture
I used the opening point of the Yin Stepping Vessel, i.e. KI-6 Zhaohai (on the right) and LU-7 Lieque (on the left). I used this Extraordinary Vessel to invigorate Blood and eliminate stasis in the Lower Burner. It is excellent for this purpose, especially in women. I also used the following other points: • L.I.-4 Hegu (on the right) to regulate the ascending and descending of Qi to help to eliminate stasis and stop pain. • LIV-3 Taichong (on the left) to invigorate Blood and eliminate stasis in the Liver channel. • SP-6 Sanyinjiao (bilateral) to invigorate Blood.
After the first treatment, the swelling of the glands in the neck disappeared. On the second treatment, I repeated the above points and I added: • BL-23 Shenshu to tonify the Kidneys.
I repeated this treatment four times as it had helped the groin pain tremendously: I was concentrating more on treating this pain than on the infertility as I did not hold very much hope on this score due to her age and the long duration of the problem (15 years). However, after four fortnightly treatments she became pregnant. I continued to treat her throughout the pregnancy because her tongue was still Purple which is not a good sign; however, she had no problems. During the pregnancy, I used a different treatment, concentrating on tonifying the Kidneys, using only a few points as follows: • ST-36 Zusanli to tonify Qi in general. • KI-9 Zhaohai and BL-23 Shenshu to tonify the Kidneys.
After a full term, she delivered a healthy baby.
Damp-Phlegm
Clinical manifestations Scanty periods, a feeling of heaviness of the lower abdomen, obesity, excessive vaginal discharge, expectoration of sputum, pre-menstrual breast distension, swelling and pain. Tongue: Swollen, with sticky coating. Pulse: Slippery. Treatment principle Resolve Phlegm, tonify the Spleen and Kidneys. Acupuncture LU-7 Lieque with KI-6 Zhaohai, ST-28 Shuidao, Ren-4 Guanyuan, KI-13 Qixue, Ren-9 Shuifen, SP-9 Yinlingquan, ST-40 Fenglong, Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu, BL-23 Shenshu. All with reducing or even method except Ren-4, KI-13, Ren-12, ST-36, BL-20 and BL-23 which should be needled with reinforcing method. Explanation
– LU-7 and KI-6 regulate the Directing Vessel. – ST-28 resolves Damp-Phlegm from the Uterus and has a long history of use in infertility. – Ren-4 and KI-13 tonify the Kidneys and strengthen the Directing and
Penetrating Vessels. – Ren-9, SP-9 and ST-40 resolve Phlegm. – Ren-12, ST-36, BL-20 and BL-23 tonify the Spleen and Kidneys. Herbal treatment
Prescription
– QI GONG WAN Variation – Arousing the Uterus Pill Variation Explanation This formula was explained above under the pattern of Dampness. – Ze Lan and Lu Lu Tong invigorate Blood and remove obstructions from the Connecting channels. Ze Lan also resolves Phlegm. – Yi Yi Ren and Huang Bo resolve Dampness and Phlegm. – Shi Chang Pu opens the orifices: in this context, it opens the orifices of the Uterus and helps to resolve Dampness and Phlegm. Women’s Treasure remedies
– CLEAR THE PALACE
This remedy is a variation of Qi Gong Wan which resolves DampPhlegm from the Uterus. Summary Damp-Phlegm
Clinical manifestations
Scanty periods, a feeling of heaviness of the lower abdomen, obesity, excessive vaginal discharge, expectoration of sputum, pre-menstrual breast distension, swelling and pain. Tongue: Swollen, with sticky coating. Pulse: Slippery. Treatment principle
Resolve Phlegm, tonify the Spleen and Kidneys. Acupuncture
LU-7 Lieque with KI-6 Zhaohai, ST-28 Shuidao, Ren-4 Guanyuan, KI-13 Qixue, Ren-9 Shuifen, SP-9 Yinlingquan, ST-40 Fenglong, Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu, BL-23 Shenshu. All with reducing or even method except Ren-4, KI-13, Ren-12, ST-36, BL-20 and BL-23 which should be needled with reinforcing method. Herbal treatment
Pre scription
• QI GONG WAN Variation Arousing the Uterus Pill Variation
Women’s Treasure remedy
• CLEAR THE PALACE
Combined patterns
Kidney-Yang deficiency with Damp-Phlegm in the Uterus
Clinical manifestations Prolonged menstrual cycle, the period could be either scanty or heavy, backache, dizziness, feeling cold, depression, frequent urination, a feeling of heaviness of the lower abdomen, obesity, excessive vaginal discharge, expectoration of sputum, pre-menstrual breast distension, swelling and pain. Tongue: Pale, Swollen, wet. Pulse: Deep, Weak and slightly Slippery. Treatment principle
– Phase 1: no treatment. – Phase 2: tonify Kidney-Yang. – Phase 3: resolve Damp-Phlegm. – Phase 4: resolve Damp-Phlegm. Herbal treatment
– Phase 1: no treatment. – Phase 2: Yu Lin Zhu Unicorn Pearl Variation. – Phase 3: Qi Gong Wan Arousing the Uterus Pill Variation. – Phase 4: Qi Gong Wan Arousing the Uterus Pill Variation.
Kidney-Yang deficiency with Dampness
Clinical manifestations Prolonged menstrual cycle, the period could be either scanty or heavy, backache, dizziness, feeling cold, depression, frequent urination, irregular periods, delayed cycle, mid-cycle pain, vaginal discharge, long-term infertility, adhesions, obesity, feeling of heaviness. Tongue: Pale, sticky coating. Pulse: Slippery. Treatment principle
– Phase 1: no treatment. – Phase 2: tonify Kidney-Yang. – Phase 3: resolve Dampness. – Phase 4: resolve Dampness. Herbal treatment
– Phase 1: no treatment. – Phase 2: Yu Lin Zhu Unicorn Pearl Variation. – Phase 3: Si Miao San Four Wonderful Powder. – Phase 4: Si Miao San Four Wonderful Powder.
Kidney-Yang deficiency with Blood stasis
Clinical manifestations Prolonged menstrual cycle, the period could be either scanty or heavy, backache, dizziness, feeling cold, depression, frequent urination, irregular and painful periods, dark blood with clots, irritability, mental restlessness, abdominal pain. Tongue: Pale or Pale-Purple. Pulse: Weak but Firm on the middle level. Treatment principle
– Phase 1: invigorate Blood (if the period is not heavy). – Phase 2: tonify Kidney-Yang. – Phase 3: tonify Kidney-Yang. – Phase 4: invigorate Blood. Herbal treatment
– Phase 1: Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction. – Phase 2: Yu Lin Zhu Unicorn Pearl Variation – Phase 3: Yu Lin Zhu Unicorn Pearl Variation. – Phase 4: Ge Xia Zhu Yu Tang Eliminating Stasis below the
Diaphragm Decoction.
Kidney-Yang deficiency with Blood stasis and Dampness
Clinical manifestations Prolonged menstrual cycle, the period could be either scanty or heavy, backache, dizziness, feeling cold, depression, frequent urination, irregular and painful periods, dark blood with clots, irritability, mental restlessness, abdominal pain, irregular periods, delayed cycle, mid-cycle pain, vaginal discharge, long-term infertility, adhesions, obesity, feeling of heaviness. Tongue: Pale or Pale-Purple, sticky coating. Pulse: Weak but Slippery or Weak but Firm at the middle level. Treatment principle
– Phase 1: invigorate Blood. – Phase 2: tonify Kidney-Yang. – Phase 3: resolve Dampness. – Phase 4: invigorate Blood. Herbal treatment
– Phase 1: Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction. – Phase 2: Yu Lin Zhu Unicorn Pearl Variation.
– Phase 3: Si Miao San Four Wonderful Powder. – Phase 4: Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction.
Ancient acupuncture prescriptions for infertility16
1. Infertility with white vaginal discharge: BL-31 Shangliao. Infertility from stasis of Blood: Ren-4 Guanyuan. With abdominal pain: ST-30 Qichong. Ren-8, moxa on salt. (ABC of Acupuncture, Zhen Jiu Jia Yi Jing, AD 259.) 2. SP-5 Shangqiu and Ren-3 Zhongji (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601). 3. Du-4 Mingmen, BL-23 Shenshu, Ren-6 Qihai, Ren-3 Zhongji, LIV-11 Yinlian, KI-2 Rangu, Ren-4 Guanyuan (with direct moxa cones). Cold Uterus: Baomen (2 cun left of Ren-4), Zihu (2 cun right of Ren-4), KI-6 Zhaohai. (Essays Handed over by Luo, Luo Yi Pian, 1763.) 4. SP-6 Sanyinjiao, SP-10 Xuehai, Ren-6 Qihai, Du-4 Mingmen, BL-23 Shenshu, Ren-3 Zhongji, Ren-4 Guanyuan, LIV-11 Yinlian, KI-2 Rangu, KI6 Zhaohai, Baomen (2 cun left of Ren-4), Qimen (3 cun below navel and 3 cun lateral to midline). (The Classic of Miraculous Moxibustion, Shen Jiu Jing Lun, 1851.) 5. LIV-8 Ququan (infertility from stasis of Blood). ST-36 Zusanli, BL-67 Zhiyin, L.I.-4 Hegu, SP-6 Sanyinjiao, Ren-2 Qugu (7 to 77 moxa cones). (Collection of Acupuncture and Moxibustion, Zhen Jiu Ji Cheng, 1874.) 6. BL-32 Ciliao, KI-1 Yongquan and SP-5 Shangqiu (Experience of Acupuncture and Moxibustion Therapy, Zhen Jiu Zi Sheng Jing, 1220).17
Modern acupuncture prescription for retrovert uterus
– Ren-12 Zhongwan, Ren-6 Qihai, BL-23 Shenshu, KI-3 Taixi, BL-32 Ciliao, BL-20 Pishu, T.B.-4 Yanchi.
Empirical prescriptions by dr xia gui cheng18 Dr Xia Gui Cheng, Director of the Gynaecology Department of the Jiangsu Province Hospital for Chinese Medicine, has formulated four prescriptions for the treatment of infertility, in which he specializes. The four prescriptions are to be taken during the four different phases of the menstrual cycle as described in Chapter 2 on physiology. This method of treating infertility by giving four different prescriptions according to the four phases of the menstrual cycle is used by other doctors too. Although the formula for each phase is standardized according to the phase’s treatment principle, Dr Xia always uses variations of these four according to the woman’s prevailing condition. The four different principles of treatment are as follows: 1. After the period: nourish Kidney-Yin. 2. Between periods (mid-cycle): promote ovulation. 3. Before the period: tonify Kidney-Yang. 4. During the period: invigorate Blood if the period is scanty or stop the bleeding if heavy. These treatment principles follow the general characteristics of the four phases of the menstrual cycle as described in Chapter 2, according to which there is a relative deficiency of Blood and Yin after the period, the Kidneys and Directing and Penetrating Vessels become active at mid-cycle, Yang rises before the period and Blood moves during it. Note that ‘promoting ovulation’ in Chinese medicine terms means tonifying the Kidneys, nourishing the Essence and nourishing the Directing and Penetrating Vessels. It should be noted that, although each formula pursues a specific treatment principle, the first three all contain Sheng Di Huang Radix Rehmanniae, Dang Gui Radix Angelicae sinensis, Shan Yao
Rhizoma Dioscoreae and Bai Shao Radix Paeoniae alba; the former two to nourish Liver-Blood and the latter two to nourish Kidney-Yin. It is interesting to note that even the third prescription (to tonify Yang) contains Sheng Di Huang and Shan Yao. This confirms what was observed in the chapters on physiology and pathology (Chs 2 and 3), i.e. that Kidney-Yin and Kidney-Yang are interdependent and inseparable in women’s physiology and pathology, and that to tonify Kidney-Yang (the flame of the oil-lamp), it is necessary also to nourish Kidney-Yin (the oil), as illustrated in Figure 3.1. In the case of infertility, it is even more important to nourish Kidney-Yin as this corresponds to the substance of the Kidneys, the Essence, which is the basis for the transformation of the Heavenly Gui into ova. The four formulae are in Appendix 1 and the explanations are as follows. 1. After the period
Treatment principle
Tonify Kidney-Yin. No more than 7 days. Explanation
– Dang Gui and Bai Shao nourish Blood. – Sheng Di Huang, Nu Zhen Zi and Shan Yao nourish Yin. – Fu Ling resolves Dampness. – Mu Dan Pi and Ze Xie clear Empty-Heat. 2. Between periods
Treatment principle
Promote ovulation. Only 3–5 days according to rise in temperature: stop when temperature rises. Explanation
– Dang Gui and Bai Shao nourish Blood. – Sheng Di Huang, Nu Zhen Zi and Shan Yao nourish Kidney-Yin. – Tu Si Zi tonifies Kidney-Yang and promotes ovulation. – Chi Shao and Hong Hua invigorate Blood and eliminate stasis. – Xu Duan tonifies Kidney-Yang. 3. Before the period
Treatment principle
Tonify Kidney-Yang. No more than 10 days before the period. Explanation
– Dang Gui and Bai Shao nourish Blood.
– Sheng Di Huang and Shan Yao nourish Kidney-Yin. – Xu Duan, Tu Si Zi and Lu Jiao tonify Kidney-Yang. Tu Si Zi promotes ovulation and Lu Jiao nourishes the Governing Vessel. – Xiang Fu moves Qi and eliminates stagnation. 4. During the period
Treatment principle
Move Blood if scanty; stop bleeding if too heavy. Explanation
– Dang Gui, Chi Shao, Ze Lan, Hong Hua and Chong Wei Zi invigorate Blood and eliminate stasis. – Xiang Fu moves Qi, which helps to move Blood. Dr Xia adds a fifth formula in case of obstruction of the fallopian tubes: 5. In case of obstruction of tubes
Explanation This is a variation of Gui Zhi Fu Ling Wan Ramulus Cinnamomi-Poria Pill with Dang Gui substituted for Chi Shao Radix Paeoniae rubra and the addition of Yi Yi Ren Semen Coicis. This formula is specific for abdominal masses from stasis of Blood. Yi Yi Ren softens masses, drains Dampness
and resolves Toxic-Heat.
Empirical prescriptions by dr lian fang and dr sun ning quan These two gynaecologists from Nanjing also recommend the use of four formulae, one for each phase of the menstrual cycle, for the treatment of infertility. The phases identified are the same as those above, but there is more emphasis on moving Qi and invigorating Blood: the following formulae would therefore be more suitable for women with an underlying stasis of Blood, while the preceding ones by Dr Xia more suitable for women with an underlying Kidney deficiency. The treatment principles that Dr Lian and Dr Sun adopt are as follows: 1. After the period: tonify the Kidneys and regulate Qi and Blood. 2. During ovulation: warm the Yang and move Qi and Blood. 3. Before the period: tonify and warm the Kidneys and move Qi and Blood. 4. During the period: move Qi and Blood and regulate the menses. The four formulae, which are usually adapted to the woman’s condition, are in Appendix 1 and the explanations are as follows: 1. After the period (from 4th to 11th day of cycle)
Treatment principle
Tonify the Kidneys and regulate Qi and Blood Explanation
– Nu Zhen Zi and Han Lian Cao nourish Kidney-Yin. They form the formula Er Zhi Wan Two Solstices Pill. – Dang Gui nourishes Blood. – Dan Shen invigorates Blood. – Xiang Fu, Mu Xiang and Wu Yao move Qi. – Ze Xie drains Dampness. 2. During ovulation (3 days before and 3 after ovulation)
Treatment principle
Warm the Yang and move Qi and Blood. Explanation
– Gui Zhi warms the Yang and the Uterus. It also invigorates Blood by entering the blood vessels. – Dang Gui nourishes and invigorates Blood. – Hong Hua and Dan Shen invigorates Blood. – Xiang Fu, Mu Xiang and Wu Yao move Qi. – Ze Xie drains Dampness.
3. Before the period (from the 17th to 28th day of cycle)
Treatment principle
Tonify and warm the Kidneys and move Qi and Blood. Explanation
– Yin Yang Huo and Xian Mao tonify and warm Kidney-Yang. – Nu Zhen Zi and Han Lian Cao nourish Kidney-Yin. – Dang Gui and Dan Shen nourish and invigorate Blood. – Xiang Fu, Mu Xiang and Wu Yao move Qi. – Ze Xie drains Dampness. 4. During the period (from the 1st to the 4th day of the cycle)
Treatment principle
Move Qi and Blood and regulate menstruation Explanation
– Tao Ren and Dang Gui invigorate and nourish Blood.
– Zi Su Geng moves Qi and calms the fetus (i.e. prevents miscarriage). – Dang Shen tonifies Qi. – Xiang Fu, Mu Xiang and Wu Yao move Qi. – Ze Xie drains Dampness. Note Dr Lian Fang also maintains that ‘Kidney-Yin and Kidney-Yang are interdependent’ and therefore adds Kidney-Yin tonics (such as Nu Zhen Zi Fructus Ligustri lucidi and Han Lian Cao Herba Ecliptae) to the KidneyYang tonifying prescription during the pre-menstrual phase. In a clinical trial of 60 infertile women with luteal phase insufficiency, all had symptoms and signs of Kidney deficiency: 19 with Kidney-Yin deficiency; 20 with Kidney-Yang deficiency; 6 with Kidney and Spleen deficiency; 15 with Kidney deficiency with Liver-Qi stagnation. According to Dr Lian, luteal phase insufficiency and hyposecretion of gonadotropic hormones are definitely related to a Kidney deficiency; moreover, the menstrual cycle in all its phases is a manifestation of the coordination of Kidney-Yin and Kidney-Yang, or, to put it differently, of the Yin and Yang aspects of the Essence. The relationship between basal body temperature (BBT) and KidneyYin and Kidney-Yang is close. In the post-menstrual phase, Kidney-Yin starts to grow and the BBT is in the hypothermal phase. In the intermenstrual phase, Kidney-Yin begins to wane and Kidney-Yang to wax, and the temperature rises. In the pre-menstrual phase, both Yin and Yang are flourishing and the BBT persists in a hyperthermal state. During the menstrual period, both Yin and Yang become deficient and the BBT returns to a hypothermal state. Thus, in the four phases of the menstrual period, Kidney-Yin and Kidney-Yang wax and wane, but they are also interdependent, hence the
addition of Kidney-Yang tonics in Kidney-Yin deficiency and vice versa.19
Empirical prescriptions by dr zhu nan sun20 Dr Zhu Nan Sun also treats infertility by using different formulae at different times of the menstrual cycle. His treatment principle in each phase is as follows: 1. Post-menstrual phase: nourish Yin and Blood and tonify Liver and Kidneys. 2. Ovulation phase: tonify Liver and Kidneys and warm the Yang. 3. Pre-menstrual phase: nourish Yin and protect the Yang. 4. During the period: no treatment. The main difference from the previous two doctors is that Dr Zhu places the emphasis on Kidney-Yang to treat infertility: for this reason, all three formulae include Kidney-Yang tonics. 1. After the period
Treatment principle
Nourish Yin and Blood and tonify Liver and Kidneys. Explanation
– Sheng Di Huang, Shu Di Huang, Bei Sha Shen, Mai Men Dong, Gou Qi Zi, Han Lian Cao and Nu Zhen Zi nourish Yin and tonify Liver and Kidneys. Gou Qi Zi also nourishes Blood and Essence, and Nu Zhen Zi and Shu Di
Huang also nourish the Essence. – Huang Jing tonifies Qi and nourishes the Essence. – Dang Gui, Bai Shao and Sang Ji Sheng nourish Blood. – Dan Shen invigorates Blood and calms the Mind. – Xu Duan and Tu Si Zi tonify and warm Kidney-Yang. Please note that the above dosages are those recommended by Dr Zhu: for Western patients, I would personally reduce them by at least half. 2. During ovulation
Treatment principle
Tonify Liver and Kidneys and warm the Yang Explanation
– Sheng Di Huang, Shu Di Huang, Han Lian Cao, Nu Zhen Zi and Gui Ban nourish Yin and tonify Liver and Kidneys. Gui Ban also nourishes the Directing and Penetrating Vessels. – Tu Si Zi, Xu Duan, Yin Yang Huo, Zi Shi Ying and Shi Nan Ye tonify and warm Kidney-Yang and warm the Uterus. – Sang Ji Sheng nourishes Blood. Please note that the above dosages are those recommended by Dr Zhu: for Western patients, I would personally reduce them by at least half.
3. Before the period
Treatment principle
Nourish Yin and protect the Yang. Use the same formula as the one during ovulation omitting Shi Nan Ye Folia Photiniae serrulatae and Zi Shi Ying Fluoritum.
Empirical prescriptions according to western condition by dr shan dao wei21 The following prescriptions are formulated according to Western medically defined conditions. Apart from the one for blocked tubes, they are all based on tonification of the Kidneys. No ovulation
Treatment principle
Tonify the Kidneys, nourish the Essence, invigorate Blood. Explanation
– Zi He Che nourishes Blood and the Essence. – Lu Jiao Shuang nourishes Blood and the Essence and strengthens the Governing Vessel. – Shan Zhu Yu nourishes Liver- and Kidney-Yin and the Kidney-Essence. – Yin Yang Huo tonifies Kidney-Yang. – Dang Gui, Chi Shao, Dan Shen and Chuan Xiong invigorate Blood. Corpus luteum defect
Treatment principle
Tonify Kidney-Yang and nourish the Essence. Explanation
– Yin Yang Huo and Rou Cong Rong tonify Kidney-Yang. – Zi He Che nourishes Blood and the Essence. – Lu Rong tonifies Kidney-Yang, nourishes the Essence and strengthens the Governing Vessel. Underdeveloped uterus
Treatment principle
Tonify and warm Kidney-Yang, nourish Blood. Explanation
– Zi Shi Ying and Yang Qi Shi warm the Uterus and promote fertility. – Xian Ling Pi and Tu Si Zi tonify Kidney-Yang. – Shu Di Huang tonifies the Kidneys and nourishes Blood. – Xiang Fu and Sha Ren move Qi and resolve Dampness and are added to help the digestion of the first two substances which are minerals.
Blocked fallopian tubes
Treatment principle
Invigorate Blood, eliminate stasis. Explanation All the herbs in the prescription invigorate or ‘break’ Blood and eliminate stasis.
Empirical prescriptions by the shanghai college of traditional chinese medicine
Blocked fallopian tubes 22 The Shanghai College of Traditional Chinese Medicine conducted a study of 40 cases of infertility from obstruction of the tubes following salpingitis. Of the 40 cases, 24 had Liver-Qi stagnation with Kidney deficiency, 4 had Liver-Qi stagnation and Blood stasis, and 12 had a Kidney deficiency with Blood stasis. The treatment was based on two formulae, one for the follicular phase (i.e. after the period until ovulation) and one for the luteal phase (i.e. to be started immediately after the rise in temperature occurring at mid-cycle). The first formula was called Tong Guan Tang Freeing the Tubes Decoction and the second Tong Guan Er Hao Fang Freeing the Tubes No. 2 Formula. a. Prescription
– TONG GUAN TANG – Freeing the Tubes Decoction Explanation The first five herbs are a variation of Si Wu Tang Four Substances Decoction with the addition of Chi Shao, to nourish and invigorate Blood. – Tao Ren, Hong Hua and Qian Cao Gen invigorate Blood and eliminate stasis.
– Yi Yi Ren and Wu Zei Gu soften masses. Yi Yi Ren also drains Dampness. – Xiang Fu moves Qi and eliminates stagnation. – Lu Lu Tong and Shi Chang Pu invigorate Blood, eliminate stasis and open the orifices. These two herbs are often combined to treat obstructions of the Fallopian tubes. – Zao Jiao, Bai Jiang Cao and Hong Teng resolve Toxic-Heat and Phlegm. Please note that the above dosages are those recommended by the Shanghai College of Traditional Chinese Medicine: for Western patients, I would personally reduce them by at least half. b. Prescription
– TONG GUAN II HAO FANG – Freeing the Tubes No. 2 Formula Explanation
– Shu Di Huang, Dang Gui, Bai Shao, Chuan Xiong, Tao Ren and Hong Hua constitute the formula Tao Hong Si Wu Tang Persica-Carthamus Four Substances Decoction which nourishes and invigorates Blood. – Tu Si Zi, Yin Yang Huo, Rou Cong Rong and Lu Jiao Shuang tonify Kidney-Yang and promote ovulation. Lu Jiao Shuang also strengthens the Governing Vessel. – Xiang Fu moves Qi and eliminates stagnation.
– Bai Jiang Cao resolves Toxic-Heat. This formula is started immediately after the rise in temperature on midcycle and taken until the period starts. If, after a few months, symptoms of Kidney deficiency predominate over those of stagnation or stasis, the formula can be stopped and the patient should take the prepared remedy Wu Jin Bai Feng Wan Black Chicken White Phoenix Pill or He Che Da Zao Wan Placenta Great Fortifying Pill. Please note that the above dosages are those recommended by the Shanghai College of Traditional Chinese Medicine: for Western patients, I would personally reduce them by at least half. Modifications
• If there is pronounced breast distension, add Chai Hu Radix Bupleuri. • If there is lateral abdominal pain, add Yan Hu Suo Rhizoma Corydalis. • If there is a central, low abdominal pain, add Rou Gui Cortex Cinnamomi.
Prognosis and prevention Certain conditions will not respond to treatment with acupuncture and/or herbs: • Adhesions from tuberculosis of the endometrium. • Submucous myoma (if very large). • Congenital malformation or hypoplasia of the uterus. • Schistosomiasis. • Tuberculosis of the uterus. Infertility caused by blockage of the fallopian tubes from adhesions and inflammation is very difficult to treat (definitely the most difficult type of infertility) but not impossible. The chance of success of the treatment depends on whether both tubes are obstructed and how much: if only one tube is obstructed, or if both are only partially obstructed, the treatment has some chance of success. From a Chinese perspective, obstruction of the fallopian tubes is often due to a combined condition of Blood stasis, Dampness, Damp-Phlegm and Toxic-Heat. Although in a few cases women may respond to treatment for infertility in a few months, in most cases the treatment will take at least 1 year and both the woman and the practitioner need to be patient. The easiest pattern to treat is that from Blood deficiency and the most difficult that from Damp-Phlegm because this often corresponds to polycystic ovarian disease which is a complex disease caused by irregularities of the hypothalamic–pituitary–ovarian axis (see Ch. 66).
Western view Infertility is defined as the inability of a couple to conceive after 2 years or more of intercourse without contraception. Infertility is classified as primary when the female partner has never conceived before or secondary when the woman has had a previous pregnancy irrespective of the final outcome of that pregnancy (i.e. even if she miscarried). Of course, in Western medicine, both partners should be checked when a couple reports an inability to conceive: about 70% of cases are due to female infertility and 30% to male sterility. The causes of infertility are very numerous indeed. The majority of cases are due to a disturbance of the hypothalamus–pituitary–ovarian axis. To get an idea of the relative importance of various causes of infertility in women, the incidence is as follows: • Hormonal factors of ovulation: 41%. • Fallopian tube abnormalities: 32%. • Uterine factors: 16%. • Cervical factors: 4.7%. • No apparent causes: 5%. Of the hormonal factors, failure to ovulate constitutes about 25% of the total and the most common cause of this failure is polycystic ovary syndrome. In 80% of cases of hormonal abnormalities, menstruation is irregular or absent. From a Chinese perspective, it could be said that the hormonal disturbances of ovulation would fall under the Kidney deficiency or Blood deficiency types of infertility, while fallopian tube abnormalities would fall under the Full types of infertility, such as stasis of Blood, Blood-Heat, Dampness or Damp-Phlegm.
Hormonal factors
Ovulatory failure
Total or occasional failure to ovulate may both cause infertility. The pulsatile secretion of follicle-stimulating hormone (FSH)- and luteinizing hormone (LH)-releasing factors from the hypothalamus controls the production of FSH and LH by the anterior pituitary gland. FSH promotes follicular growth in the ovary. When a follicle has matured, LH is released from the anterior pituitary and luteinization of the follicle occurs. Luteinization results in follicular rupture and release of the oocyte; the remains of the follicle alter their function to become the corpus luteum. The corpus luteum secretes progesterone which results in secretory changes in the endometrium necessary for implantation of the fertilized ovum (see Figs 57.4 and 57.5). Lack of ovulation may therefore be caused by abnormalities at various levels of the above process.
Figure 57.4 Hypothalamus–pituitary–ovarian axis.
Figure 57.5 Effects of FSH and LH on follicle. (Reproduced with kind permission from Govan, Hart and Callander 1993 Gynaecology Illustrated, Churchill Livingstone, Edinburgh.)
Hypothalamus Alteration of the hypothalamic function may derive from stress (which explains the influence of emotional problems on fertility as seen in Chinese medicine), drugs (e.g. reserpine, ganglion blockers, phenothiazines), weight loss or excessive weight gain. Pituitary
The pituitary may function abnormally because of tumours which may cause elevated levels of prolactin. Levels of prolactin are elevated during breastfeeding and anovulation ensues as a result. Changes in thyroid function (hyper- or hypothyroidism) or in adrenal function (Cushing’s syndrome) result in failure to ovulate. Ovary Finally, the ovary itself may malfunction. Absence of FSH receptors in the follicle leads to failure of the ovary to respond to gonadotropins; or there may be a disturbance of the interaction between the FSH and the follicle. This leads usually to anovulation and polycystic ovary syndrome. In this condition, there is an excess of LH production and a diminished FSH secretion. The result is a lack of oestrogen and an excess of androgenic substances. Basal body temperature When an abnormality of the hypothalamus–pituitary–ovarian axis is the cause of infertility, it is important for the patient to take the basal body temperature (BBT) and plot a graph in order to detect any changes in it. The BBT chart in normal conditions shows typically a biphasic curve, i.e. a curve with distinct phases: the first phase spans the period before the ‘thermal nadir’, i.e. the fall in temperature that precedes ovulation, and the second phase occurs immediately after ovulation with a sharp rise in temperature which stays high for at least 11 days. Typical biphasic temperature curves are indicative of regular ovulation. Irregular, monophasic (i.e. without clear distinction between two phases) curves indicate an anovulatory cycle with inadequate progesterone production in about 95% of the cases. However, ovulation has been shown to occur in about 2–5% of women with monophasic temperature charts. Figure 57.6 shows a normal biphasic and an abnormal monophasic temperature chart: the arrows show the time of the LH surge
which precedes ovulation by 24 hours.
Figure 57.6 Normal biphasic (top) and abnormal monophasic (bottom) temperature chart. (Reproduced with kind permission from Govan, Hart and Callander 1993 Gynaecology Illustrated, Churchill Livingstone, Edinburgh.)
The lengths of the follicular phase (i.e. before the rise in temperature following ovulation) and of the luteal phase (after the rise in temperature following ovulation) should be noted. An irregular follicular length may indicate poor or suboptimal folliculogenesis. The temperature rise following ovulation should be at least 0.5°F (0.2°C) or more and remain at that level. A luteal phase length of 10 days or less is abnormally short. However, a normal length of the luteal phase is the necessary but not sufficient condition for normal ovulation: in fact, although the length of the luteal phase may be normal, there may still be an inadequate progesterone secretion. Tube abnormalities Salpingitis (inflammation of the fallopian tubes) may result from a variety of causes among which are infections after abortion or delivery, gonorrhoea, chlamydia, tuberculosis, use of an intra-uterine device and pelvic peritonitis from acute appendicitis. The inflammatory changes damage the tubal epithelium and in severe cases may result in tubal blockage. When the tubes are only partially blocked, fertilization of the ovum may occur but damage to the ciliated epithelium may prevent the fertilized egg from being carried down to the uterus and ectopic pregnancy may result. Uterine factors
Uterine myomas
These do not usually cause infertility unless they are so large as to distort the
uterine cavity or block the interstitial parts of the tubes. Cervical factors
Cervical hostility
This is a condition in which the cervical mucus is unreceptive to spermatozoa, either preventing their advance or killing them. It may be due to infection or the presence of antibodies. Cervical incompetence
This is not so much a cause of infertility as of recurrent miscarriage. General factors
Hypothyroidism
This is often associated with infertility and should be suspected in obese women with other symptoms such as lethargy, swelling of the ankles, feeling cold and amenorrhoea. From a Chinese perspective, hypothyroidism usually manifests with the classic symptoms of Kidney-Yang deficiency. Hyperthyroidism
This may also be associated with infertility. From a Chinese perspective, this often corresponds to a Full cause of infertility, mostly from Blood-Heat
affecting the Liver and Heart. Endometriosis
Endometriosis may cause infertility as a result of peritubal or periovarian adhesions.
Clinical trials
Acupuncture
A clinical observation of acupuncture combined with medication for the treatment of anovulation infertility
– Zhongguo Zhen Jiu, Chinese Acupuncture and Moxibustion, 2009 29(1): 21–24. – Jiang D S, Ding D. – Department of TCM, Hubei College of TCM, Wuhan, China. Objective
To explore the therapeutic effect of acupuncture combined with medication on anovulation infertility. Methods
Fifty cases of anovulation infertility were randomly divided into an observation group and a control group with 25 cases in each group. The observation group was treated with Chinese herbal medicine and acupuncture. The herbal medicine consisted of Cu Luan Pao Tang Promote the Follicle Decoction, Cu Pai Luan Tang Promote Ovulation Decoction and Cu Huang Ti Tang Promote the Corpus Luteum Decoction respectively given according to different menstrual cycles. Acupuncture and moxibustion were administered at Ren-4 Guanyuan and Ren-3 Zhongji among other points. The control group was treated with an oral administration of clomifene and intramuscular injection of human chorionic
gonadotropin (hCG). Both groups were treated for six cycles, and ovulation and pregnancy rates were observed. Results
There was no significant difference in the ovulation rate between the two groups (P > 0.05). The pregnancy rate of 44.0% in the observation group was significantly higher than 16.0% in the control group (P < 0.05). The observation group was superior to the control group in the score of mucus and the endometrial thickness. Conclusion
Both acupuncture combined with medication and oral administration of clomifene plus intramuscular injection of hCG obtain a higher ovulation rate, but the pregnancy rate was higher in the Chinese medicine group. A clinical observation of acupuncture for treatment of infertility due to ovulatory disturbance
– Zhongguo Zhen Jiu, Chinese Acupuncture and Moxibustion 2008 28(1): 21–23. – Song F J, Zheng SL, Ma D Z. – Section of Acupuncture, Wenzhou City Hospital of TCM, Zhejiang, China. Objective
To ascertain the clinical therapeutic effect of acupuncture on infertility due to ovulatory disturbance and to understand the mechanism behind the treatment. Methods
One-hundred and twenty patients with a diagnosis of infertility due to ovulatory disturbance were randomly divided into one of two groups with 60 cases in each group. Group A received acupuncture and moxibustion at Ren3 Zhongji, Ren-4 Guanyuan, Zigong, ST-36 Zusanli and SP-6 Sanyinjiao, and moxa was waved over Ren-8 Shenque and SP-6 Sanyinjiao. Group B received oral administration of clomifene (50 mg). After treatment for three menstrual cycles, the pregnancy rate, basal body temperature, B-ultrasonic examination and ovulation rates were assessed. Results
Both groups obtained a higher ovulation rate with no significant difference between them (P > 0.05); the pregnancy rate in the acupuncture and moxibustion group was significantly higher than that in the medication group (P < 0.05). Conclusion
Acupuncture and moxibustion, and clomifene have a similar effect on ovulation. However, the pregnancy rate is higher and the abortion rate is lower for patients receiving acupuncture and moxibustion treatment compared with oral administration of clomifene. A controlled study of acupuncture for the treatment of endocrine dysfunctional infertility
– Zhongguo Zhen Jiu, Chinese Acupuncture and Moxibustion 2005 25(5): 299–300. – Yang J R, Ma Y Y, Liu Y L, Wang H L, Liu Z. – Lanzhou City First People’s Hospital, Gansu, China. Objective
To compare the therapeutic effects of acupuncture and Western medicine for promoting ovulation on endocrine dysfunctional infertility. Methods
Two-hundred and forty women with a diagnosis of infertility were randomly divided into an acupuncture group (n = 160) and a Western medicine group (n = 80). They were treated with acupuncture and clomifene respectively and their therapeutic effects were compared. Results
The pregnancy rate was 65.0% in the acupuncture group and 45.0% in the Western medicine group with a significant difference between the two groups (P < 0.05). Conclusion
Acupuncture may cure endocrine dysfunctional infertility.
A study on the relationship between the ovulation-inducing effect of Chinese herbal medicine and acupuncture, and the endometrial contents of oestradiol and progesterone receptors
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 1998 18(4): 225–226. – Tian D, Xie X, Wang B. – Maternity and Child Health Institute, Changqing, China. Objective
To study the effect of Chinese herbal medicine for tonifying the Kidneys combined with acupuncture in treating anovulation and infertility, and the relationship between the ovulation-inducing effect and endometrial levels of oestradiol receptors (ER) and progesterone receptors (PR). Methods
Twenty-nine women were treated with Kidney tonics combined with acupuncture for 1–3 months. Patients’ ER and PR were measured by immunohistochemical methods. Patients were classified according to PR content into a PR positive group and a mild PR positive group. Results
In the PR positive group, 15 women completed 45 cycles of treatment. Among them, 40 cycles showed ovulation, the ovulation rate being 88.89%. Ten out of 14 women who were infertile became pregnant, the pregnancy
rate being 71.43%. In the mild PR positive group, 11 women completed 33 cycles of treatment with 10 cycles showing ovulation (30.30%). Nine out of the 11 were infertile and the pregnancy rate was 22.22% (2/9). The difference between the two groups was significant (P < 0.01). Conclusion
The Kidney-tonifying medicine combined with acupuncture treatment could result in a good effect in treating infertility due to anovulation, especially for women with high endometrial PR levels. A reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture
– Human Reproduction 1996 11(6): 1314–1317. – Stener-Victorin E, Waldenström U, Andersson S A, Wikland M. – Department of Obstetrics and Gynaecology, Fertility Centre Scandinavia, University of Gothenburg, Gothenburg, Sweden. Objective
To ascertain whether or not electro-acupuncture (EA) can reduce high blood flow impedance in the uterine arteries of infertile women. Methods
Ten infertile but otherwise healthy women with a pulsatility index (PI) ≥3.0 in the uterine arteries were treated with EA in a prospective, non-randomized
study. Before inclusion in the study and throughout the entire study period, the women were downregulated with a gonadotropin-releasing hormone analogue (GnRHa) in order to exclude any fluctuating endogenous hormone effects on the PI. The baseline PI was measured when the serum oestradiol was ≤0.1 nmol/l, and thereafter the women were given EA eight times, twice a week for 4 weeks. The PI was measured again closely after the eighth EA treatment, and once more 10–14 days after the EA period. Skin temperature on the forehead (STFH) and in the lumbrosacral area (STLS) was measured during the first, fifth and eighth EA treatments. Results
Compared to the mean baseline PI, the mean PI was significantly reduced both shortly after the eighth EA treatment (P < 0.0001) and 10–14 days after the EA period (P < 0.0001). STFH increased significantly during the EA treatments. Conclusion
It is suggested that both the decrease in the mean PI and the increase in STFH are due to a central inhibition of sympathetic activity. Clinical studies on the mechanism of acupuncture stimulation for ovulation
– Journal of Traditional Chinese Medicine 1993 13(2): 115–119. – Mo X, Li D, Pu Y, Xi G, Le X, Fu Z. – Zhejiang College of Traditional Chinese Medicine, Hangzhou, China.
Objective
To understand the mechanism of acupuncture stimulation for ovulation. Methods
Thirty-four patients with ovulatory dysfunction were treated with acupuncture at the points BL-18 Ganshu, BL-23 Shenshu, Ren-4 Guanyuan, Ren-3 Zhongji and SP-6 Sanyinjiao. The patients were treated an average of 30 times. Changes in clinical symptoms and some endocrine markers were recorded. Results
The marked effective rate was 35.29%, the total effective rate being 82.35%. Basal body temperature, VS, cervical mucus score and Bultrasonic picture all improved to some degree. The results also showed that acupuncture may adjust FSH, LH and E2 levels and raise the progesterone level, normalising all levels. Conclusion
Results showed that acupuncture may adjust endocrine function of the generative and physiologic axis of women, thus stimulating ovulation. The results of this research will provide some scientific basis for treating and further studying this disorder. Auricular acupuncture in the treatment of female infertility
– Gynaecological Endocrinology 1992 6(3): 171–181. – Gerhard I, Postneek F. Objective
To ascertain the effect of auricular acupuncture in the treatment of female infertility. Methods
Ninety infertile women were allocated into one of two treatment groups. One group received auricular acupuncture (n = 45) and the other group received hormone treatment (n = 45). Within the auricular acupuncture group, 27 women suffered from oligoamenorrhoea and 18 from luteal insufficiency. Both the acupuncture and hormone treatment groups were matched for age, duration of infertility, body mass index, previous pregnancies, menstrual cycle and tubal patency. Results
Twenty-two women in the acupuncture group became pregnant, and 20 women in the hormone treatment group became pregnant. Four women in each group had abortions. Endometriosis was seen in 4% of the women who became pregnant and 35 (38%) of the women who did not become pregnant. Women who continued to be infertile after hormone therapy had higher body mass indices and testosterone values than those who became pregnant. Women who became pregnant after acupuncture suffered more often from menstrual abnormalities and luteal insufficiency with lower oestrogen, thyrotropin (TSH) and dehydroepiandrosterone sulfate (DHEAS) concentrations than the women who achieved pregnancy after hormone
treatment. Although the pregnancy rate was similar for both groups, eumenorrhoeic women treated with acupuncture had adnexitis, endometriosis, out-of-phase endometria and reduced post-coital tests more often than those receiving hormones. Twelve of the 27 women (44%) with menstrual irregularities remained infertile after therapy with acupuncture, compared to 15 of the 27 (56%) controls treated with hormones, even though hormone disorders were more pronounced in the acupuncture group. Side effects were observed only during hormone treatment. Various disorders of the autonomic nervous system normalized during acupuncture. Conclusion
Auricular acupuncture seems to offer a valuable alternative therapy for female infertility due to hormone disorders.
Herbal treatment
A clinical observation on anovulatory infertility due to deficiency of blood and Essence treated by Lin Er Lai
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2007 27(11): 1028–1030. – Huang Y, Cheng Q, Zhou A F. – Jingzhou Hospital of TCM, Hubei, China. Objective
To observe the clinical effect of Lin Er Lai (LEL) in treating anovulatory infertility due to Blood and Essence deficiency. Methods
Sixty patients with a diagnosis of infertility due to anovulation and classified with Blood and Essence deficiency were allocated to one of two groups. The treatment group was given LEL and the control group was administered Clomid. Ovulation and pregnancy rates were observed. Results
The total effective rate in the treatment group was 96.7%, which was significantly higher than that in the control group (53.3%, P < 0.05). The
abortion rate was 10.0% in the treatment group, significantly lower than that in the control group (54.6%, P < 0.05); the TCM symptom score decreased significantly in the treatment group (P < 0.01), but was unchanged in the control group. Conclusion
LEL has a good effect in treating anovulatory infertility due to Blood and Essence deficiency. The effects of combined therapy of salpingostomy and Bu Shen Huo Xue on Fallopian tube obstructive infertility
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2006 26(4): 325–328. – Jiang Y C, Liang R N, Liu R T. – The Affiliated Hospital of Jiangxi College of Traditional Chinese Medicine, Nanchang, China. Objective
To compare the effect of treatment of fallopian tube obstructive infertility by salpingostomy alone and in combination with Bu Shen Huo Xue (BSHX) decoction to tonify the Kidneys and invigorate blood. Methods
Patients were split into a treatment group which received BSHX decoction
daily from the fifth day of the menstrual cycle for 14 days and a control group which did not receive any oral medication. Salpingostomy was performed on all patients 3 to 7 days after menstruation, and hydrotubation with Xiang Dan (XI) was performed once in the next menstrual cycle. The therapeutic course lasted for 3 months and the observation period was four courses. Results
Follicular development, endometrial thickness and level of serum oestradiol in the pre-ovulatory phase after treatment were all significantly increased in both groups (P < 0.05 and P < 0.01); but the improvement in the treatment group was significantly superior to that of the control group. The pregnancy rate was also higher in the treatment group (P < 0.05). Conclusion
The combined therapy of salpingostomy and traditional Chinese medicine (TCM) for tonifying the Kidneys and invigorating blood is an effective therapy for fallopian tube obstructive infertility. It has the effect of enhancing follicular development and increasing endometrial thickness, and may elevate the pregnancy rate in patients. A clinical observation on the treatment of 2062 cases of immune infertility with integrated traditional Chinese and Western medicine
– Journal of Traditional Chinese Medicine 2005 25(4): 278–281. – Du Y, Zhao Y, Ma Y, Bai H, Li X. – Cellular and Molecular Immunology Laboratory, Henan University, Kaifeng Henan, China.
Objective
To study the therapeutic effect of integrated traditional Chinese and Western medicine on female immune infertility. Methods
Three-thousand four-hundred and ninety-six women suffering from primary or secondary infertility had their anti-spermal antibodies (ASAb), endometrial antibodies (EMAb), anti-ovarian antibodies (AOAb) and anti-citrulline antibodies (ACAb) levels tested, with the positive rate of 23.11%, 34.95%, 20.77% and 30.41% respectively. Two-thousand and sixty-two positive cases were periodically treated with the TCM Xiao Kang Wan plus dexamethasone, vitamin E and vitamin C for two periods as a course of treatment. Results
At the end of a treatment course, 85% of the antibodies turned negative and the average pregnancy rate was 36.66%. Conclusion
The treatment of immune infertility with an integrated approach may reduce or eliminate the influence of antibodies in the serum of patients thus proving effective in the treatment of infertility. The external application of Chinese herbal medicine on Ren-8 Shenque combined with salpingostomy for the treatment of sterility caused by obstruction of the fallopian tube
– Journal of Traditional Chinese Medicine 2005 25(3): 174–176. – Huang J. – Shenzhen Municipal Hospital of Traditional Chinese Medicine, Guangdong, China. Objective
To observe the therapeutic effect of external application of Chinese herbal medicine on Ren-8 Shenque combined with salpingostomy for treatment of sterility caused by obstruction of the fallopian tube. Methods
Seventy-five women were randomly divided into one of two groups. Fortyfive patients in the treatment group were treated with an external application of Chinese herbal medicine on Ren-8 Shenque combined with salpingostomy, while 30 patients in the control group were treated with salpingostomy only. Results
The results showed that in the treatment group, 26 cases were cured, 11 cases improved and 8 cases failed, with a total effective rate of 82.22%; while in the control group, 14 cases were cured, 7 cases improved and 9 cases failed, with a total effective rate of 70.00%. There was a significant difference in the total effective rate between the groups (P < 0.05). Conclusion
The therapeutic effect of external application of Chinese herbal medicine on Ren-8 Shenque combined with salpingostomy is better than that of salpingostomy only. A clinical observation on the effect of Chinese herbal medicine in adjusting hypoestrogenemia caused by clomiphene given to promote ovulation
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2005 25(4): 360–362. – Ma S X, Yin D E, Zhu Y L. – Institute of Infertility, Traditional Chinese Medicine Hospital of Ju County, Shandong, China. Objective
To explore the effect of Yi Jing Huo Xue Cu Yun (YHCD) Benefit the Jing, Invigorate Blood and Promote Fertility Decoction in adjusting a clomifene-induced hypoestrogenemic response. Methods
Infertile patients with ovulatory problems were randomly divided into two groups. The 60 patients in the observed group were treated with clomifine plus YHCD, and the 58 patients in the control group were given clomifine plus oestradiol valerate. Outcome measures were based on the Insler score, endometrial thickness and pregnancy rate. The Insler score gives a total score out of 12 examining each of the following four criteria and giving them
0–3 points: volume of cervical mucus, cervical relaxation, quality of cervical mucus (should be Spinnbarkheit) and ferning pattern that the mucus adopts when dried on a microscope slide. Results
Thirty-eight patients (63.3%) in the observed group had an Insler score of more than 8 points, compared with 25 (43.1%) in the control group showing a significant difference between the two groups (P < 0.05). The endometrial thickening in the observed group was 0.98 ± 0.19 cm, significantly different to that in the control group (0.85 ± 0.21 cm, P < 0.01). Twenty-five patients in the observed group (41.7%) and 14 patients in the control group (24.1%) became pregnant, which was a significant difference (P < 0.05). Conclusion
YHCD may ameliorate hypoestrinemia induced by clomifene and increase the pregnancy rate in patients. An exploration on the relationship between antispermal antibodies and nitric oxide levels of infertile patients treated by integrated Chinese and Western medicine
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2004 24(4): 306–308. – Liao D L, Yu L Q, Xin H. – Second Affiliated Hospital of Jiangxi Medical College, Nanchang, China. Objective
To study the relationship between the anti-spermal antibodies (ASAb) and nitric oxide (NO) content in blood of infertile patients and the therapeutic effect of integrated Chinese and Western medicine (ICWM) treatment upon the disease. Methods
Seventy-five infertile patients who were ASAb positive and 68 infertile patients who were ASAb negative took part in the trial. The pregnancy and abortion rates were observed. Serum NO levels were measured before treatment to observe the relationship between NO and positive ASAb. Patients were treated with ICWM and followed up for 5 years. Results
The mean value of serum NO in patients with positive ASAb was significantly higher than that in fertile women, and there was no significant difference between patients with negative ASAb and fertile women (P < 0.01). In the 5 years after treatment, the pregnancy rate between the two groups showed insignificant difference (P > 0.05). Conclusion
ASAb positive and abnormal NO levels may both interfere in the reproductive process. ICWM therapy could effectively regulate autoimmunity and endocrine function, and help to treat infertility. The therapeutic effect of Chinese herbal medicines in treating patients with anovulatory infertility with a diagnosis of Kidney deficiency and the influence of the medicines on the haemodynamics
in the ovarian and uterine arteries
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2004 24(4): 299–302. – Xia Y W, Cai LX, Zhang S C. – Xiyuan Hospital, China Academy of TCM, Beijing, China. Objective
To observe the clinical therapeutic effect of Nu Zhen Yun Yu Decoction (NYD) Ligustrum Facilitating Fertility Pill and its influence on the haemodynamic parameters in the ovarian and uterine arteries. Methods
Sixty-eight patients were randomly divided into two groups at the ratio of 2:1, 45 in the TCM group treated with Chinese medicine and 23 in the control group treated with clomifene citrate. The menstrual cycle was observed and basal body temperature, cervical mucus, vaginal exfoliative cells and serum hormones were measured along with a B-ultrasonic examination. These were all used as indices for ovulation and pregnancy. The haemodynamic parameters of the uterus and ovaries were determined by using colour Doppler ultrasonography, and the growth of follicles and ovulation, and thickness of the uterine endometrium were also continuously monitored. Results
Results of three cycles of treatment and a 1 year follow-up study showed that the ovulation promoting rate, pregnancy rate and abortion rate in the two groups were similar, but the treated group showed better effects than that of the control group. This was in regulation of menstruation, follicle growth and development, and improved blood supply to the endometrium, and of the uterine and ovarian arteries (P < 0.05, P < 0.01). Conclusion
NYD is effective in promoting ovulation and holistic regulation of the reproductive system. A clinical observation on the effect of Zhen Qi Zhuan Yin decoction combined with intrauterine insemination in treating Spleen-Kidney deficiency in fertile patients who have antispermal antibodies
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2002 22(2): 95–97. – Lian F, Zhang N, Zhang J W. – Department of Gynaecology, Affiliated Hospital of Shandong, TCM University, Jinan, China. Objective
To compare the effect of combined therapy of Zhen Qi Zhuan Yin Decoction (ZQZYD) and timely intra-uterine insemination (IUI) with that of using ZQZYD and IUI separately in treating infertile patients with anti-spermal antibodies (ASAb).
Methods
One-hundred and three patients were randomly divided into three groups: Group A was treated with combined ZQZYD and IUI (n = 34), Group B was treated with ZQZYD alone (n = 34) and Group C was treated with IUI alone (n = 35). The negative conversion rate of ASAb, pregnancy rate in patients, pregnancy rate in ASAb converted patients as well as amelioration of the TCM pattern and T-lymphocyte subsets were observed. Results
The negative conversion rate of ASAb in the three groups was 76.47% (26/34), 82.35% (28/34) and 8.57% (3/35) respectively. In Group A, the pregnancy rate was 41.18% (14/34) and 50.0% (13/26) in the ASAb negative converted patients; in Group B, the results were 20.59% (7/34) and 21.43% (6/28) respectively; and in Group C the pregnancy rate was 11.43% (4/35). The pregnancy rate in Group A was significantly higher than that in Group B or C (P < 0.01). The effective rate on the TCM pattern in Group A and B was 88.23% and 91.18% respectively (P > 0.05). In Groups A and B, CD4 decreased, CD8 increased and the CD4/CD8 ratio decreased after treatment, with significantly different results to baseline levels and compared to Group C results after treatment (P < 0.05). Conclusion
Combined therapy of ZQZYD and IUI shows a better effect in treating infertility with positive ASAb than that by ZQXYD or IUI alone. A clinical study on the treatment of oviductal obstruction with integrated traditional Chinese and Western medicine
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2001 21(6): 416–418. – Kang J L, Xia W, He Q Y. – Department of Gynaecology and Obstetrics, First People’s Hospital of Guangzhou, Guangzhou, China. Objective
To find an effective and practical treatment of oviductal obstruction (OvO). Methods
One-hundred and twenty OvO patients were randomly divided into three groups: the TCM–Western medicine (WM) group was treated with integrated traditional Chinese and Western medicine, the TCM group was treated with Chinese herbal medicine alone and the WM group was treated with Western medicine alone. The therapeutic effect as well as the effect of treatment on serum C-reactive protein (CRP) and interleukin-1 beta (IL-1 beta) were observed. Results
After treatment, in the TCM–WM group, the Fallopian tube patency rate was 86.7% and the pregnancy rate 85.0%, while in the TCM group the results were 66.7% and 63.3% respectively, and in the WM group 53.3% and 50.0% respectively. Comparison among the three groups showed that the effect in the TCM–WM group was significantly superior to that in the other two groups (P < 0.01). The levels of CRP and IL-1 beta were all
lowered after three courses of treatment, and the effect was more evident in the TCM–WM group (P < 0.01). Conclusion
TCM–WM treatment is an effective and practical method in treating oviductal obstruction. The improvement of luteal insufficiency in fertile women with the formula Tokishakuyakusan (Dang Gui Shao Yao San)
– American Journal of Chinese Medicine 2002 30(2–3): 27–38. – Usuki S, Higa T N, Soreya K. – Department of Obstetrics and Gynaecology, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan. Objective
To ascertain the effectiveness in treating fertile women with luteal insufficiency with the Chinese herbal medicine Tokishakuyakusan (Dang Gui Shao Yao San Angelica Peonia Powder). Methods
Women with luteal insufficiency and women with normal menstrual cycles were given Tokishakuyakusan. Luteal insufficiency was determined by daily measurement of basal body temperature and plasma progesterone levels. The effect of the herbal medicine upon luteal insufficiency was studied, as
well as the effects on prolactin, gonadotropins, steroids, angiotensin II, atrial natriuretic peptide and renin levels in the blood of women with normal menstrual cycles and the effects on oestrogens, pregnenediol and LH in the urine of the same women. Results
Tokishakuyakusan improved luteal insufficiency. There were no adverse effects on hormonal levels in either blood or urine and no clinical side effects were detected. Conclusion
These results suggest that Tokishakuyakusan improves luteal insufficiency in women but does not affect the hormonal levels of women with normal menstrual cycles. A preliminary report of the treatment of luteal phase insufficiency by tonifying the Kidneys
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western medicine 1992 12(8): 473–474, 452–453. – Zhang H Y, Yu X Z, Wang G L. – Xijing Hospital, Fourth Military Medical University, Shaanxi, China. Objective
To ascertain the effect of tonifying the Kidneys on luteal phase insufficiency.
Methods
Fifty-three patients with luteal phase insufficiency were treated with a variety of Chinese herbs at different phases of their menstrual cycles. On the fifth day of the menstrual cycle, the focus of the treatment was to nourish Kidney-Yin, tonify the Spleen and Qi, and move and tonify Blood in order to promote follicular development. The focus for the post-ovulatory treatment was to tonify the Kidney-Yang to enhance and maintain the development of the corpus luteum. The patients were treated for three menstrual cycles. Results
The endometrium in the luteal phase improved significantly with prolonged basal body temperature elevation and a tendency for normalization of the wave forms after the treatment. In the mid-progestational stage, the level of serum LH and prolactin were reduced (P < 0.05) and that of serum progestin rose significantly (P < 0.01), as compared with those before the treatment. Among the 53 cases, 22 (41.5%) conceived but 68.18% of them required other measures to preserve the pregnancy. Conclusion
The findings suggested that Chinese herbal medicines that tonify the Kidneys could regulate the hypothalamus–pituitary–ovarian axis and thus improve the luteal function.
Appendix: male sterility Although male sterility is obviously outside the scope of gynecology, I shall include here a few formulae for this problem for reference. Male sterility may be caused by a deficient sperm count, insufficient motility of the sperm or poor morphology of the sperm. From a Chinese perspective, the main causes of male sterility fall under three broad categories: a deficiency of the Kidneys (usually Kidney-Yang), and Damp-Heat and Damp-Phlegm in the genital system. Thus one needs to make a basic distinction between an Empty and a Full cause of sterility. I often find that it is a good idea to treat the woman’s partner too if he has one of the above three patterns, even if he is not sterile from a Western point of view. Kidney-Yang deficiency
– WU ZI YAN ZONG WAN – Five Seeds Developing the Ancestors Pill Damp-Heat
– LONG DAN XIE GAN TANG and SI MIAO SAN – Gentiana Draining the Liver Decoction and Four Wonderful Powder Damp-Phlegm
– FANG JI HUANG QI TANG Variation
– Stephania-Astragalus Decoction Variation End note 1. Zhu Dan Xi 1983 The Heart and Essence of Dan Xi’s Methods of Treatment ( Dan Xi Zhi Fa Xin Yao ), People’s Health Publishing House, Beijing, p.129. (Zhu Dan Xi, 1280– 1358).
2. Gynaecology Department of the Long Hua Hospital affiliated to theShanghai College of Traditional Chinese Medicine 1987 Report on the Differentiation and Treatment of 257 Cases of Infertility, Journal of Chinese Medicine ( Zhong Yi Za Zhi ) 28(10): 38..
3. Ibid., p. 38..
4. Shandong College of Traditional Chinese Medicine 1980 An Explanation of the ABC of Acupuncture (Zhen Jiu Jia Yi Jing Jiao Shi
), People’s Health Publishing House, Beijing, p. 1473. The ABC of Acupuncture was written by Huang Fu Mi, c. AD 259..
5. Yang Jia San 1988 Great Dictionary of Chinese Acupuncture (Zhong Guo Zhen Jiu Da Ci Dian
), Beijing Physical Training College Publishing House, Beijing, p. 725..
6. Zhang Hong 1993 Infertility from Kidney Deficiency Treated by Combining Moxibustion and
Oral Administration of Herbs, Journal of Chinese Medicine ( Zhong Yi Za Zhi ) 34(3): 163..
7. Shang Xian Min 1990 Practical Traditional Chinese Medicine and Pharmacology – Clinical Experiences, New World Press, Beijing, p. 226..
8. Maciocia G 2008 The Practice of Chinese Medicine, 2nd edn,Churchill Livingstone, Edinburgh..
9. Affiliated Hospital to the Shanghai College of Traditional Chinese Medicine 1998 The Experience of Dr Zhu Nan Sun in the Differentiation and Treatment of Infertility, Journal of Chinese Medicine ( Zhong Yi Za Zhi ) 29(8): 19..
10. Practical Traditional Chinese Medicine, p. 228..
11. Ibid., p. 229..
12. Ibid., p. 228..
13. Ibid., p. 227..
14. An Explanation of the ABC of Acupuncture, p. 1474..
15. Practical Traditional Chinese Medicine and Pharmacology, p. 227..
16. Chen You Bang 1990 Chinese Acupuncture Therapy ( Zhong Guo Zhen Jiu Zhi Liao Xue ), China Science Publishing House, Beijing, p. 957..
17. Wang Xue Tai 1995 Great Treatise of Chinese Acupuncture ( Zhong Guo Zhen Jiu Da Quan ), Henan Science and Technology Publishing House, p. 505..
18. Dr Xia Gui Cheng, personal communication, Nanjing, November 1987..
19. Lian Fang and Sun Ning Quan 1992 Traditional Chinese Medicine Treatment of Luteal Phase Defect, Journal of Chinese Medicine 38: 19..
20. The Experience of Dr Zhu Nan Sun in Treating Infertility, p. 17..
21. Personal communication, London 1989..
22. Shanghai College of Traditional Chinese Medicine 1985 Clinical Experiences in the Differentiation and Treatment of Obstruction of the Fallopian Tubes from Salpingitis, Journal of Chinese Medicine ( Zhong Yi Za Zhi ) 26(8): 35..
Chapter 58 Menopausal Syndrome
AETIOLOGY 736 PATHOLOGY 737 IDENTIFICATION OF PATTERNS AND TREATMENT 738 Kidney-Yin deficiency 738 Kidney-Yang deficiency 740 Kidney-Yin and Kidney-Yang deficiency 741 Kidney- and Liver-Yin deficiency with Liver-Yang rising 745 Kidneys and Heart not harmonized 748 Accumulation of Phlegm and stagnation of Qi 749 Stasis of Blood 750 PROGNOSIS AND PREVENTION 751 WESTERN VIEW 753 CLINICAL TRIALS 755 Acupuncture 755 Herbal treatment 761 Western medicine 766 ‘Menopause’ indicates the complete or permanent cessation of menstruation: an interval of 6–12 months is usually necessary to establish the diagnosis. ‘Climacteric’ indicates the phase in a woman’s life during which she makes the transition from a reproductive to a non-reproductive stage: this
transition is a period of declining ovarian function which usually spans 2–5 years around the menopause. Thus, when we refer to the discomfort and symptoms appearing during these years, it would be more appropriate to call them Climacteric Syndrome rather than Menopausal Syndrome: however, since the latter term is more generally used and understood, I shall use it throughout this book. Menopause usually occurs between the ages of 48 and 55 and the median age in industrialized countries is about 51. It will be remembered that the very first chapter of the Simple Questions describes the 7-year cycles of women, according to which menopause occurs at 49 (7 × 7): this is not far from the above-mentioned median age of 51. Furthermore, data analyses indicate that the menopausal age has remained unchanged for centuries.1 Indeed, the mean age at menopause is just over 50 and this is remarkably constant not only throughout the Western world but also in other countries. A survey of Malaysian women showed a mean age at menopause of 50.7 years, and another of seven Asian countries found that most women reached menopause at around 50.2 Menopause is classified as premature when the woman’s age is 35 or less. The age at which it occurs is linked to various factors such as obesity (later), smoking (earlier), blindness (earlier), precocious puberty (earlier) and social class (later for higher social classes). The number of menopausal women in society is increasing not only because of the general increase in life expectancy but also because of the increased number of hysterectomies (with oophorectomy) performed. The primary basis for the progressive decline of reproductive power in women is in the ovary itself, as ovarian follicles are greatly depleted by the time of the menopause. It is interesting to note that there is a progressive decline of follicles even from the time before birth. In fact, at the time the ovaries are formed in the fetus, there are approximately 6 000 000 primordial follicles, which decrease to about 600 000 at birth, to 300 000 at menarche and to about 10 000 at the time of the menopause. This would seem to confirm that the menopause is not an event that takes place suddenly in a woman’s life but one that reflects a gradual physiological process
throughout her lifetime, starting even before her birth. The implications of this are two-fold. First, it confirms that the biological basis of the menopause is determined during a woman’s lifetime and that, therefore, her lifestyle and dietary habits from childhood onwards determine what kind of menopause she is going to have. If a woman has a poor diet and if she overworks for several years prior to the onset of the menopause, she will be more likely to develop problems during the climacteric years. Second, the fact that there are 6 million primordial follicles in the fetus, gradually declining to about 10 000 at menopause, seems to confirm the Chinese medicine view according to which the Essence (which is the biological basis for the development of follicles) performs many functions other than purely reproductive ones: basis of our hereditary constitution, it flows in the Extraordinary Vessels, it determines energy, drive and strength, it influences our resistance to pathogenic factors and is the foundation for the immune system. Thus any detrimental lifestyle habits influence a woman’s reproductive system and, vice versa, a taxation of the reproductive energy (through having too many children too close together or through having an active sexual life at too early an age) affects her body and mind in other areas. As the follicle activity decreases and then ceases, there is a lack of oestrogen and therefore a cessation of the menses. Although Western medicine seems to place all the emphasis on oestrogen depletion occurring during the menopause (reflected at a therapeutic level with the use of hormone replacement therapy which is mostly based on supplying oestrogen), it should not be forgotten that during menopause there is obviously also a decrease of progesterone, which is secreted by the corpus luteum after ovulation occurs: no ovulation, no progesterone. Menopause is not a disease, it is the normal physiological transition in a woman’s life from a reproductive to a non-reproductive age: indeed, many women experience no ‘symptoms’ during this time. The menopause needs medical intervention only when a woman experiences uncomfortable symptoms which affect her life to a greater or lesser degree. In a minority of cases, such symptoms may be very severe and make the woman’s life a
misery. From a Chinese perspective, menopausal symptoms (if there are any) are generally due to a decline of Kidney-Essence in its Yin or Yang aspect; however, within this basic pathology there can be many variations of pattern. Moreover, the deficiency of the Kidneys may often be combined with excess patterns, especially Dampness, stagnation of Qi, stasis of Blood, Empty-Heat or Liver-Yang rising. In a few cases, premature menopause may be caused by stagnation and Phlegm rather than by a Kidney deficiency. Of course, I am now discussing the menopause as the natural transition that occurs as a result of the decline in ovarian function. The menopause that occurs abruptly in a woman under the menopausal age as a result of oophorectomy (the removal of ovaries during a hysterectomy) is quite different. This is not the result of a gradual, natural decline in Kidney-Essence but purely the result of the removal of the ovaries. Also, early menopause is quite different than the one occurring as a result of the natural, gradual decline of Kidney-Essence. Early menopause, defined in my opinion as that occurring under 40 years of age, is not due to the natural decline of Kidney-Essence (which is physiological) but to a pathology such as Blood stasis and/or Phlegm. The severity of the problems a woman experiences during the menopause depends, as we have mentioned above, on the lifestyle and dietary habits throughout her life. The main problems she is likely to experience with varying degrees of severity are: hot flushes (flashes), vaginal dryness, headaches, tiredness, lethargy, irritability, anxiety, nervousness, depression, insomnia, inability to concentrate and sweating. By far the commonest symptom is hot flushes (flashes), from which 85% of menopausal women suffer; 45% may experience them for 5–10 years after the menopause. Indeed, some gynecologists say that, strictly speaking, only hot flushes and vaginal dryness are oestrogen-deficiency-related manifestations in their opinion; most of the other manifestations are due to increased stress at this time of life. Considering the increased stress posed on women through work and family in the past 40–50 years, there is some truth in this view. However, seen from a Chinese perspective, it does not really matter which symptoms are due to oestrogen deficiency and which are not, as the
underlying pattern in most of them is a Kidney deficiency.
Aetiology Having just said above that the menopause is not a disease, it may seem contradictory to discuss its ‘aetiology’. Although the menopause is not a disease, its symptoms are influenced by the lifestyle factors, chief among them emotional stress, overwork and diet. Thus, the factors discussed below are not the causes of the menopause but simply factors that would aggravate its symptoms. Emotional stress Emotional stress is an extremely important cause of menopausal problems, building up for year after year before the onset of the menopause. Worry, anxiety, anger, guilt and fear weaken the Kidneys and would aggravate the decline of Kidney-Essence. Overwork, too many children too close together Overwork, in the sense of working long hours without adequate rest usually combined with irregular diet and worry, is the most important and frequent cause of Kidney deficiency (and especially Kidney-Yin). Having too many children too close together also contributes to weakening the Kidneys. Irregular diet
Excessive consumption of greasy foods
Excessive consumption of greasy foods and dairy foods over many years leads to the formation of Phlegm. In my experience, Phlegm is common in
many menopausal women and it aggravates the symptoms of hot flushes, insomnia and mental restlessness. Diet lacking in nourishment
Women who have a vegetarian diet for many years may suffer from Blood and/or Yin deficiency if they do not pay particular attention to food combining and to getting enough vegetable protein. Excessive consumption of tea, coffee, alcohol
Tea, coffee and especially alcohol are warm in energy and would aggravate menopausal hot flushes (flashes). Smoking Tobacco is hot and drying and it damages Blood, Fluids, Essence and Yin. Tobacco was introduced into China in 1575 and Chinese doctors analysed its effects to see if it could be used as a medicinal herb. They came to the conclusion that it cannot as it is toxic: they also identified its energy as hot and drying. It is interesting that although the ancient Chinese doctors realized that tobacco injures the Lungs, they seemed to place more emphasis on injury of the Essence and of the Kidneys. As such, it therefore injures the KidneyEssence and would aggravate menopausal symptoms.
Pathology As mentioned above, menopausal problems are fundamentally due to a decline of Kidney-Essence which can take the form of Kidney-Yin, KidneyYang or a combined Kidney-Yin and Kidney-Yang deficiency. Some sources say that menopausal symptoms are due to Kidney-Yin deficiency: this is not accurate as they are due to a decline of Kidney-Essence that can take the form of Kidney-Yin or Kidney-Yang deficiency. Indeed, I would say that roughly half of the menopausal women I see have a Pale tongue and therefore suffer from Kidney-Yang deficiency. However, the most common situation in the menopausal age is that there is a deficiency of both Kidney-Yin and Kidney-Yang albeit in differing proportions; if Kidney-Yang deficiency predominates, the tongue will be Pale. As mentioned in Chapter 3 on pathology, a combined deficiency of both Kidney-Yin and Kidney-Yang in women over 40 is very common: indeed, it is probably more the rule than the exception. With Kidney-Yin deficiency, it is easy to explain the hot flushes (flashes): when Yin is deficient, Empty-Heat develops. How to explain hot flushes in Kidney-Yang deficiency? This is due to the fact that when Kidney-Yang is deficient, Kidney-Yin is also deficient (albeit to a lower degree) and therefore some Empty-Heat also develops. Quite simply, in a menopausal woman, if the tongue is Pale, Kidney-Yang deficiency predominates: if the tongue lacks a coating (completely or partially), Kidney-Yin deficiency predominates (see Figures 3.2 and 3.3 in Chapter 3). For this reason, when using prepared remedies, one can often use two remedies simultaneously (each with a reduced dosage): the Yin-nourishing remedy can be given in the evening and the Yang-tonifying one in the morning, with the dosages of each reduced (compared with when a single remedy is used) and adjusted according to the predominant deficiency, e.g. a higher dose of the Yin-nourishing remedy if deficiency of Kidney-Yin predominates and vice versa if deficiency of Kidney-Yang predominates. The following are three examples of common combination of remedies
for menopausal problems from a combined deficiency of both Kidney-Yin and Kidney-Yang: • Qi Ju Di Huang Wan Lycium-Chrysanthemum-Rehmannia Pill and Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill. If deficiency of Kidney-Yin predominates, eight pills of Qi Ju Di Huang Wan in the evening and four of Jin Gui Shen Qi Wan in the morning; vice versa if deficiency of Kidney-Yang predominates. • Zuo Gui Wan Restoring the Left [Kidney] Pill and You Gui Wan Restoring the Right [Kidney] Pill. The dosages are the same as above. • Ease the Journey-Yin and Ease the Journey-Yang (of the Women’s Treasure line). If deficiency of Kidney-Yin predominates, three tablets of Ease the Journey-Yin in the evening and one of Ease the Journey-Yang in the morning; vice versa if deficiency of Kidney-Yang predominates. Although a deficiency of the Kidney-Essence (in its Yin or Yang aspect) is always at the root of menopausal problems (with the exception of premature menopausal problems from Phlegm), such deficiency does not occur in a vacuum and there will be some other pathology that has been accumulating over the years preceding the menopause. Thus, the menopause is often accompanied by some other pathology, notably Dampness, Phlegm, Liver-Yang rising, stagnation of Qi or stasis of Blood. So, if a tailored formula is used, this should be modified to treat the above patterns too. If the above Full patterns are pronounced, then it might be advisable to deal with these first by using a decoction that resolves Dampness, moves Qi or invigorates Blood. For example, were the deficiency of the Kidneys accompanied by a pronounced stasis of Blood, one might invigorate Blood and eliminate stasis first by using for a few weeks a formula such as Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction. Similarly, were Dampness pronounced, one might start with a decoction to resolve Dampness in the Lower Burner such as Si Miao San Four Wonderful Powder. The patterns discussed are:
• Kidney-Yin deficiency • Kidney-Yang deficiency • Kidney-Yin and Kidney-Yang deficiency • Kidney- and Liver-Yin deficiency with Liver-Yang rising • Kidneys and Heart not harmonized • accumulation of Phlegm and stagnation of Qi • stasis of Blood.
Identification of patterns and treatment Before discussing the treatment of various patterns, it should be clarified that if a woman is taking hormone replacement therapy (HRT or ERT), treatment with Chinese herbs is not in contradiction with it as the two work in markedly different ways. If the woman desires, HRT (ERT) can be stopped without dangerous reactions, but she should be warned that the menopausal symptoms may return before the Chinese herbs have time to take effect (which is about 2 months). For a discussion of HRT (ERT), see the end of this chapter.
Kidney-Yin deficiency
Clinical manifestations Dizziness, tinnitus, malar flush, night sweating, hot flushes, lower backache, dry mouth, dry hair, dry skin, itching, constipation. Tongue: without coating (completely or partially); Red if there is Empty-Heat. Pulse: Floating-Empty, or Fine-Rapid, or very Deep-Weak on both Rear positions and Overflowing on both Front positions. Treatment principle Nourish Kidney-Yin, subdue Yang, calm the Mind, clear Heart Empty-Heat. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, KI10 Yingu, Ren-4 Guanyuan, KI-13 Qixue, SP-6 Sanyinjiao, HE-6 Yinxi, KI-7 Fuliu, L.I.-4 Hegu. All with reinforcing method, except for HE-6 which should be needled with even method. No moxa. Explanation
– LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and nourish Yin. They also benefit and moisten the throat, alleviating the symptom of dry throat at night. – KI-3, SP-6 and KI-10 nourish the Kidneys.
– HE-6 and KI-7 stop night sweating. – Ren-4 and KI-13 strengthen the Uterus and nourishes the Kidneys. – L.I.-4 calms the Mind and regulates the ascending and descending of Qi. Herbal treatment
a Prescription
– ZUO GUI YIN Variation – Restoring the Left [Kidney] Decoction Variation Explanation The first six herbs constitute the root formula which nourishes Kidney-Yin. – Shou Wu nourishes Blood and the Essence. – Gui Ban nourishes Kidney-Yin and strengthens the Directing and Penetrating Vessels. This formula is primarily for Yin deficiency without much Empty-Heat or Heart Empty-Heat. b Prescription
– EMPIRICAL PRESCRIPTION by Dr Meng Jing Chun Explanation
– Sheng Di Huang and Shu Di Huang nourish Kidney-Yin. – Gui Ban nourishes Kidney-Yin and strengthens the Directing and Penetrating Vessels. – Gou Teng and Mu Li subdue Liver-Yang. Mu Li also nourishes Yin and ‘absorbs’, stopping sweating. – Suan Zao Ren and Fu Shen calm the Mind. Suan Zao Ren is also astringent and will therefore help to stop sweating. – Fu Ling resolves Dampness. This formula is also primarily for Yin deficiency without much EmptyHeat. Compared with the previous formula, it is more absorbent and therefore better suited to sweating. c Prescription
– GENG NIAN FANG – Menopause Formula Explanation
– Sheng Di Huang, Nu Zhen Zi and Han Lian Cao nourish Yin and clear Empty-Heat. – Suan Zao Ren, Long Chi and He Huan Pi calm the Mind and pacify the Liver. Suan Zao Ren is also astringent and will therefore help to stop sweating.
– Gou Teng subdues Liver-Yang. – Lian Xin clears Heart-Heat and calms the Mind. – Fu Ling resolves Dampness. – Zi Cao cools Blood. This formula places the emphasis on nourishing Yin, absorbing fluids and calming the Mind: it is therefore used for hot flushes with sweating and mental restlessness. d. Prescription
– GENG NIAN AN – Peaceful Menopause Explanation The first six herbs constitute the formula Liu Wei Di Huang Wan which nourishes Liver- and Kidney-Yin. – Sheng Di Huang nourishes Kidney-Yin. – Shou Wu nourishes Blood and Essence. – Xian Mao tonifies Kidney-Yang. This formula nourishes both Kidney-Yin and Kidney-Yang, but primarily Kidney-Yin. Modifications
These modifications apply to all the above formulae. • Itching: add Chan Tui Periostracum Cicadae, Fang Feng Radix Saposhnikoviae, Hai Tong Pi Cortex Erythrinae variegatae, Yu Zhu Rhizoma Polygonati odorati. • Dizziness, headache: add Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus Uncariae cum Uncis, Shi Jue Ming Concha Haliotidis, Niu Xi Radix Achyranthis bidentatae seu Cyathulae, Sang Ji Sheng Herba Taxilli. • Liver-Yin deficiency: add Nu Zhen Zi Fructus Ligustri lucidi and Han Lian Cao Herba Ecliptae. • Kidney and Heart not harmonized: use Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill. Table 58.1 compares and contrasts the four above formulae for menopausal problems from Kidney-Yin deficiency. Table 58.1 Comparison of formulae for menopausal problems from Kidney-Yin deficiency
Women’s Treasure remedy
– EASE THE JOURNEY-YIN This remedy nourishes Kidney-Yin, clears Empty-Heat and absorbs fluids, and is specific for menopausal problems from Kidney-Yin deficiency. Summary Kidney-Yin deficiency
Clinical manifestations
Dizziness, tinnitus, malar flush, night sweating, hot flushes, lower backache, dry mouth, dry hair, dry skin, itching, constipation. Tongue: without coating (completely or partially); Red if there is Empty-Heat. Pulse: Floating-Empty, or Fine-Rapid, or very Deep-Weak on both Rear positions and Overflowing on both Front positions. Treatment principle
Nourish Kidney-Yin, subdue Yang, calm the Mind, clear Heart Empty-Heat. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, KI10 Yingu, Ren-4 Guanyuan, KI-13 Qixue, SP-6 Sanyinjiao, HE-6 Yinxi, KI-7 Fuliu, L.I.-4 Hegu. All with reinforcing method, except for HE-6 which should be needled with even method. No moxa. Herbal treatment
Pre scriptions
• ZUO GUI YIN Variation Restoring the Left [Kidney] Decoction Variation • EMPIRICAL PRESCRIPTION by Dr Meng Jing Chun • GENG NIAN FANG Menopause Formula • GENG NIAN AN Peaceful Menopause Wome n’s Tre asure remedy
• EASE THE JOURNEY-YIN
Kidney-Yang deficiency
Clinical manifestations Hot flushes but cold hands and feet, night sweating in the early morning, pale face, depression, chilliness, backache, oedema of ankles. Tongue: Pale. Pulse: Weak, Deep. Treatment principle Tonify and warm the Kidneys, tonify Yang, warm the Centre, strengthen the Spleen. Acupuncture BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-15 Jiuwei, KI-7 Fuliu. All with reinforcing method; moxa can be used. Explanation
– BL-23 and BL-52 tonify Kidney-Yang and Kidney-Essence. BL-52 has also a good mental effect, tonifying the Will-Power (Zhi) and relieving depression. – KI-3 tonifies the Kidneys. – LU-7 and KI-6 regulate the Directing Vessel and tonify the Kidneys. – Ren-4, with moxa cones, tonifies Kidney-Yang and strengthens the
Uterus. – Ren-15 calms the Mind. – KI-7 tonifies Kidney-Yang and relieves oedema. Herbal treatment
Prescription
– YOU GUI WAN and LI ZHONG WAN – Restoring the Right [Kidney] Pill and Regulating the Centre Pill Explanation The formula You Gui Wan, already explained, tonifies and warms KidneyYang. The formula Li Zhong Wan tonifies Spleen-Yang. Tonifying SpleenYang is often necessary when tonifying Kidney-Yang. Women’s Treasure remedy
– EASE THE JOURNEY-YANG This remedy tonifies Kidney-Yang and is specific for menopausal problems from Kidney-Yang deficiency: for this reason, the remedy also clears Empty-Heat. The tongue presentation appropriate to this remedy is a Pale body. Summary
Kidney-Yang deficiency
Clinical manifestations
Hot flushes but cold hands and feet, night sweating in the early morning, pale face, depression, chilliness, backache, oedema of ankles. Tongue: Pale. Pulse: Weak, Deep. Treatment principle
Tonify and warm the Kidneys, tonify Yang, warm the Centre, strengthen the Spleen. Acupuncture
BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-15 Jiuwei, KI-7 Fuliu. All with reinforcing method; moxa can be used. Herbal treatment
Pre scription
• YOU GUI WAN and LI ZHONG WAN Restoring the Right [Kidney] Pill and Regulating the Centre Pill Wome n’s Tre asure remedy
• EASE THE JOURNEY-YANG
Kidney-Yin and Kidney-Yang deficiency
Clinical manifestations Hot flushes but cold hands and feet, night sweating, frequent, pale urination, flushed around the neck when talking, slightly agitated, chilliness, dry throat, dizziness, tinnitus, backache. Tongue: Pale or without coating, depending on which deficiency predominates. Red if there is Empty-Heat. Pulse: FloatingEmpty or Weak-Deep. Treatment principle Nourish the Kidneys, nourish Yin, gently tonify Yang, calm the Mind. Acupuncture KI-3 Taixi, LU-7 Lieque and KI-6 Zhaohai, Ren-7 Yinjiao, HE-6 Yinxi, Ren-4 Guanyuan, BL-23 Shenshu, BL-52 Zhishi, SP-6 Sanyinjiao. Reinforcing method; moxa can be used if deficiency of Yang predominates. Explanation
– KI-3 nourishes the Kidneys. – LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and nourish the Kidneys. – Ren-7 nourishes Kidney-Yin. – HE-6 clears Empty-Heat and calms the Mind.
– Ren-4 nourishes the Kidneys and strengthens the Uterus. Direct moxa can be used on this point if the deficiency of Kidney-Yang predominates. – BL-23 tonifies Kidney-Yang. – BL-52 tonifies the Kidneys and nourishes the Essence. It also strengthens Will-Power. – SP-6 helps to nourish the Kidneys. Herbal treatment
a Prescription
– ER XIAN TANG and ER ZHI WAN – Two Immortals Decoction and Two Solstices Pill Explanation The formula Er Xian Tang specifically nourishes Kidney-Yin and tonifies Kidney-Yang. – Xian Mao, Yin Yang Huo and Ba Ji Tian tonify Kidney-Yang. – Huang Bo and Zhi Mu clear Empty-Heat. – Dang Gui nourishes Blood. – Nu Zhen Zi and Han Lian Cao nourish Kidney-Yin, clear Empty-Heat and stop night sweating.
b Prescription
– EMPIRICAL PRESCRIPTION by Dr Meng Jing Chun Explanation
– Yin Yang Huo and Xian Mao tonify Kidney-Yang. – Bai Zhu and Dang Shen tonify Qi. – Mu Xiang moves Qi: this is added to balance the Yin tonics within the formula. – Gou Teng subdues Liver-Yang. – Fu Ling resolves Dampness: this is added to balance the Yin tonics within the formula. – Fu Shen calms the Mind. – Sheng Di Huang nourishes Kidney-Yin. This formula is better if Kidney-Yang deficiency predominates; it also addresses headaches deriving from Liver-Yang rising, itself stemming from Kidney-Yin deficiency. c Prescription
– GENG NIAN LE – Happy Menopause
Explanation The first five herbs constitute the formula Xiao Chai Hu Tang Small Bupleurum Decoction which harmonizes the Lesser Yang and therefore treats feeling of heat and cold alternating. – Fu Xiao Mai stops sweating. – Da Zao tonifies the Nutritive Qi and helps to stop sweating. – Shan Zhi Zi clears Heat and resolves Damp-Heat. – Zhen Zhu Mu calms the Mind and settles the Ethereal Soul. – Yin Yang Huo tonifies Kidney-Yang. This formula tonifies Liver and Kidneys and harmonizes Yin and Yang when they are both deficient. It is especially for sweating and hot flushes and to calm the Mind. d Prescription
– GENG NIAN FANG (two formulae) – Menopause Formulae Formula I
– Sheng Di Huang, Nu Zhen Zi and Han Lian Cao nourish Kidney-Yin, clear Empty-Heat and stop night sweating. – Suan Zao Ren, He Huan Pi and Long Chi calm the Mind and settle the
Ethereal Soul. – Gou Teng subdues Liver-Yang and treats headaches. – Lian Zi Xin clears Heart-Heat and calms the Mind. – Fu Ling resolves Dampness. – Zi Cao cools Blood and treats skin rashes or itching. Formula II
– Yin Yang Huo, Xian Mao and Xu Duan tonify Kidney-Yang. – Huang Qi and Dang Shen tonify Qi. – Suan Zao Ren and He Huan Pi calm the Mind and settle the Ethereal Soul. – Fang Ji and Fu Ling resolve Dampness and treat skin rashes from Dampness. – Lian Xin clears Heart-Heat and calms the Mind. These two formulae should be alternated. They tonify both Kidney-Yin and Kidney-Yang and calm the Mind. e Prescription
– FU GENG YIN – Woman’s Menopause Decoction Explanation
– Sheng Di Huang nourishes Kidney-Yin. – Zi Cao cools Blood and treats skin rashes. – Yin Yang Huo tonifies Kidney-Yang. – Sang Ji Sheng and Dang Gui nourish Blood. – Gou Teng subdues Liver-Yang. – Xiang Fu moves Liver-Qi. – Mai Ya promotes digestion and calms the Mind. Table 58.2compares and contrasts the above five formulae for menopausal problems from deficiency of both Kidney-Yin and Kidney-Yang. Table 58.2 Comparison of formulae for menopausal problems from Kidney-Yin and Kidney-Yang deficiency
Women’s Treasure remedy
– EASE THE JOURNEY-YIN and EASE THE JOURNEY-YANG
Ease the Journey-Yin is a variation of Zuo Gui Wan Restoring the Left [Kidney] Pill, with the addition of herbs to stop sweating and hot flushes, and Ease the Journey-Yang is a variation of You Gui Wan Restoring the Right [Kidney] Pill, with the addition of herbs to clear Empty-Heat and stop hot flushes. If deficiency of Kidney-Yin predominates, use three tablets of Ease the Journey-Yin in the evening and one of Ease the Journey-Yang in the morning; vice versa if deficiency of Kidney-Yang predominates. Ideally, the evening tablets are best taken with very slightly salted warm water. The above dosages are merely a guideline and they can be increased or, in some cases, even decreased. Summary Kidney-Yin and Kidney-Yang deficiency
Clinical manifestations
Hot flushes but cold hands and feet, night sweating, frequent, pale urination, flushed around the neck when talking, slightly agitated, chilliness, dry throat, dizziness, tinnitus, backache. Tongue: Pale or without coating, depending on which deficiency predominates. Red if there is Empty-Heat. Pulse: FloatingEmpty or Weak-Deep. Treatment principle
Nourish the Kidneys, nourish Yin, gently tonify Yang, calm the Mind. Acupuncture
KI-3 Taixi, LU-7 Lieque and KI-6 Zhaohai, Ren-7 Yinjiao, HE-6 Yinxi, Ren-4 Guanyuan, BL-23 Shenshu, BL-52 Zhishi, SP-6 Sanyinjiao.
Reinforcing method; moxa can be used if deficiency of Yang predominates. Herbal treatment
Pre scriptions
• ER XIAN TANG and ER ZHI WAN Two Immortals Decoction and Two Solstices Pill • EMPIRICAL PRESCRIPTION by Dr Meng Jing Chun • GENG NIAN LE Happy Menopause • GENG NIAN FANG (two formulae) Menopause Formulae • FU GENG YIN Woman’s Menopause Decoction Women’s Treasure re me die s
• EASE THE JOURNEY-YIN and EASE THE JOURNEY-YANG
Case history A 50-year-old woman had started experiencing menopausal problems 2 years previously after her periods stopped. She complained of hot flushes, night sweating, some hair loss, nails breaking easily and backache. Her tongue was slightly Pale and her pulse was Weak in general and especially Weak and Deep on both Rear positions. Diagnosis Although she had few symptoms, the prevailing patterns are those of KidneyYang deficiency and some Liver-Blood deficiency. The menopausal symptoms of hot flushes and night sweating indicate Empty-Heat from
Kidney deficiency, as do the backache and hair loss. Since the pulse is Weak on both Rear positions, the only factor that points to Kidney-Yang deficiency is the Pale colour of the tongue. As explained in Chapter 3 on pathology, in women over 50 a deficiency of the Kidneys nearly always involves a deficiency of both Yin and Yang, albeit always in differing proportions. Thus, when Kidney-Yang is primarily deficient, Kidney-Yin also becomes slightly deficient, giving rise to the Empty-Heat symptoms that cause the menopausal problems. Figures 3.1, 3.2 and 3.3 illustrate this clinical situation. In this patient, the brittle nails indicate some Liver-Blood deficiency. Treatment principle The treatment principle in this case is to tonify Kidney-Yang primarily and nourish Kidney-Yin secondarily, and to nourish Liver-Blood. She was treated only with herbal medicine. Herbal treatment
Since her menopausal symptoms were not very severe and she did not have many other symptoms, I opted for treating her only with prepared remedies. I used the Women’s Treasure remedies Ease the Journey-Yang combined with Ease the Journey-Yin: I suggested two tablets of the former in the morning and one of the latter in the evening. The combination of these two remedies at such a low dose controlled the menopausal symptoms very effectively after 2 months and she felt much better in general. I suggested to her that she should continue taking the remedies for quite a long time to help her during the transition years. Case history A 53-year-old woman complained of menopausal problems for the previous 3 years, after her periods stopped. Her main problems were severe hot flushes, night sweating, depression, anxiety, mood swings, a tingling
feeling all over and insomnia. She also complained of severely cold feet and frequent urination. Her tongue was Red with a slightly rootless, yellow and dry coating (Plate 10) and her pulse Rapid, Overflowing on both Front positions and Weak and Deep on both Rear positions. Although most of these symptoms started after her periods stopped, she had a history of severe stress in the years leading up to the menopause (husband’s redundancy, father’s death and daughter’s breakdown) and this obviously accounted for the severity of the menopausal symptoms. As explained in Chapter 4 on aetiology, the kind of menopause a woman experiences depends on her lifestyle in the years preceding it. Diagnosis Most of this patient’s symptoms are due to deficiency of Kidney-Yin with Empty-Heat affecting the Heart and harassing the Mind. The symptoms of Kidney-Yin deficiency are hot flushes, night sweating, Red tongue with a slightly rootless coating and a Weak and Deep pulse on both Rear positions. The symptoms of Empty-Heat affecting the Heart and harassing the Mind are depression, anxiety, mood swings, insomnia and a pulse that is Rapid and Overflowing on both Front positions. As in the previous case history, in this case too there is an overlapping of Kidney-Yin and Kidney-Yang deficiency; although the primary condition is one of Kidney-Yin deficiency, there is also some Kidney-Yang deficiency as evidenced by the cold feet and frequent urination. Treatment principle The treatment principle adopted was to nourish Kidney- and Heart-Yin, clear Heart Empty-Heat and calm the Mind; a secondary aim was to tonify Kidney-Yang. She was treated with acupuncture and prepared remedies. Acupuncture
The points used were selected from the following: • LU-7 Lieque and KI-6 Zhaohai to regulate the Directing Vessel, strengthen the Uterus and nourish Kidney-Yin. • Ren-15 Jiuwei to calm the Mind and clear the Heart. • Ren-4 Guanyuan to nourish the Kidneys and calm the Mind. • Du-24 Shenting and G.B.-13 Benshen to calm the Mind. • Du-20 Baihui to lift depression. • HE-6 Yinxi and KI-7 Fuliu to stop night sweating and clear Heart Empty-Heat. • SP-6 Sanyinjiao to nourish Yin, calm the Mind and promote sleep. Herbal treatment
Initially, I treated this patient only with acupuncture for 2 years (at infrequent intervals, see below); after that, I prescribed the Women’s Treasure remedies Ease the Journey-Yin to nourish Kidney-Yin combined with Ease the Journey-Yang: I prescribed three tablets of the former to be taken in the evening and only half of the latter to be taken in the morning. This patient came quite infrequently as she found that one acupuncture treatment controlled her menopausal symptoms for up to 4 months. After 2 years, I prescribed the above remedies to consolidate results: using these remedies, she found that she no longer needed to have acupuncture.
Kidney- and Liver-Yin deficiency with Liver-Yang rising
Clinical manifestations Irritability, dizziness, tinnitus, blurred vision, dry eyes, dry skin, hot flushes, ache in joints, night sweating, sore back, headaches. Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty, Wiry on the left Middle position. Treatment principle Nourish Kidney- and Liver-Yin, subdue Liver-Yang, calm the Mind, settle the Ethereal Soul. Acupuncture KI-3 Taixi, LIV-8 Ququan, Ren-4 Guanyuan, LU-7 Lieque and KI-6 Zhaohai, LIV-3 Taichong, Du-24 Shenting, G.B.-13 Benshen, G.B.-20 Fengchi, P-7 Daling. KI-3, LIV-8 and Ren-4 with reinforcing method, the others with reducing method. Explanation
– KI-3 nourishes the Kidneys. – LIV-8 nourishes Liver-Blood and Liver-Yin. – Ren-4 nourishes the Kidneys and strengthens the Uterus. – LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and
nourish Kidney-Yin. – LIV-3 and G.B.-20 subdue Liver-Yang. – Du-24, G.B.-13 and P-7 calm the Mind and settle the Ethereal Soul. Herbal treatment
a Prescription
– KUN BAO TANG – Female Treasure Decoction Explanation
– Sheng Di Huang, Bai Shao and Nu Zhen Zi nourish Liver- and KidneyYin. – Ju Hua subdues Liver-Yang. – Huang Qin clears Heat in the Upper Burner and helps to subdue LiverYang. – Suan Zao Ren and Long Chi subdue Liver-Yang, nourish the Liver, calm the Mind and settle the Ethereal Soul. b Prescription
– QI JU DI HUANG WAN – Lycium-Chrysanthemum-Rehmannia Pill Explanation This formula is a variation of Liu Wei Di Huang Wan Six Ingredients Rehmannia Pill which nourishes Liver- and Kidney-Yin. The first six ingredients make up the original prescription. – Gou Qi Zi nourishes Liver- and Kidney-Yin, nourishes the Essence and brightens the eyes. – Ju Hua subdues Liver-Yang and treats headaches. c Prescription
– QING XIN PING GAN TANG – Clearing the Heart and Balancing the Liver Decoction Explanation
– Huang Lian clears Heart-Heat. – Mai Men Dong nourishes Heart-Yin. – Bai Shao nourishes Yin and pacifies the Liver. – Bai Wei clears Heat and cools Blood. – Dan Shen invigorates Blood and calms the Mind. It also acts as a
messenger to direct the formula to the Heart channel. – Long Gu absorbs fluids (hence stops sweating), calms the Mind, settles the Ethereal Soul and subdues Liver-Yang. – Suan Zao Ren nourishes the Liver and Heart, absorbs fluids (hence stops sweating), calms the Mind and settles the Ethereal Soul. Table 58.3 compares and contrasts the formulae for menopausal problems from Liver- and Kidney-Yin deficiency and Liver-Yang rising. Table 58.3 Comparison of formulae for menopausal problems from Liver- and Kidney-Yin deficiency and Liver-Yang rising
Women’s Treasure remedy
– FEMALE TREASURE This remedy is a variation of the formula Kun Bao Tang Female
Treasure Decoction which nourishes Liver- and Kidney-Yin and subdues Liver-Yang. The tongue presentation appropriate to this remedy is a Red body with redder sides and without coating. Three Treasures remedies
– EASE THE JOURNEY-YIN and BEND BAMBOO Ease the Journey-Yin nourishes Kidney-Yin, Bend Bamboo nourishes Liver-Yin and Liver-Blood and subdues Liver-Yang: the combination of these two remedies is therefore recommended for menopausal problems from Liver- and Kidney-Yin deficiency with Liver-Yang rising, with headaches as a predominant symptom. The tongue presentation appropriate to this remedy is a Red body without coating. Summary Kidney- and Liver-Yin deficiency with Liver-Yang rising
Clinical manifestations
Irritability, dizziness, tinnitus, blurred vision, dry eyes, dry skin, hot flushes, ache in joints, night sweating, sore back, headaches. Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty, Wiry on the left Middle position. Treatment principle
Nourish Kidney- and Liver-Yin, subdue Liver-Yang, calm the Mind, settle the Ethereal Soul. Acupuncture
KI-3 Taixi, LIV-8 Ququan, Ren-4 Guanyuan, LU-7 Lieque and KI-6 Zhaohai, LIV-3 Taichong, Du-24 Shenting, G.B.-13 Benshen, G.B.-20 Fengchi, P-7 Daling. KI-3, LIV-8 and Ren-4 with reinforcing method, the others with reducing method. Herbal treatment
Pre scriptions
• KUN BAO TANG Female Treasure Decoction • QI JU DI HUANG WAN Lycium-Chrysanthemum-Rehmannia Pill • QING XIN PING GAN TANG Clearing the Heart and Balancing the Liver Decoction Women’s Treasure re me dy
• FEMALE TREASURE Three Treasures re me die s
• EASE THE JOURNEY-YIN and BEND BAMBOO
Case history A 55-year-old woman had started suffering from menopausal symptoms a year after the stoppage of her periods. Her main problems were hot flushes, night sweating, a ‘prickly feeling’ over her skin, depression, tiredness, dry eyes and mouth, headaches and irritability. Other symptoms included backache, frequent urination, constipation and cold feet. Her tongue was Red on the sides and her pulse was Weak on both Rear positions and slightly Overflowing on the left Middle and Front positions.
Diagnosis The main underlying pattern is that of Kidney-Yin deficiency (hot flushes, constipation, night sweating, dry eyes and mouth). As often happens, there is also a concurrent deficiency of Kidney-Yang (tiredness, frequent urination, backache, cold feet). The depression is due to the weakening of Will-Power (Zhi) consequent to the Kidney deficiency. In addition to the Kidney deficiency, there is Liver-Yang rising (from Kidney-Yin deficiency) as evidenced by the headaches, irritability, Red sides of the tongue and pulse Overflowing on the left Middle and Front positions. Treatment principle The treatment principle adopted was to nourish Kidney-Yin, tonify KidneyYang, subdue Liver-Yang, strengthen Will-Power and calm the Mind. She was treated with acupuncture and prepared remedies. Acupuncture
The points used were selected from the following: • LU-7 Lieque and KI-6 Zhaohai to regulate the Directing Vessel, strengthen the Uterus and nourish Kidney-Yin. • Ren-4 Guanyuan to nourish the Kidneys. • P-7 Daling to calm the Mind. • LIV-2 Xingjian to subdue Liver-Yang. • SP-6 Sanyinjiao to nourish Yin and calm the Mind. • BL-23 Shenshu, BL-52 Zhishi and BL-47 Hunmen to tonify the Kidneys, strengthen Will-Power, pacify the Liver and settle the Ethereal Soul. Herbal treatment
I prescribed the Women’s Treasure remedy Female Treasure which nourishes Liver- and Kidney-Yin and subdues Liver-Yang (see above). This patient received only four acupuncture treatments, which had a strong initial impact; after that, she took the above remedy for several months inducing a remarkable improvement in her symptoms.
Kidneys and Heart not harmonized
Clinical manifestations Hot flushes, palpitations, insomnia, night sweating, blurred vision, dizziness, tinnitus, anxiety, mental restlessness, backache, a malar flush, feeling of heat in the evening, dry mouth and throat, poor memory, dry stools. Tongue: Red body without coating with a redder tip. Pulse: Rapid-Fine, or FloatingEmpty, or Weak-Deep on both Rear positions and Overflowing on both Front positions. This pattern consists of Kidney-Yin deficiency with Heart Empty-Heat. Treatment principle Nourish Kidney-Yin, calm the Mind, clear Empty-Heat. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-13 Qixue, HE-6 Yinxi, KI-7 Fuliu, HE-8 Shaofu, P-7 Daling, Ren-15 Jiuwei, Du-24 Shenting. HE-6, HE-8 and P-7 with reducing or even method; all the others with reinforcing method. Explanation
– LU-7 and KI-6 regulate the Directing Vessel, strengthen the Uterus and nourish the Kidneys. – KI-3 and SP-6 nourish Kidney-Yin.
– Ren-4 and KI-13 nourish the Kidneys, strengthen the Uterus and nourish the Directing and Penetrating Vessels. – HE-6 and KI-7 stop night sweating. – HE-8 and P-7 clear Heart-Heat and calm the Mind. – Ren-15 and Du-24 nourish the Heart and calm the Mind. Herbal treatment
a Prescription
– TIAN WANG BU XIN DAN – Heavenly Emperor Tonifying the Heart Pill Explanation This formula nourishes Kidney-Yin, clears Heart Empty-Heat and calms the Mind: it is ideally suited to treat menopausal problems occurring with these patterns. – Sheng Di Huang, Xuan Shen, Mai Men Dong and Tian Men Dong nourish Kidney- and Heart-Yin. – Ren Shen tonifies the Original Qi. – Fu Ling resolves Dampness and counteracts the cloying effect of Yin tonics.
– Wu Wei Zi calms the Mind, nourishes the Essence and nourishes the Heart. – Dang Gui and Bai Zi Ren nourish Blood, tonify the Heart and calm the Mind. – Dan Shen invigorates Blood and calms the Mind. It also acts as a messenger to direct the formula to the Heart channel. – Suan Zao Ren and Yuan Zhi calm the Mind, nourish the Heart and open the Mind’s orifices. – Jie Geng acts as a messenger to direct the formula to the Upper Burner (to affect the Heart and Mind). b Prescription
– LIU WEI DI HUANG WAN and HUANG LIAN E JIAO TANG – Six-Ingredient Rehmannia Pill and Coptis-Colla Corii Asini Decoction Explanation The formula Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill, already explained, nourishes Liver- and Kidney-Yin. The formula Huang Lian E Jiao Tang Coptis-Colla Corii Asini Decoction, clears Heart-Heat and nourishes Yin. – Huang Lian and Huang Qin clear Heat-Heat. – Bai Shao, Ji Zi Huang and E Jiao nourish Blood and Yin.
Women’s Treasure remedy
– HEAVENLY EMPRESS This remedy is a variation of the formula Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill which nourishes Kidney- and Heart-Yin, clears Heart Empty-Heat and calms the Mind. The tongue presentation appropriate to this remedy is a Red body with redder tip and without coating. Summary Kidneys and Heart not harmonized
Clinical manifestations
Hot flushes, palpitations, insomnia, night sweating, blurred vision, dizziness, tinnitus, anxiety, mental restlessness, backache, a malar flush, feeling of heat in the evening, dry mouth and throat, poor memory, dry stools. Tongue: Red body without coating with a redder tip. Pulse: Rapid-Fine, or FloatingEmpty, or Weak-Deep on both Rear positions and Overflowing on both Front positions. Treatment principle
Nourish Kidney-Yin, calm the Mind, clear Empty-Heat. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-13 Qixue, HE-6 Yinxi, KI-7 Fuliu, HE-8
Shaofu, P-7 Daling, Ren-15 Jiuwei, Du-24 Shenting. HE-6, HE-8 and P-7 with reducing or even method; all the others with reinforcing method. Herbal treatment
Pre scriptions
• TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill • LIU WEI DI HUANG WAN and HUANG LIAN E JIAO TANG SixIngredient Rehmannia Pill and Coptis-Colla Corii Asini Decoction Wome n’s Tre asure remedy
• HEAVENLY EMPRESS
Accumulation of Phlegm and stagnation of Qi
Clinical manifestations Obesity, a feeling of oppression of the chest, sputum in the chest, a feeling of fullness of the epigastrium, a feeling of distention of the breasts, irritability, belching, nausea, no appetite, moodiness, depression. Tongue: slightly Red sides, Swollen body, sticky coating. Pulse: Wiry. This is a pattern that appears in premature menopause in young women: in a few cases, menopause may arise not from a decline of the Kidneys but from obstruction of the Lower Burner. Treatment principle Resolve Phlegm, pacify the Liver, eliminate stagnation, free the Connecting channels. Acupuncture Ren-17 Shanzhong, P-6 Neiguan, LU-7 Lieque, Ren-6 Qihai, Ren-10 Xiawan, T.B.-6 Zhigou, ST-40 Fenglong, SP-6 Sanyinjiao, SP-9 Yinlingquan, ST-28 Shuidao, Ren-4 Guanyuan. All with reducing or even method. Explanation
– Ren-17, P-6 and T.B.-6 move Qi, pacify the Liver and eliminate stagnation.
– LU-7 moves Qi in the Upper Burner. – Ren-6 moves Qi in the Lower Burner. – Ren-10 helps to resolve Phlegm. – ST-40, SP-6 and SP-9 resolve Dampness and Phlegm. – ST-28 and Ren-4 open the Water passages in the Lower Burner, eliminate Dampness from the Lower Burner and strengthen the Uterus. Herbal treatment
Prescription
– YUE JU WAN – Gardenia-Chuanxiong Pill Explanation
– Cang Zhu eliminates stagnation of Dampness and Phlegm. – Chuan Xiong eliminates stasis of Blood. – Xiang Fu eliminates stagnation of Qi. – Shan Zhi Zi eliminates stagnation of Heat. – Shen Qu eliminates stagnation of Food.
Three Treasures remedies
– CLEAR THE SOUL and RELEASE CONSTRAINT Clear the Soul resolves Phlegm-Heat and affects the breasts while Release Constraint moves Qi, pacifies the Liver, eliminates stagnation and also resolves Dampness. The combination of these two remedies may therefore be used for premature menopause deriving from Phlegm and stagnation of Qi. The tongue presentation appropriate to the combination of these two remedies is a Swollen body with Red sides and a sticky, yellow coating. Summary Accumulation of Phlegm and stagnation of Qi
Clinical manifestations
Obesity, a feeling of oppression of the chest, sputum in the chest, a feeling of fullness of the epigastrium, a feeling of distention of the breasts, irritability, belching, nausea, no appetite, moodiness, depression. Tongue: slightly Red sides, Swollen body, sticky coating. Pulse: Wiry. Treatment principle
Resolve Phlegm, pacify the Liver, eliminate stagnation, free the Connecting channels. Acupuncture
Ren-17 Shanzhong, P-6 Neiguan, LU-7 Lieque, Ren-6 Qihai, Ren-10
Xiawan, T.B.-6 Zhigou, ST-40 Fenglong, SP-6 Sanyinjiao, SP-9 Yinlingquan, ST-28 Shuidao, Ren-4 Guanyuan. All with reducing or even method. Herbal treatment
Pre scription
• YUE JU WAN Gardenia-Chuanxiong Pill Thre e Tre asure s remedies
• CLEAR THE SOUL and RELEASE CONSTRAINT
Stasis of Blood
Clinical manifestations Hot flushes, mental restlessness, menopause preceded by a period when menses are very irregular stopping for a long time then starting again, dark, clotted blood, insomnia, high blood pressure, abdominal pain. Tongue: Purple. Pulse: Wiry or Choppy. This pattern may also be seen in premature menopause or it may accompany the other patterns in normal menopause. Treatment principle Invigorate Blood, eliminate stasis, calm the Mind, open the Mind’s orifices, move Qi and eliminate stagnation. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), KI-14 Siman, SP-10 Xuehai, BL-17 Geshu, Ren-4 Guanyuan, Ren-6 Qihai, LIV-3 Taichong, P-7 Daling. All with reducing or even method. Moxa can be used if stasis of Blood derives from Cold. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel, invigorate Blood and eliminate stasis as this vessel is the Sea of Blood. – KI-14, a point of the Penetrating Vessel, invigorates Blood and
eliminates stasis. – SP-10 and BL-17 invigorate Blood and eliminate stasis. – Ren-4, a point on both the Directing and Penetrating Vessels, strengthens the Uterus. – Ren-6 moves Qi in the abdomen. – LIV-3 invigorates Blood and eliminates stasis: it is also related to the Penetrating Vessel. – P-7 is used in case of pronounced mental restlessness to calm the Mind and open the Mind’s orifices. Herbal treatment
a Prescription
– GE XIA ZHU YU TANG – Eliminating Stasis below the Diaphragm Decoction Explanation This formula, already explained, invigorates Blood and eliminates stasis in the Lower Burner. With the opportune modifications, it can be used for stasis of Blood with Heat or with Cold. b Prescription
– WEN JING TANG – Warming the Menses Decoction Explanation This formula, already explained, invigorates Blood and eliminates stasis deriving from Cold, associated with Blood deficiency and Empty-Heat deriving from it. Modifications These modifications apply to both formulae. • If the symptoms of Heat rising are pronounced, add Gou Teng Ramulus Uncariae cum Uncis and Bai Ji Li Fructus Tribuli. • If there are symptoms of distension, irritability and breast distension, add Yue Ju Wan Gardenia-Chuanxiong Pill, which could be taken as a prepared remedy (Release Constraint in the Three Treasures). Women’s Treasure remedy
– STIR FIELD OF ELIXIR This remedy is a variation of Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction and it invigorates Blood and eliminates stasis in the Lower Burner. The tongue presentation appropriate to this remedy is a Purple body. Summary
Stasis of Blood
Clinical manifestations
Hot flushes, mental restlessness, menopause preceded by a period when menses are very irregular stopping for a long time then starting again, dark, clotted blood, insomnia, high blood pressure, abdominal pain. Tongue: Purple. Pulse: Wiry or Choppy. Treatment principle
Invigorate Blood, eliminate stasis, calm the Mind, open the Mind’s orifices, move Qi and eliminate stagnation. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), KI-14 Siman, SP-10 Xuehai, BL-17 Geshu, Ren-4 Guanyuan, Ren-6 Qihai, LIV-3 Taichong, P-7 Daling. All with reducing or even method. Moxa can be used if stasis of Blood derives from Cold. Herbal treatment
Pre scriptions
• GE XIA ZHU YU TANG Eliminating Stasis below the Diaphragm Decoction • WEN JING TANG Warming the Menses Decoction Wome n’s Tre asure remedy
• STIR FIELD OF ELIXIR
Prognosis and prevention Chinese medicine can help women to minimize their problems in the transition from a reproductive to a non-reproductive age. Herbal treatment is more effective than acupuncture because herbs are better at nourishing the Essence. Generally speaking, if menopausal problems occur against a background of Kidney-Yin deficiency, the treatment will be more difficult and one can say that the redder and more peeled the tongue body, the more difficult the treatment. The tongue indicating the worst prognosis would be one with a dark Red body, completely peeled, cracked and dry. As mentioned in the beginning of this chapter, the severity of menopausal symptoms (if at all) depends on the pre-existing condition of the Kidneys and therefore on the woman’s diet and lifestyle throughout her lifetime. Thus, it is important that the patient understands this and is willing to wait; Chinese medicine can help a woman in this transition period only in a slow and gradual way. It is becoming more difficult to explain this to patients given the ‘quick results’ they are offered (and sometimes experience) through hormone replacement therapy (HRT or ERT). Bearing in mind the aetiological factors that aggravate the menopausal symptoms, in the past 15–20 years I have been advising and counselling young women before they reach the menopausal age. If I see a woman in her thirties for example, and detect life habits that might be conducive to a problematic menopause, I advise them about lifestyle and diet and I tell them that now is the time to do something about the menopause. My advice to young women revolves mainly around the following aspects: • Do not smoke. • Do not consume too much alcohol, tea, coffee. • Do not overwork. • Avoid the excessive consumption of greasy and dairy foods.
• Eat plenty of vegetables and whole grains. • Deal with emotional stress to minimize its impact. Phytoestrogens The question of the use of phytoestrogens in the menopause has received a lot of attention in the past few years with contradictory views. The name ‘phytoestrogens’ is rather misleading as it implies a plant source of oestrogens. Phytoestrogens are not oestrogens: they have a chemical structure that is similar to but not the same as that of oestrogens and their effect on the body is different to that of oestrogens. Rather than describing an actual class of compounds, the term ‘phytoestrogen’ actually describes a property that has been identified in compounds found in foods, plants and herbs. There is not, as yet, a definitive list of substances that contain phytoestrogens. However, they have been found in the following classes of substances: • Lignans. • Isoflavones. • Coumestans. Isoflavones is the group in which there is most interest and which is present in soya products: genistein and dadzein are the two most-studied isoflavones. So, when we use the term ‘phytoestrogen’, it is important to bear in mind that it is rather a misnomer and that it refers to the property of a substance rather than a substance in itself. Although phytoestrogens are often compared to oestrogens, the effect that they have on oestrogen levels in the body is not clearly defined. However, the vast majority of the clinical studies done so far point towards the fact that phytoestrogens do not have the same effect as oestrogens. Phytoestrogens bind to oestrogen receptors in the same way oestrogen does
and studies seem to show that phytoestrogens may have opposite effects: by binding to oestrogen receptors, they may have an oestrogenic effect; but, by doing so, they also prevent the body’s oestrogen from binding to those receptors. Preventing oestrogen from locking onto its receptors (for example in the breast), they would have an anti-oestrogenic effect. This is not surprising as many herbs (when used in their whole state and not as isolated constituents) may have opposite effects on the body and that is precisely why they have a modulatory, homeostatic effect quite unlike that of drugs. There are many examples of such homeostatic effects of the compounds present in the whole plant: Ren Shen Radix Ginseng, for example, can stimulate but also depress the central nervous system, Dang Gui Radix Angelicae sinensis can contract but also relax the uterus, etc. Some scientific sources acknowledge this too. For example, a pharmacognosy textbook says: Procedures involving continuous monitoring of fractions for biological activity are not free from anomalies. It is quite well known that isolated constituents of a plant drug may not give the same clinical response as a crude preparation of that plant drug. Very often, the total therapeutic activity is greater than, or different from, the therapeutic activity of the individuals. Synergism or antagonism resulting from the complex nature of the extract are probably the causes of such observations. It is thus possible that a fraction from a plant extract, although showing significant biological activity, possesses no single constituent with this activity. Conversely, a fraction showing no activity may still contain an active constituent.3 Thus, it is quite possible that phytoestrogens may stimulate the production of oestrogen if it is deficient and restrain it if it is excessive (by blocking its receptors). Thus, there are conflicting studies, some supporting the use of phytoestrogens in the prevention of oestrogen-dependent cancers, some showing that phytoestrogens may stimulate oestrogen-dependent cancers in the same way as the body’s oestrogen does. However, it is a fact that Japan,
a country where the consumption of phytoestrogens (in soy) is very high, has rates of breast cancer that are considerably lower than in Western countries.4 As for the use of phytoestrogens in the treatment and prevention of menopausal vasomotor symptoms (hot flushes and night sweating), some studies do not seem to support their use. A meta-analysis from the Cochrane Library concluded that there is no evidence of effectiveness in the alleviation of menopausal symptoms with the use of phytoestrogen treatments.5 The problem with most of these studies is that they are based on the use of isolated phytoestrogens: when eaten as part of our food and in the context of a balanced diet, their effect is quite different and that is when, in my opinion, they can have a modulatory, homeostatic effect. Plants contain many types of phytoestrogens; additionally, they contain minerals and other constituents which help our bodies modify the phytoestrogens, making them safe. For example, red clover (Trifolium pratense) is mineral rich and contains all four of the major types of phytoestrogens: lignans, coumestans, isoflavones and resorcylic acid lactones. Research shows that red clover may have some anti-cancer effect. However, when isolated (usually from soy), isoflavone has the opposite effect: in the lab it encourages the growth of breast cancer cells but clinical studies do not show this effect. A double-blind study on the effect of isolated isoflavones showed that they had no effect on breast density. As mentioned above, this study also makes use of isolated isoflavones and not of the whole plant.6 My view is that it is safer for women to avoid any type of hormonal manipulation including oestrogen medication, so-called bio-identical hormones and also isolated isoflavones. It is far better to derive phytoestrogens from whole foods such as yam. Very many foods contain phytoestrogens but the ones that are richest in these are (in descending order): • flax seeds • yam
• soy beans • tofu • soy yoghurt • sesame seeds • soy milk.
Western view The ovarian changes associated with the menopause have already been mentioned in the introduction. The main endocrine change is a decreased oestrogen production by the ovary which is the main source of oestrogen (in the form of oestradiol) in the reproductive years. After menopause, the ovarian oestrogen production decreases markedly and the main circulating oestrogen is oestrone rather than oestradiol. Most of the oestrogen present in menopausal women is derived from adipose tissue from the conversion of androstenedione to oestrone. The amount of oestrone produced in adipose tissue is determined by the overall amount of this tissue. Therefore, thin women convert a smaller percentage of androstenedione to oestrone (1.5%) compared with obese women who may convert as much as 7%. The main source of androstenedione is the adrenal glands. The time preceding the menopause is characterized by an increasingly irregular menstrual cycle which may become either scanty or heavy and irregular in timing. The symptoms associated with the menopause may be classified according to the organ or tissue involved: • Brain: hot flushes, depression, anxiety, insomnia, poor memory and concentration. • Heart: coronary heart disease. • Blood vessels: arteriosclerosis. • Bone: osteoporosis. • Skin: thinning, slow healing, itching. • Vagina: vaginal dryness and atrophy. As mentioned before, some gynecologists consider only hot flushes and vaginal dryness as oestrogen-related menopausal symptoms. Hot flushes
(flashes) are the most common menopausal symptom: up to 85% of menopausal women suffer from them and 45% of them do so for up to 10 years after the menopause. Associated with an increase in temperature, increased pulse rate and increased blood flow in the head, each hot flush lasts on average 2.7 minutes. Hot flushes are a mechanism for dissipating heat through vasodilatation and perspiration in response to the thermoregulatory centres in the anterior hypothalamus. The vasomotor symptoms (hot flushes) occurring during the climaterium are probably due to fluctuating pulses of pituitary follicle-stimulating hormone (FSH) which rises to abnormal blood levels at this time in an effort to provoke ovulation from increasingly unresponsive follicles. Oestrogen in the form of HRT (ERT) ‘deceives’ the pituitary that normal ovulation and oestrogen production is continuing so that the overproduction of FSH ceases and so do the hot flushes. The Western treatment of menopausal problems is based on the administration of hormone replacement therapy (HRT or ERT) in different forms: these could be native oestrogens (oestradiol, oestrone, oestriol), conjugated equine oestrogens and synthetic oestrogens (such as ethinyl oestradiol) in a dose ranging between 5 and 10 μg. This is a lower dose (usually about 1/7th) than the one used in the contraceptive pill and, for this reason, many gynecologists believe that the potential side effects of HRT (ERT) have been wrongly extrapolated from those of the contraceptive pill. Indeed, they say that some of the side effects, far from being that, are actually indications: for example, while the contraceptive pill carries the potential adverse reaction of cardiovascular disease, HRT (ERT) is, presumably, effective in ‘protecting’ menopausal women from cardiovascular disease.7 However, this thesis is hotly debated as we shall see shortly. In any case, the potential adverse effects of HRT (ERT) include endometrial hyperplasia and cancer, thromboembolism, strokes, hypertension, breast cancer, gall bladder dysfunction, gall stones and lesser symptoms such as nausea, vomiting, water retention and headaches.8 As most practitioners will know, in spite of the potential adverse effects, menopausal women are increasingly being prescribed HRT (ERT) almost
routinely. The one adverse effect that is usually taken seriously is the potential risk of breast cancer: for this reason, HRT (ERT) should never be given to a woman who has or has had breast cancer or to a woman who has a breast lump of an unknown nature. However,this view is also debated as there are doctors who think that women who have been ‘cured’ of their breast cancer can receive HRT (ERT) without risk.9 The oestrogen present in HRT (ERT) is often supplemented by the administration of progestins principally to oppose the effect of oestrogen on the endometrium (hyperplasia and increased risk of endometrial cancer). For this reason, women who had a hysterectomy are prescribed unopposed oestrogen. There are two classes of progestins used: native progestins (progesterone and 17-hydroxyprogesterone) and synthetic progestins (19nortestosterone derivatives and 21-carbon-atom compounds such as medroxyprogesterone and megestrol). If oestrogen is given for 25 days (with a break of 5 days), progestin is added in the last 12 days. If oestrogen is given continuously for 30 days without a break, progestin is usually administered in the last 12 days. Vaginal bleeding usually occurs with cyclic oestrogen/progesterone therapy and is caused by the progesterone component. Progesterone therapy for menopausal women has not proved of much benefit and also has potential side effects such as depression, breast fullness and tenderness, a distended feeling, weight gain and symptoms like those of pre-menstrual tension. However, the theoretical side effects of progesterone are rarely manifest in practice when it is combined with oestrogen for the relief of menopausal symptoms. Progesterone’s undisputed role in HRT (ERT) is to neutralize oestrogen’s potentially carcinogenic effect on the endometrium and breast. HRT (ERT) therapy can be administered in the following forms: • oral (tablets) • transdermal (patches) • percutaneous (gel)
• subcutaneous (implants) • vaginal (creams, pessary, tablets). Contraindications to oestrogen treatment are: • hormone-related cancer • active liver disease • a history of hormone-induced thromboembolism • vaginal bleeding of an unknown cause • untreated hypertension.10 Please note that I have reported the above contraindications mostly for the practitioner’s information; it should be borne in mind, however, that new research is being carried out on the effects of HRT (ERT) all the time so that new findings are reported every few months. Thus, not all gynecologists would agree with the above list of contraindications: for example, there are some who claim that having had breast cancer is not always a contraindication for HRT (ERT). Furthermore, it would be unwise for the practitioner of Chinese medicine to discuss these contraindications with the patient as it might only instil fear and worry in her and no benefit derives from these emotions. From a Western point of view, menopausal problems are almost exclusively attributed to a ‘deficiency’ of oestrogen and the ‘cure’ is therefore HRT (ERT). In modern industrialized societies, HRT (ERT) is increasingly prescribed almost routinely as soon as a woman approaches the menopause, both to alleviate menopausal symptoms and because of its alleged protective effect against osteoporosis and heart disease. More and more, the menopause has been medicalized and defined as a ‘deficiency disease’. For example, a recent text on women’s problems in general practice says: “In the USA, Australia and Western Europe, the concept has emerged of the menopause as a deficiency disease which needs treatment by hormone
replacement therapy.”11 There are many flaws in this thinking. First of all, the menopause is not a ‘disease’ and it needs medical intervention only if its symptoms are uncomfortable and distressing. Second, the decline in oestrogen levels following the reduction in follicles is a natural, physiological process that is part of a woman’s biological rhythms. Seen from this perspective, menopause is no more a ‘disease’ than menarche. Third, the ‘protective’ effect of HRT (ERT) against osteoporosis and heart disease is hotly debated and not at all conclusively proven. The many studies which have been conducted are confusing and contradictory. For example, a review of English language literature on oestrogen therapy from 1970 to 1992 concluded that oestrogen use by menopausal women reduces the risk of coronary heart disease by about 35% and the risk of hip fracture in post-menopausal women by about 25%.12 Moreover, meta-analysis of epidemiological data demonstrates that women using HRT (ERT) after menopause experience lower rates of heart disease.13 On the other hand, a study of 1234 postmenopausal women observed over a period of 12 years found that women using oestrogen had over a 50% elevated risk of cardiovascular morbidity and more than a two-fold risk of cerebrovascular disease. The study also concluded that no benefits from oestrogen use were observed in the study group.14 Moreover, two recent studies demonstrated a (small) increased risk of venous thromboembolism in users of HRT (ERT).15,16 Fourth, and probably most important, there are many studies showing that HRT (ERT) does increase the risk of endometrial and breast cancer. The review of literature mentioned above found that since 1970 at least 35 epidemiological studies have shown a significantly increased risk of endometrial cancer in women who have taken oestrogen. Similarly, the same review showed that the risk of breast cancer increases with long-term use of oestrogen.17 In fact, a Swedish study of 23 000 hormone users reported that the incidence of breast cancer compared with that in non-users was increased after 6 years’ use.18 One of the most recent British studies of 5000 women taking HRT (ERT) showed that breast cancer mortality in these women compared with
the general population rose from 0.55 per 1000 in the earlier period of follow up to 1984, to 1 per 1000 between 1984 and 1988.19 In both the Swedish and British studies, no protective effect was observed when progestogen was given.20 However, other studies show that the risk of breast cancer is reduced or nullified if progesterone is administered (in addition to oestrogen) continuously rather than sequentially.21 Fifth, ‘protecting’ a woman from osteoporosis and heart disease must surely depend on very many factors such as diet and lifestyle before the onset of the menopause: thus, it is simplistic, at best, to think that oestrogen taken as soon as the menopause approaches is going to ‘protect’ a woman from these diseases. Although the potential impact of HRT (ERT) on the risk of endometrial and breast cancer is still debated and not conclusively proven, taking all the above factors into account, it does seem that Chinese medicine, with its gentle and steady tonification of the Kidney-Essence without side effects, can offer a safe, effective and logical alternative to HRT (ERT), even though its effects will never be as rapid as those of HRT (ERT). In any case, the treatment of menopausal problems with acupuncture and Chinese herbs should not necessarily be seen as an ‘alternative’ to HRT (ERT) as the two may also be combined because HRT (ERT) and a Chinese treatment work in different ways. HRT (ERT) works by ‘tricking’ the body into thinking that it is still ovulating but it does not tonify the Kidneys.22 Chinese medicine, on the contrary, works by gently tonifying the Kidneys and the Kidney-Essence to help the woman in this transition time of life. The Women’s Health Initiative in the USA conducted a trial to assess the risks and benefits of HRT (ERT) in healthy post-menopausal women.23 Sixteen-thousand six-hundred and eight postmenopausal women aged 50–79 with intact uterus were given conjugated equine oestrogens 0.625 mg plus medroxyprogesterone acetate 2.5 mg or a placebo. The trial was to last 8.5 years. The main outcomes checked were breast cancer and coronary heart disease. On 31 May 2002, after 5.2 years, the trial was stopped because it showed an unacceptable increased risk of breast cancer (26%), coronary heart disease (29%) and stroke (41%) in the women who were taking HRT (ERT). The investigators concluded that the overall health risks exceeded the
benefits from use of combined oestrogen and progesterone.
Clinical trials
Acupuncture
Acupuncture for vasomotor menopausal symptoms: a systematic review
– Menopause 2009 16(5): 1065–1073. – Cho S H, Whang W W. – Hospital of Korean Medicine, Kyung Hee University Medical Centre, Seoul, Korea. Objective
The aim of this study was to critically assess whether acupuncture reduces vasomotor menopausal symptoms and to evaluate the adverse effects of acupuncture on the basis of the results of randomized controlled trials (RCTs). Methods
Nineteen electronic databases including English, Korean, Japanese and Chinese databases were systematically searched for RCTs in which acupuncture was used to reduce vasomotor menopausal symptoms before July 2008. There were no language restrictions. The methodological quality of the eligible studies was assessed using the categories provided by the Menstrual Disorders and Subfertility Review Group. Results
Eleven studies which included a total of 764 individual cases were systematically reviewed. The methodological quality of the trials varied substantially. Six trials compared acupuncture treatment to sham or placebo acupuncture. Only one study using a non-penetrating placebo needle found a significant difference in the severity outcomes of hot flushes between groups (mean difference, 0.48; 95% CI, 0.05–0.91). Five studies reported a reduced frequency of hot flushes within groups; however, none found a significant difference between groups. An analysis of the outcomes of the trials that compared acupuncture with hormone therapy or Oryzanol for reducing vasomotor symptoms showed that acupuncture was superior. Three RCTs reported minimal acupuncture-related adverse events. Conclusion
There is no evidence from RCTs that acupuncture is an effective treatment in comparison to sham acupuncture for reducing menopausal hot flushes. Some studies have shown that acupuncture is better than hormone therapy for reducing vasomotor symptoms. However, the number of RCTs compared with a non-penetrating placebo control needle or hormone therapy was too small, and the methodological quality of some of the RCTs was poor. Further evaluation of the effects of acupuncture on vasomotor menopausal symptoms based on a well-controlled placebo trial is therefore warranted. Moxibustion for treating menopausal hot flushes: a randomized clinical trial
– Menopause 2009 16(4): 660–665. – Park J E, Lee M S, Jung S, Kim A, Kang K, Choi J, Park J, Choi S M. – Department of Medical Research, Korea Institute of Oriental Medicine,
Daejeon, South Korea. Objective
The aim of this study was to evaluate the effect of moxibustion on hot flushes in peri-menopausal and post-menopausal women. Methods
Fifty-one participants were randomly assigned into three groups: Moxa 1, Moxa 2 and a waiting list (control). Both moxibustion groups received 14 sessions of moxibustion treatment for 4 weeks at acupuncture points; however, Moxa 1 participants received treatment based on evidence from clinical experts whereas Moxa 2 participants received treatment at points detailed in published literature. All participants were followed for an additional 2 weeks after the end of the study. The primary outcome measures were frequency and severity of hot flushes. Secondary outcome parameters included quality of life (Menopausal-Specific Quality of Life Scale) and Menopause Rating Scale. Results
By week 4, the difference in severity and frequency of hot flushes had become statistically significant between the treatment groups and the control participants. In addition, there was a statistically significant difference in Menopausal-Specific Quality of Life Scale scores between the Moxa 2 group and the other groups. Conclusion
The results suggest that moxibustion reduces both the frequency and severity of menopausal hot flushes as compared with those in control participants. Further studies are recommended with larger samples and possibly including placebo controls. A clinical observation of the combination of source and back-shu points for the treatment of perimenopausal syndrome
– Zhongguo Zhen Jiu, Chinese Acupuncture and Moxibustion 2009 29(6): 444–448. – Shang Y J, Zhang Y, Kong L L, Wang Y Y, Wang D S, Liu J. – Department of Acupuncture, Heilongjiang Academy of TCM, Harbin, China. Objective
To observe the clinical therapeutic effect of combining source and back-shu points in the treatment of perimenopausal syndrome. Methods
Eighty patients with peri-menopausal syndrome were randomly divided into two groups of 40 patients. Group A was treated with a combination of source and back-shu points and Group B was treated with routine acupuncture. The source and back-shu points used were: KI-3 Taixi, LIV-3 Taichong, SP-3 Taibai, SP-6 Sanyinjiao, BL-23 Shenshu, BL-18 Ganshu, BL-20 Pishu and Ren-4 Guanyuan. The routine acupuncture points used were: Du-20 Baihui, Ren-4 Guanyuan, BL-23 Shenshu, KI-3 Taixi and SP6 Sanyinjiao. The Kupperman index and the changes of serum oestradiol
(E2), follicle stimulating hormone (FSH) and luteinizing hormone (LH) were observed, before and after treatment, in both groups. Results
Group A had a total effective rate of 92.5% versus 80.0% in Group B which was a significant difference (P < 0. 05). Group A’s Kupperman index of 24.85 ± 8.35 was a significant decrease as compared with 35.38 ± 9.83 in Group B (P < 0.05). The contents of E2, FSH and LH in Group A were significantly improved (P < 0.01) and with a significant difference compared to Group B (P < 0.05). Conclusion
The combination of source and back-shu points has a benign regulatory function for E2, FSH and LH, and can significantly improve the Kupperman index; it is also superior to routine acupuncture for peri-menopausal syndrome. Acupuncture treatment for hot flushes among menopausal women: a randomized controlled trial
– Menopause 2009 16(3): 484–493. – Borud E K, Alraek T, White A, Fonnebo V, Eggen A E, Hammar M, Astrand L L, Theodorsson E, Grimsgaard S. – The National Research Centre in Alternative and Complementary Medicine, University of Tromsø, Tromsø, Norway. Objective
This study compared the effectiveness of individualized acupuncture plus selfcare versus self-care alone on hot flushes and health-related quality of life in postmenopausal women. Methods
This study involved a multicentre, pragmatic, randomized, controlled trial with two parallel arms. Participants were post-menopausal women experiencing, on average, seven or more hot flushes per 24 hours during 7 consecutive days. The acupuncture group (n = 134) received 10 treatment sessions and advice on self-care, and the control group (n = 133) received advice on selfcare only. The frequency and severity (0–10 scale) of hot flushes were registered in a diary. Urine excretion of calcitonin gene-related peptide was assessed at baseline and after 12 weeks. The primary end point was a change in mean hot flush frequency from baseline to 12 weeks. The secondary end point was a change in health-related quality of life measured by the Women’s Health Questionnaire. Results
Hot flush frequency decreased by 5.8 per 24 hours in the acupuncture group and 3.7 per 24 hours in the control group, which was a significant difference (P < 0.001). Hot flush intensity decreased by 3.2 units in the acupuncture group and 1.8 units in the control group, which was also a significant difference (P < 0.001). The acupuncture group experienced statistically significant improvements in the vasomotor, sleep and somatic symptoms dimensions of the Women’s Health Questionnaire compared with the control group. Urine calcitonin gene-related peptide excretion remained unchanged from baseline to week 12. Conclusion
Acupuncture plus self-care can contribute to a clinically relevant reduction in hot flushes and increased health-related quality of life in post-menopausal women. A randomized, controlled pilot study of acupuncture treatment for menopausal hot flushes
– Menopause 2008 15(6): 1070–1078. – Avis NE, Legault C, Coeytaux R R, Pian-Smith M, Shifren J L, Chen W, Valaskatgis P. – Wake Forest University School of Medicine, Winston-Salem, NC, USA. Objective
To investigate the feasibility of conducting a randomized trial on the effect of acupuncture in decreasing hot flushes in peri- and post-menopausal women. Methods
Fifty-six women aged 44 to 55 with no menstruation in the past 3 months and at least four hot flushes per day were recruited from two clinical centres and randomized to one of three treatment groups: usual care (n = 19), sham acupuncture (n = 18) or traditional Chinese medicine (TCM) acupuncture (n = 19). Acupuncture treatments were scheduled twice weekly for 8 consecutive weeks. The sham acupuncture group received shallow needling in non-therapeutic sites. The TCM acupuncture group received one of four treatments based on a TCM diagnosis. Usual care participants were
instructed to not initiate any new treatments for hot flushes during the study. Daily diaries were used to track frequency and severity of hot flushes. The mean daily index score was based on the number of mild, moderate and severe hot flushes. Follow-up analyses were adjusted for baseline values, clinical centre, age and body mass index. Results
There was a significant decrease in mean frequency of hot flushes between weeks 1 and 8 across all groups (P = 0.01), although the differences between the three study groups were not significant. Both acupuncture groups showed a significantly greater decrease than the usual care group (P < 0.05), but did not differ from each other. Results followed a similar pattern for the hot flush index score. There were no significant effects for changes in hot flush interference, sleep, mood, health-related quality of life or psychological well-being. Conclusion
These results suggest either that there is a strong placebo effect or that both traditional and sham acupuncture significantly reduce hot flush frequency. Multicentral randomized controlled clinical trials on the treatment of perimenopausal syndrome with electro-acupuncture at SP-6 Sanyinjiao
– Zhen Ci Yan Jiu, Acupuncture Research 2008 33(4): 262–266. – Xia X H, Hu L, Qin Z Y, Zhou J, Meng L, Li W L, Tian L Y, Zhang Y J. – Anhui College of Chinese Medicine, Hefei, China.
Objective
To evaluate the effect of electro-acupuncture (EA) at SP-6 Sanyinjiao on perimenopausal syndrome. Methods
Single-blind, randomized controlled trials took place at several centres. A total of 157 peri-menopausal patients were randomly divided into an acupuncture group (n = 81) and a medication group (n = 76). Participants in the acupuncture group received EA (2/100 Hz, 8–10 mA) bilaterally to SP-6 Sanyinjiao three times a week for 3 months. Patients in the medication group were treated by oral administration of Nylestriol, 2 mg/time, twice a month for 3 months. All patients were given medroxyprogesterone at a dosage of 6 mg/day for 10 days from the third month of the treatment. The therapeutic effect was evaluated by using ‘symptoms–signs score scale’, and changes of serum oestradiol (E2), follicle stimulating hormone (FSH) and luteotropic hormone (LH) were detected by chemiluminescence immunoassay. The Kupperman index was determined at baseline and after the treatment. Results
From baseline to post treatment, the Kupperman index of the EA group decreased significantly (P < 0.01). After the treatment, contents of serum FSH and LH of the EA group also decreased significantly (P < 0.01), while serum E2 contents of both the EA and medication groups increased significantly (P < 0. 01). Serum LH and E2 levels of the EA group were significantly lower than those of the medication group (P < 0.05). Regarding the Kupperman index, there were no significant differences in the markedly effective and total effective rates between the two groups (P > 0.05).
Conclusion
Electro-acupuncture at SP-6 Sanyinjiao is able to regulate serum E2, FSH and LH levels and effectively improve peri-menopausal syndrome. Long-term follow-up of acupuncture and hormone therapy on hot flushes in women with breast cancer: a prospective, randomized, controlled multicentre trial
– Climacteric: Journal of the International Menopause Society 2008 11(2): 166–174. – Frisk J, Carlhäll S, Källström A C, Lindh-Astrand L, Malmström A, Hammar M. – Division of Obstetrics and Gynaecology, Department of Molecular and Clinical Medicine, University Hospital of Linköping, Sweden. Objective
To evaluate the effects of electro-acupuncture (EA) and hormone therapy (HT) on vasomotor symptoms in women with a history of breast cancer. Methods
Forty-five women were randomized to EA (n = 27) for 12 weeks or HT (n = 18) for 24 months. The number of, and distress caused by, hot flushes were registered daily before, during and up to 24 months after the start of the treatment.
Results
After 12 weeks of EA in 19 women who completed the treatment, the median number of hot flushes/24 hours decreased from 9.6 at baseline to 4.3 (P < 0.001). Twelve months after the start of the treatment, 14 women with only the initial 12 weeks of EA had a median number of flushes/24 hours of 4.9, and at 24 months 7 women with no other treatment than EA had 2.1 flushes/ 24 hours. Another 5 women had a decreased number of flushes after having additional EA. The 18 women with HT had a baseline median number of flushes/24 hours of 6.6, and at 12 weeks this figure decreased to 0.0. Conclusion
Electro-acupuncture is a possible treatment of vasomotor symptoms for women with breast cancer and should be further studied for this group of women. Acupuncture for postmenopausal hot flushes
– Maturitas: the official journal of the European Menopause and Andropause Society 2007 56(4): 383–395. – Nir Y, Huang M I, Schnyer R, Chen B, Manber R. – Stanford University School of Medicine, USA. Objective
To determine whether individually tailored acupuncture is an effective treatment option for reducing post-menopausal hot flushes and improving
quality of life. Methods
In a randomized, placebo-controlled pilot study, 29 post-menopausal participants averaging at least 7 moderate to severe hot flushes per 24 hours, with a baseline oestradiol concentration of less than 50 pg/ml and a normal thyroid-stimulating hormone level, were randomized to receive 7 weeks (9 treatment sessions) of either active acupuncture or placebo acupuncture. Participants recorded hot flushes in logs that were reported daily. Global indices of the severity and frequency of hot flushes were derived from the participants’ daily logs. Results
Participants receiving the active treatment had a greater reduction in hot flush severity compared to those receiving placebo (P = 0.042). Within-group repeated measures analyses of variance revealed a significant reduction in hot flush severity in the active (P = 0.042) but not in the placebo treatment group (P = 0.15). Although there was no significant group difference in the reduction of hot flush frequency between the active and placebo groups (P > or = 0.352), within-group repeated measures analyses of variance revealed that the reduction was statistically significant in both groups (P < or = 0.001). Conclusion
Standardized, individually tailored acupuncture treatment was associated with significantly greater decrease in the severity, but not the frequency, of hot flushes in symptomatic post-menopausal women when compared to placebo acupuncture of equal duration. Future, larger scale studies are needed.
The effects of acupuncture, applied relaxation, oestrogens and placebo on hot flushes in postmenopausal women: an analysis of two prospective, parallel, randomized studies
– Climacteric 2007 10(1): 38–45. – Zaborowska E, Brynhildsen J, Damberg S, Fredriksson M, LindhAstrand L, Nedstrand E, Wyon Y, Hammar M. – Division of Obstetrics and Gynaecology, Department of Molecular and Clinical Medicine, University Hospital, Linköping, Sweden. Objective
To assess if transdermal or oral oestrogens, acupuncture and applied relaxation decrease the number of menopausal hot flushes/24 hours and improve climacteric symptoms, as assessed by the Kupperman index, more than transdermal placebo treatment. Methods
A total of 102 postmenopausal women were recruited to two studies performed in parallel at a Swedish university hospital outpatient clinic. In Study I, the women were randomized between transdermal placebo or oestrogen treatment and, in Study II, between oral oestrogens, acupuncture or applied relaxation for 12 weeks. Climacteric symptoms were measured with daily logbooks on hot flushes. Women completed the assessment questionnaire for the Kupperman index at baseline and after 12 weeks. Results
The number of flushes/24 hours decreased significantly after 4 and 12 weeks in all groups except the placebo group. Both at 4 and 12 weeks, acupuncture decreased the number of flushes more than the placebo treatment (P < 0.05, P < 0.01 respectively). At 12 weeks, applied relaxation decreased the number of flushes more than the placebo treatment (P < 0.05). The Kupperman index decreased significantly in all groups except in the placebo group (P < 0.01). Conclusion
Acupuncture and applied relaxation both reduced the number of hot flushes significantly better than placebo and should be further evaluated as alternatives to hormone therapy in women with menopausal vasomotor complaints. The effects of electro-acupuncture on psychological distress in postmenopausal women
– Complementary Therapies in Medicine 2002 10(3): 161–169. – Sandberg M, Wijma K, Wyon Y, Nedstrand E, Hammar M. – Division of Rehabilitation Medicine, Faculty of Health Sciences, University Hospital, Linköping, Sweden. Objective
To evaluate the effects of electro-acupuncture (EA) on general psychological distress in 30 post-menopausal women.
Methods
A randomized, single-blind, controlled design was used to evaluate the effects of EA and extremely superficial needle insertion, with the latter serving as a near-placebo control. The trial took place at the Linköping University Hospital in Sweden. Fourteen treatments were administered during 12 weeks with follow ups at 3 and 6 months. The outcome measures were general psychological well-being, mood and experience of climacteric symptoms. Results
The Mood Scale improved only in the EA group and not until 12 weeks compared to baseline, from 110 to 129 (P = 0.01), and to 120 at the 3month follow up (P = 0.04). Participants’ moods were significantly better in the EA group compared to the control group at 8 (P = 0.05) and 12 weeks (P = 0.01). Visual analogue scale estimation of climacteric symptoms was decreased at 4 weeks in both groups, and lasted throughout the study period. In the EA group, it decreased from 5 to 2 (P = 0.04) and in the control group it decreased from 5 to 3 (P = 0.02) at the 6-month follow up. Well-being improved from 4 weeks in the EA group and from 8 weeks in the control group until the end of study (P = 0.01; P = 0.03). No significant differences on climacteric symptoms or well-being existed between the groups. Conclusion
This study does not show that EA is better than superficial needle insertion for the amelioration of general psychological distress and experience of climacteric symptoms in women with vasomotor symptoms after the menopause. However, the more pronounced effect on mood suggests that EA might have additional effects compared with superficial needle insertion.
Herbal treatment
A pilot observational study to assess the safety and efficacy of Menoprogen for the management of menopausal symptoms in Chinese women
– Journal of Alternative and Complementary Medicine 2009 15(1): 79– 85. – Liu D, Lu Y, Ma H, Wei R C, Li J, Fang J, Mahady G B. – Natural Herbal Farm, Inc., Edison, NJ 08820, USA. Objective
To assess the effects of Menoprogen, which contains 0.2 g extracts of Gou Qi Zi Fructus Lycii, Kun Bu Thallus Eckloniae, Shan Zha Fructus Crataegi, Hong Hua Flos Carthami and Sang Shen Zi Fructus Mori per capsule, in the management of menopausal symptoms in peri-menopausal and post-menopausal women. Methods
A multicentre prospective study was conducted at four clinical centres in China. Female subjects were eligible if they had menopausal diagnosis for at least 3 months and wished to use an alternative to hormone replacement therapy (HRT). Subjects received 2 capsules of Menoprogen orally, twice daily. The primary outcome measured was an improvement of the Kupperman Menopausal Index (KMI) from baseline. Secondary outcomes
measured included hormone levels and the status of the endometrial and vaginal cytology after completion of the treatment. Results
After treatment, a significant reduction in the KMI was observed (P < 0.01) as compared with baseline and both endogenous oestrogen levels and progesterone were significantly increased (P < 0.01, P < 0.01). Also folliclestimulating hormone (FSH) and luteinizing hormone (LH) levels showed significant before-and-after treatment difference (P < 0.01). No significant endometrial hyperplasia was observed post treatment. Most of the postmenopausal women exhibited a vaginal cell proliferation degree of 2–3, suggesting a possible oestrogenic effect. Conclusion
The present pilot study found that Menoprogen reduced symptoms associated with peri-menopausal and post-menopausal complaints. Therefore, the rationale for a randomized, placebo-controlled clinical trial is supported. A randomized, double-blind, placebo-controlled study of the effect of Dang Gui Bu Xue Tang Angelica Tonifying Blood Decoction on menopausal symptoms in Hong Kong Chinese women
– Climacteric 2008 11(3): 244–251. – Haines C J, Lam P M, Chung T K, Cheng K F, Leung P C. – Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
Objective
To examine the effect of Dang Gui Bu Xue Tang on menopausal symptoms in Hong Kong Chinese women. Methods
This was a 6-month randomized, double-blind, placebo-controlled study of the effect of Dang Gui Bu Xue Tang on acute menopausal symptoms. Onehundred women were allocated to either a treatment group which received Dang Gui Bu Xue Tang (n = 50) or a placebo group (n = 50). Results
After 6 months there was a significant reduction in the number of mild hot flushes per month in the treatment group compared with the placebo group (P < 0.01 vs. P = 0.062). However, after 6 months, for moderate flushes, there was a significant reduction in the placebo group compared with the treatment group (P < 0.05 vs. P = 0.107). Regarding severe hot flushes, there was no significant change in either group. Episodes of night sweats decreased significantly in the placebo but not in the treatment group (P < 0.05 vs. P = 0.471). In the vasomotor domain of the Menopause-Specific Quality of Life, there was a significant reduction in scoring in the placebo group but not in the treatment group (P < 0.01 vs. P = 0.247). Conclusion
This study found that the frequency of mild, moderate and severe hot flushes decreased in both the treatment and the placebo groups, but Dang Gui Bu Xue Tang was statistically superior to placebo only in the treatment of mild
hot flushes. There were no serious adverse events attributable to the treatment during the study period. The treatment of menopausal symptoms with Er Xian Tang Two Immortals Decoction: a systematic review
– American Journal of Chinese Medicine 2008 36(2): 233–244. – Chen H Y, Cho W C, Sze S C, Tong Y. – School of Chinese Medicine, The University of Hong Kong, China. Objective
The objective of this systemic review was to assess the efficacy of Er Xian Decoction (EXD) in relieving menopausal symptoms. Methods
Seven databases were analysed, three of which are Chinese and four are English. The Chinese databases are: VIP Information, CBMdisc and CNKI. The English databases are AMED, CINAHL, Cochrane Library and MEDLINE. Randomized, controlled trials using EXD as a main intervention were included in the study selection. The quality of studies was assessed by the Jadad scale and the criteria based on that in the Cochrane reviewers’ handbook. Two independent reviewers were responsible for data extraction and assessment. Discrepancies were rectified referring to the original articles. The efficacy of EXD treatment for menopausal symptoms was evaluated by meta-analysis. There were 154 articles retrieved according to the search strategy, and 677 participants involved in the five studies that satisfied the selection criteria.
Results
Meta-analysis indicated that administration of EXD significantly relieved at least one menopausal symptom when compared to the control group at a 95% confidence interval (P < 0.01). The ability of EXD to relieve all symptoms was significant as compared with the control groups (P < 0.01). The results also indicated that the efficacy of EXD was better than other nonmenopausal hormone therapy (P < 0.01); however there was no significant difference between the EXD and menopausal hormone therapy groups. Conclusion
Er Xian decoction is effective in treating menopausal symptoms. However, owing to the low quality of the investigated studies, more randomized, controlled trials are needed before evidence-based recommendation regarding the effectiveness of the formula in the management of menopausal symptoms can be provided. The effect of Chinese medicinal herbs in relieving menopausal symptoms in ovariectomized Chinese women
– Explore 2007 3(5): 478–484. – Zhou J, Qu F, Nan R, Tang D. – College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China. Objective
The aim of this study was to explore the effect of Geng Nian An (GNA) Peaceful Menopause Powder in relieving menopausal symptoms in ovariectomized women. Methods
A double-blind, randomized, placebo-controlled trial took place between May 2003 and June 2006 involving 69 ovariectomized Chinese women. They were split into two groups and given GNA (n = 36) or placebo (n = 33) twice daily for 12 weeks. Clinical symptoms were assessed by the modified Kupperman index. The levels of venous blood serum folliclestimulating hormone (FSH), luteinizing hormone (LH), oestradiol (E2) and the maturation index (MI) of vaginal epithelial cells were all measured. Results
At the end of the 12 weeks, significant differences existed between the group given GNA and the placebo group in the total Kupperman scoring, MI of vaginal exfoliative cells, and the levels of FSH, LH and E2 (P < 0.05). Conclusion
Geng Nian An may be a useful alternative treatment for ovariectomized women suffering from menopausal symptoms, who are unable, or do not want, to receive hormone replacement therapy. The efficacy and tolerability of a medicinal product containing an isopropanolic black cohosh extract in Chinese women with menopausal symptoms: a randomized, double-blind, parallelcontrolled study versus tibolone
– Maturitas 2007 58(1): 31–41. – Bai W, Henneicke-von Zepelin H H, Wang S, Zheng S, Liu J, Zhang Z, Geng L, Hu L, Jiao C, Liske E. – The First Hospital of Peking University, Department of Gynaecology, Beijing, China. Objective
To investigate the efficacy–safety balance of the isopropanolic extract of black cohosh (Sheng Ma Rhizoma Cimicifugae) which is sold as Remifemin, in comparison with tibolone, in Chinese women with climacteric complaints. Methods
This was a randomized, double-blind, controlled study which took place over 3 months in five centres across three cities in China. Two-hundred and forty-four menopausal patients aged 40–60 years were enrolled with a Kupperman Menopause Index (KMI) > or = 15. The participants were assigned to receive either 40 mg daily of the black cohosh extract (iCR, n = 122) or 2.5 mg of tibolone per day (n = 122). The primary end point was the combination of the Mann-Whitney values of the KMI and the frequency of adverse events (benefit–risk balance) at the end of the treatment. Results
The KMI decreased significantly in both groups at 4 and 12 weeks. There were good safety and tolerability profiles for both groups; however there was
a significantly lower incidence of adverse events in the iCR group (P < 0.0001). None of the post-menopausal iCR patients experienced vaginal bleeding in contrast to 17 cases in the tibolone group. Breast and abdominal pain as well as leucorrhoea were mostly observed in the tibolone group (P = 0.015, P = 0.008 and P = 0.002 respectively). No serious adverse affects were observed in the iCR group; however two occurred in the tibolone group. The benefit–risk balance for iCR was significantly superior to tibolone (P = 0.01). Conclusion
The efficacy of iCR is as good as tibolone for the treatment of climacteric complaints, even for moderate to severe symptoms. However, iCR is clearly superior with regard to the safety profile. The effect of Chinese herbal medicines (CHM) on menopausal symptoms compared to hormone replacement therapy (HRT) and placebo
– Maturitas 2007 58(1): 83–90. – Kwee S H, Tan H H, Marsman A, Wauters C. – Private Clinics, Amsterdam and The Hague, The Netherlands. Objective
To evaluate within the traditional Chinese medicine (TCM) setting the effect of CHM formulae on menopausal symptoms. Methods
A double-blind and double-dummy, randomized, placebo-controlled trial took place between February and June 2002 and June and October 2004 involving 31 peri- and post-menopausal Dutch women. They completed 12 weeks of treatment with either CHM formulae (n = 10), HRT (n = 11) or placebo (n = 10) medications plus 4 weeks of non-treatment follow-up observation. The CHM prescriptions were tailored to each individual. The primary outcome measure was the reduction in frequency of vasomotor symptoms (hot flushes and night sweats). Secondary outcome measures were the improvements measured in the quality of life questionnaire SF-36 and other symptoms and signs related to the peri- and post-menopausal period. Results
Placebo medications had a score of 30%; on average CHM was 29% more effective in reducing the amount of hot flushes compared to placebo treatments which was a significant difference (P < 0.05), while HRT was almost 50% more effective. Although quantitatively there was a significant difference in the reduction of hot flushes between the groups, qualitatively there was no overall improvement. Conclusion
This pilot study proved clearly that CHM could help women with their menopausal problems. The chosen trial methodology with its TCM differential diagnosis after orthodox medicine diagnosis is fully compatible with TCM practice and hence acceptable for Western and Chinese medical practitioners. However, in order for TCM to have a place in the Western healthcare system, a larger trial with a more menopause-specific questionnaire is needed.
A comparison of the effects of vitamin E and Unkeito (Wen Jing Tang) on peripheral blood flow in perimenopausal women with a cold feeling in the lower extremities: a randomized prospective study
– American Journal of Chinese Medicine 2006 34(6): 969–979. – Ushiroyama T, Sakuma K, Nosaka S. – Department of Nursing, Aino Gakuin College, Ibaraki, Osaka, Japan. Objective
To examine the association between blood flow and a cold feeling in the lower extremities, and compare the changes in blood flow induced by vitamin E and Unkeito (Wen Jing Tang, Warm the Menses Decoction) in perimenopausal women. Methods
One-hundred and sixty-one peri-menopausal women aged 42–61 years (mean: 50.4 ± 3.8 years) with cold sensations in the lower extremities were randomized for treatment with Wen Jing Tang or a vitamin E preparation containing 600 mg of tocopherol nictinate per day for 8 weeks. Blood flow measurement was performed by laser Doppler fluxmetry to determine tissue under the jaw, in the middle finger and in the third toe. Results
Wen Jing Tang significantly increased the peripheral blood flow in the skin surface in the tiptoe (P = 0.0068) from basal levels (6.0 ± 5.1), although no
significant change was observed in the blood flow in the fingertip or under the jaw during the treatment. The rate of increase of blood flow in the skin surface of the lower extremities was significantly higher in the Wen Jing Tang group (116.4 ± 46.5%) than in the vitamin E group (39.8 ± 21.3%) (P < 0.0001). When the effects of Wen Jing Tang and vitamin E treatment were compared in the subjects with baseline upper extremity blood flow above the mean +1.5 SD, mean blood flow through the upper extremities was found to have been significantly decreased after Wen Jing Tang treatment (from P = 0.0277), whereas it remained unchanged after treatment with vitamin E. Conclusion
This study using laser Doppler fluxmetry demonstrated that treatment with Wen Jing Tang significantly increased blood flow through the periphery of the lower extremities in patients who complained of cold extremities. It also showed that Wen Jing Tang suppresses excessive blood flow through the upper half of the body and thus stimulates restoration of physiological distribution of blood flow throughout the entire body. Chai-hu-gui-zhi-gan-jiang-tang regulates plasma interleukin-6 and soluble interleukin-6 receptor concentrations and improves depressed mood in climacteric women with insomnia
– American Journal of Chinese Medicine 2005 33(5): 703–711. – Ushiroyama T, Ikeda A, Sakuma K, Ueki M. – Department of Obstetrics and Gynaecology, Osaka Medical College, Takatsuki, Osaka, Japan. Objective
This study was performed to compare the effects of Chai Hu Gui Zhi Gan Jiang Tang (CHGZGJT) in improving depression and on plasma interleukin-6 (IL-6) and soluble interleukin-6 receptor (sIL-6R) concentrations with those of anti-depressants (AD) in peri- and post-menopausal women. Methods
Ninety patients complaining of menopausal symptoms including insomnia who were diagnosed with a mood disorder based on the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) were recruited and separated into two groups: the CHGZGJT group (n = 42) and the AD group (n = 48). Plasma IL-6 and sIL-6R concentrations were determined before and after 3 months of the treatment. Results
There were no significant differences in the decrease in both climacteric and Hamilton depression scores after treatment between the groups. Plasma IL-6 and sIL-6R concentrations were significantly lower in the CHGZGJT group than in the anti-depressant group after 3 months of treatment (P < 0.05). Correlations between the rate of decrease in the climacteric score and plasma IL-6 (R = 0.498, P = 0.0056) and sIL-6R (R = 0.512, P = 0.0045) concentrations were observed. CHGZGJT reduced plasma IL-6 and sIL-6R concentrations in relation to the improvement of depression during treatment. Conclusion
The findings of this study suggest that Chai Hu Gui Zhi Gan Jiang Tang has the potential to decrease morbidity by alleviation of stress reactions in periand post-menopausal women.
Comparing the effects of oestrogen and herbal medicine on peripheral blood flow in post-menopausal women with hot flushes: hormone replacement therapy versus Gui Zhi Fu Ling Wan Ramulus Cinnamomi Poria pill
– American Journal of Chinese Medicine 2005 33(2): 259–267. – Ushiroyama T, Ikeda A, Sakuma K, Ueki M. – Department of Obstetrics and Gynaecology, Osaka Medical College, Takatsuki, Osaka, Japan. Objective
To investigate the association between blood flow in the extremities and hot flushes, and to compare the change in blood flow following hormone replacement therapy (HRT) and Gui Zhi Fu Ling Wan (GZFLW). Methods
Three-hundred and fifty-two post-menopausal women aged 46–58 years (mean: 53.4 ± 3.6 years) with climacteric complaints participated in the study. One-hundred and thirty-one patients with hot flushes were treated with HRT (n = 64) or GZFLW (n = 67). Blood flow was measured with laser Doppler fluxmetry under the jaw, in the middle finger and in the third toe. Results
The 129 post-menopausal women with hot flushes showed significantly higher blood flow under the jaw than the 166 women without hot flushes (P
< 0.0001). Blood flow at this site decreased significantly after treatment with both HRT and GZFLW (P < 0.0001). However, GZFLW significantly increased the blood flow in the lower extremities (P = 0.002), whereas HRT decreased the blood flow. Conclusion
Gui Zhi Fu Ling Wan is suggested as the more appropriate therapy compared to HRT in the treatment of hot flushes in the face and upper body with concomitant coldness in the lower body. A study on the treatment of climacteric depression with Bu Shen Tiao Gan Qing Xin Tonifying the Kidneys, Regulating the Liver and Clearing the Heart formula
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2004 24(10): 889–892. – He J Q, Tang X W, Chen H X, Xiang Z. – Department of TCM, Hospital of Obstetrics and Gynaecology, Beijing, China. Objective
To observe the effects of Bu Shen Tiao Gan Qing Xin (BTQR) on the Hamilton rating scale for depression (HAMD), monoamine neurotransmitter and endocrine function in patients with climacteric depression, and to explore its mechanism. Methods
Patients were randomly divided into two groups: the treatment group received BTQR (n = 25) and the control group received hormone replacement therapy (HRT; n = 15). The HAMD score, levels of 5hydroxytryptamine (5-HT), plasma norepinephrine (NE), serum oestradiol (E2), follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were determined before and after treatment. The thickness of the endometrium was measured by B-Doppler ultrasonographic technique. Results
The total effective rate, evaluated by the reduction in the HAMD score, was 87.2% in the treatment group and 67.3% in the control group which was a significant difference (P < 0.05). After the treatment, 5-HT decreased (P < 0.01), NE increased (P < 0.05) and the 5-HT/NE ratio lowered (P < 0.01) in the treatment group; E2 increased in both groups; FSH, LH and FSH/LH ratio decreased in the treatment group (P < 0.05 or P < 0.01), FSH/LH ratio decreased in the control group (P < 0.05) and the thickness of the endometrium increased in the control group (P < 0.05). Conclusion
The mechanism of Bu Shen Tiao Gan Qing Xin in treating climacteric depression might be related to the following actions: the regulation of the synthesis and release of monoamine neurotransmitter; the adjustment of the reproductive endocrine function; and the coordination of neuroendocrinal function.
Western medicine
The association between hormone replacement therapy (HRT) and subsequent arterial and venous vascular events: a meta-analysis
– European Heart Journal 2008 29(16): 2031–2041. – Sare G M, Gray L J, Bath P M. – Stroke Trials Unit, Institute of Neuroscience, University of Nottingham, UK. Objective
To ascertain the effect of HRT upon coronary heart disease (CHD) by a meta-analysis of randomized controlled trials (RCTs). Methods
RCTs of HRT were identified and the event rates for cerebrovascular disease (stroke, transient ischaemic attack (TIA)), CHD (myocardial infarction, unstable angina, sudden cardiac death) and venous thromboembolism (VTE) (pulmonary embolism, deep vein thrombosis) were analysed. Sensitivity analyses were performed by the type of HRT (mono vs. dual) and subject age. Thirty-one trials including 44 113 subjects were identified. Results
HRT was associated with increases in stroke (odds ratio (OR) 1.32; 95% CI 1.14–1.53) and VTE (OR 2.05; 95% CI 1.44–2.92). However, CHD events were not increased (OR 1.02; 95% CI 0.90–1.11). Ordinal analyses confirmed that stroke severity was increased with HRT (OR 1.31; 95% CI 1.12–1.54). Although most trials included older subjects, age did not significantly affect risk. The addition of progesterone to oestrogen doubled the risk of VTE. Conclusion
HRT is associated with an increased risk of stroke, stroke severity and VTE, but not of CHD events. Combined HRT increases the risk of VTE compared with oestrogen monotherapy. HRT and ovarian cancer risk: a meta-analysis
– Gynaecologic Oncology 2008 108(3): 641–651. – Zhou B, Sun Q, Cong R, Gu H, Tang N, Yang L, Wang B. – Department of Pharmacology, Nanjing Medical University, Jiangsu, China. Objective
As epidemiologic findings are inconsistent concerning the risk for ovarian cancer associated with HRT, a meta-analysis was conducted to evaluate the evidence from observational studies. Methods
The databases PubMed and MEDLINE were searched for relevant studies that were published between 1 January 1966 and 1 May 2007. Studyspecific risk estimates were pooled by the use of a random-effects model. Eight cohort studies (including 4715 cases and 1 555 374 participants) and 19 case-control studies (involving 8240 cases and 20 996 controls) were included. Results
A summary relative risk (RR) of 1.24 (95% CI 1.15–1.34) from cohort studies and a summary odds ratio (OR) of 1.19 (95% CI 1.02–1.40) from case-control studies for HRT use were found. However, the risk estimates of case-control studies might be upwardly biased. Summary risk estimates of four cohort and six case-control studies that distinguished oestrogen replacement treatment (ERT) and oestrogen–progestin replacement treatment (EPRT) indicated that the ovarian cancer association was stronger amongst ERT users. The duration of HRT use was not significant based on data abstracted from six case-control studies. The summary risk estimates for less than 5 years, 6–10 years and more than 10 years use were 1.02, 1.13 and 1.2 respectively with a 95% CI for each estimate. Conclusion
HRT use was associated with an increased risk of ovarian cancer. However, this association should be considered in the context of HRT’s other favourable effects. End notes 1. Clarke-Pearson D L, Dawood M Y 1990 Green’s Gynaecology: Essentials of Clinical
Practice, Little, Brown and Company, Boston, p. 457..
2. McPherson A 1993 Women’s Problems in General Practice, Oxford University Press, Oxford, p. 198..
3. Evans W C 1996 Pharmacognosy, W B Saunders, London, p. 411..
4. Armstrong B, Doll R 1975 Environmental Factors and Cancer Incidence and Mortality in Different Countries, with Special Reference to Dietary Practices, International Journal of Cancer 15: 617–631.
5. Lethaby A E, Brown J, Marjoribanks J et al 2007 Phytoestrogens for Vasomotor Menopausal Symptoms, Cochrane Database of Systematic Reviews (4): CD001395. doi:10.1002/14651858. CD001395.pub3..
6. Atkinson C, Warren R M, Sala E et al 2004 Red Clover-derived Isoflavones and Mammographic Breast Density: a Bouble-Blind, Randomized, Placebo-Controlled Trial, Breast Cancer Research 6: R170–R179..
7. Govan A, Hart D, Callander R 1993 Gynaecology Illustrated, Churchill Livingstone, Edinburgh, p. 477..
8. Gomel V, Munro M. 1989 Gynaecology: a Practical Approach, Williams and Wilkins, Baltimore, p. 131..
9. Fentiman I S 1995 Hormone Replacement Therapy and Breast Cancer: Proceed with Caution, Journal of the British Menopause Society 1(2): 21.
10. Ravnikar V A 1996 Barries for Taking Long-term Hormone Replacement Therapy: Why Do Women not Adhere to Therapy? European Menopause Journal 3(2 Suppl.): 93..
11. Women’s Problems in General Practice, p. 198..
12. Grady D, Rubin S M, Petitti D B et al 1992 Hormone Therapy to Prevent Disease and Prolong Life in Postmenopausal Women, Annals of Internal Medicine 117(12): 1021– 1023..
13.
Mijatovic V, Pines A 1995 Menopause-induced Changes in Cardiovascular Functions and HRT, European Menopause Journal 2(1): 4.
14. Wilson P W, Garrison R J, Castelli W P 1985 Postmenopausal Oestrogen Use, Cigarette Smoking, and Cardiovascular Morbidity in Women over 50, New England Journal of Medicine 313(17): 1038–1043..
15. Daly E, Vessey M P, Hawkins M M et al 1996 Risk of Venous Thromboembolism in Users of Hormone Replacement Therapy, The Lancet 348(9033): 977–980..
16. Jick H, Derby L E, Myers M W et al 1996 Risk of Hospital Admission for Idiopathic Venous Thromboembolism among Users of Postmenopausal Oestrogens, Lancet 348(9033): 981–983..
17. Hormone Therapy to Prevent Disease and Prolong Life in Postmenopausal Women, pp 1018–1020..
18. Bergkvist L, Adami H O, Persson I, Hoover R, Schairer C 1989 The Risk of Breast Cancer after Estrogen and Estrogen–Progestin Replacement, New England Journal of Medicine 321(5): 293–297..
19. Hunt K, Vessey M, McPherson K 1990 Mortality in a Cohort of Long-term Users of Hormone Replacement Therapy: an Updated Analysis, British Journal of Obstetrics and Gynaecology 97: 1080–1086..
20. Women’s Problems in General Practice, p. 216.
21. Wren B G 1995 Hormonal Replacement Therapy and Breast Cancer, European Menopause Journal 2(4): 13..
22. The relationship between HRT and Chinese treatment is similar to that between antibiotics and Chinese treatment: antibiotics kill bacteria but they do not release the Exterior, restore the descending and diffusing of Lung-Qi, clear Heat or resolve Phlegm. Thus, if a patient is already taking antibiotics, this is not a contraindication for treatment with Chinese herbs..
23. Rossouw J E, Anderson G L, Prentice R L et al 2002 Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial, Journal of the American Medical
Association 288(3): 321–333..
CHAPTER 59 Breast Lumps
AETIOLOGY 771 PATHOLOGY AND TREATMENT PRINCIPLES 772 DIAGNOSIS 776 Channels 776 IDENTIFICATION OF PATTERNS AND TREATMENT 777 Stagnation of Liver-Qi 777 Spleen-Yang deficiency with Phlegm 781 Directing and Penetrating Vessel (Ren and Chong Mai ) disharmony 782 Stagnant Liver-Qi turned into Fire 784 Toxic-Heat 785 Liver- and Kidney-Yin deficiency 786 PROGNOSIS AND PREVENTION 787 Herbal treatment 788 Acupuncture 788 WESTERN VIEW 788 The
old
name
for
breast
lumps
was
Ru
Yan
(
), the character yan being composed of a mountain and a rock which denote the hardness of the lump. Breast lumps, however, are also included in other breast conditions such as
Ru Li (breast scrofula,
), Ru
Pi (breast lump, ), and Ru Lao Tan (breast Phlegm-Exhaustion, or tuberculosis of the breast,
). Of course, ancient Chinese medicine did not have a concept of cancer or malignancy and could not differentiate lumps according to benign and malignant. However, the doctors were well aware of the seriousness and poor prognosis of certain types of lump, and Ru Yan indicated a lump which
was difficult to treat and often led to death, while Ru Pi, judging by its description, corresponds to a benign lump such as those found in fibroadenoma or cysts. The Concise Dictionary of Chinese Medicine defines Ru Pi as: a lump (or lumps) in the breast which is like a plum seed or an egg or nodules which feel hard and are painless and mobile. The breast does not feel hot or cold to the touch, the skin colour is unchanged and the size of the lump varies according to the mood of the woman.1 The description of such lumps appeared in the Classic of the Central Treasure of the Han dynasty (206 BC–AD 220). Ru Yan, on the other hand, judging from its descriptions reported below, resembles more closely breast cancer or other types of breast diseases: in fact, the hardness of the lump, its lack of mobility on palpation, its progressive increase in size and the nipple inversion all seem to point, although not exclusively, to breast cancer more than to benign tumours. The Discussion on the Origin of Diseases (Zhu Bing Yuan Hou Lun, AD 610) mentions hard breast nodules (called ru shi yong
, i.e. ‘breast stone carbuncle’) that cannot be moved on palpation. It says: “The Stone Carbuncle is not very big, not red nor hot … it is an accumulation like a stone” and “There is a hidden accumulation in the breast without pain or itching.” Also: “There is an accumulation under the skin like a cow’s neck.” 2 The Complete Manual of Ulcers (Chuang Yang Jing Yan Quan Shu) of the Song dynasty says: “Ru Yan [is due to] extreme Yin and exhaustion
of Yang, Blood without Yang scatters into the Heart channel and causes this disease.” Note the reference to Heart rather than the usual Liver. This book also gave correct indications on prognosis: If it is not broken it can be treated, if it is broken it is difficult to treat. The earlier it is treated, the better. If it bursts inside it burns the flesh, it spreads to the internal organs and causes death.3 This description clearly shows that, although the ancient Chinese did not have a conception of malignancy, they did conceive the idea of the disease spreading from the breast to the internal organs and leading to death, i.e. metastasis from a carcinoma. Chen Bai Ming in the Beneficial Formulae of the Great Compendium of Gynaecology (Fu Ren Da Quan Liang Fang, 1273)
differentiates between breast carbuncle (yong
) and lump
(yan ) saying that the former is characterized by redness, swelling and heat, the latter by its process of development: in the beginning there is a small accumulation like a turtle egg which is not red nor painful, after several months it gets bigger, then the lump breaks up like a ripe pomegranate, it bursts through like in a deep hole, this is due to Liver and Spleen being affected by anger, Qi and Blood are exhausted and it is called Ru Yan.4
Zhu Dan Xi (Yuan dynasty, 1281–1358) discussed the treatment of breast lumps in detail. He said: Worry, anger and depression cause accumulation, Spleen-Qi is weakened, Liver-Qi free flow fails, there is a hidden nodule formed like an egg without pain or itching; after several years it forms an
ulcer (chuang ) and it is called Ru Yan. It looks like an ulcer on the surface and is like a stone in a cavity, it cannot be treated.5 During the Ming dynasty, a doctor gave an accurate account of the development of breast lumps. He said: In the beginning it is like a bean, then like an egg, without pain or itching, after one year pain develops. Then it grows into a heap, the skin becomes purple, then ulcers develop and the lump is like a rock, there is blood oozing from the nipple, then the five Yin organs are exhausted.6 Dr Ma Pei (1820–1903) makes a clear differentiation between breast
nodules (ru he ) and breast cancerous lumps (ru yan). He highlights the following as the main differences between these two pathologies:
• Nodules are not dangerous, lumps serious. • Nodules are small, lumps big. • Nodules are like scrofula of the neck, round or flat and moveable. Lumps are hard, they stick out like a mountain, concave or convex, the muscles are contracted. • Nodules are due to Qi and Phlegm stagnating, lumps are due to Qi and Fire stagnating. • Nodules are painful; lumps are not painful but the muscle channels all around them may pull and contract and cause pain. • To treat nodules, eliminate stagnation and resolve Phlegm; to treat lumps, eliminate stagnation and clear the Liver.7 Fu Qing Zhu makes a similar distinction between a breast carbuncle (ru yong) and cancerous breast lump (ru yan). He says: A swelling of the breast with red nodules that lasts several days with pain and oozing of pus which then heals, is due to Toxic Heat in Stomach and Gall-Bladder with stagnation of Qi and Blood and it is called Breast Carbuncle: this is easy to treat. If inside the breast there are small nodules, not red, not swollen and not painful, but which last for months forming [a lump] like a rocky mountain, and then like a ripe pomegranate when they break, these are difficult to treat.8 Please note that some of the above descriptions of breast lumps in the ancient texts refer to breast carcinomas that went untreated and led to infections in the breast, hence the references to “oozing of pus”, “ripe pomegranate that breaks”, “ulcers develop”, “blood oozes from the nipple”, etc. We are unlikely to see any of the above manifestations due to the early detection and treatment of carcinoma of the breast in Western countries. The discussion in this chapter will be confined to benign lumps only. The
treatment principles and prescriptions used for breast cancer are quite different from those used for benign breast lumps; however, the aetiology, pathology and differentiation of breast lumps is the same, whether benign or malignant. Indeed, the ancient Chinese doctors quoted above obviously did not know the difference between a benign lump and a malignant one and, therefore, the aetiology, pathology and differentiation which they identified were the same for benign or malignant lumps. However, it is interesting to note that, although the ancient doctors could not know the difference between a benign or malignant lump, they were well aware of symptoms and signs indicating a poor prognosis. For example, the quotation from Zhu Dan Xi reported above clearly ends by saying that, in the presence of the symptoms and signs described, the patient “cannot be treated”. Similarly, the Ming dynasty doctor quoted above refers to the spread of the disease from the breast to the “Five Yin organs”, a reference that can be interpreted as metastasis from a malignant lump.
Aetiology
Emotional problems Emotional problems are by far the most important cause. Worry, pensiveness, sadness, ‘bitter weeping’, anger, frustration, resentment, hatred, repressed anger and guilt can all cause stagnation of Qi which in the long run may lead to Blood stasis which forms masses. Stagnant Qi, over a long period of time, may also ‘implode’ to cause Fire and Toxic-Heat. It is important to realize that stagnation of Qi comes not only from the Liver but also from the Heart and the Lungs. In fact, even emotions that cause depletion of Qi, such as sadness and grief, may cause stagnation of Qi (of the Lungs) because, when Qi is depleted in the chest, it does not circulate well and therefore stagnates. In the particular case of breast lumps, the stagnation of Qi of the Lungs and Heart is particularly relevant because these two organs and channels are situated in the chest. Zhu Dan Xi says: When a woman is worried and depressed, accumulation develops, Spleen-Qi becomes weak, Liver-Qi rebels horizontally, stagnant Qi turns into nodules like turtle eggs, there is no pain or itching. After ten years ulcers develop and the disease is called Ru Yan.9 This statement clearly points out the emotional influence on the development of the disease and also its long-term development. Furthermore, it is important to remember that stagnation of Qi in women is very often secondary, as it may be the consequence of a deficiency of the Liver and Kidneys affecting the Directing and Penetrating Vessels (Ren and Chong Mai). The Orthodox Manual of External Diseases (Wai Ke Zheng Zong), written by Chen Shi Gong in 1617, mentions the Heart in connection with stagnation when it says: “Depression injures the Liver, pensiveness affects
the Spleen, accumulation develops in the Heart, the channel-Qi stagnates and generates nodules.”10 Dr Xia Shao Nong thinks that breast lumps and breast cancer are due to separation and loss, i.e. the loss deriving from widowhood, breaking of relationships, divorce, death of one’s children and bereavement at a young age from the death of one’s spouse. These events, especially if they occur suddenly, upset the Mind and lead to Qi stagnation and Qi depletion. It is interesting to note that all the events mentioned by Dr Xia involve separation and loss. One could form the hypothesis that the breast represents for a woman the instinctive link with her loved ones (through breastfeeding), and that it is therefore affected by separation. ! According to Dr Xia Shao Nong, the stagnation causing breast lumps and breast cancer is caused by the sadness and grief that follows loss and separation. Disharmony of the Directing and Penetrating Vessels (Ren and Chong Mai) Disharmony of the Directing and Penetrating Vessels after the menopause results from the cessation of the periods causing a relative imbalance between the top and bottom parts of the body. The Lower Burner is deficient in Blood and Essence so that the Qi of the Penetrating Vessel may rebel upwards and cause stagnation above. The Penetrating Vessel originates from the Uterus (in women) and connects with the breast and there is a connection between the uterus Blood and breast milk. In fact, a saying states that “the Uterus is the lower source of milk and the breast is the upper source of Blood”. Thus the drying up of Blood and Essence below may cause stagnation in the breast and lead to lumps. The main Penetrating Vessel symptom, called Li Ji, results from
rebellious Qi rising from the abdomen to the chest; Li Ji indicates, on the one hand, ‘a feeling of anxiety’ and, on the other hand, a feeling of constriction (or contracture) of the chest. These phenomena are related to the Penetrating Vessel and have an effect on the pathogenesis of breast lumps and cancer. Because of the Penetrating Vessel’s influence on the Uterus and breast, some Chinese books also mention abortion, miscarriage and lack of breastfeeding as contributory factors in breast lumps. In my opinion, what Chinese books call ‘disharmony of the Directing and Penetrating Vessels’ is also caused by hormonal manipulation throughout a woman’s lifetime. This may derive from the use of the contraceptive pill, the hormonal stimulation for assisted fertilization and also hormones present in foods and the environment. Irregular diet Excessive consumption of dairy foods, fats and sweets leads to Phlegm which may form lumps. This is an important contributory cause of breast lumps in Western women. Overwork Overwork, in the sense of working long hours without adequate rest and with an irregular routine and diet, weakens Liver- and Kidney-Yin. Liver-Yin is the root of Liver-Qi, the Liver is the ‘root of stopping extremes’, i.e. the harmonizing organ that needs a balance between its Yin and Yang part. Deficiency of Liver-Blood or Liver-Yin may often lead to stagnation of Liver-Qi. Very often stagnation of Liver-Qi is secondary to Liver-Blood or Liver-Yin deficiency: when this happens, a woman has all the symptoms of Liver-Qi stagnation but a Choppy pulse and Thin-Pale tongue.
Pathology and treatment principles The pathology of breast lumps is complex. Stagnant Qi (of Liver–Lungs– Heart–Stomach) leads to accumulation in the channels, the breast Connecting channels are obstructed and stagnation of Qi leads to stasis of Blood. Stagnation of Qi and deficiency of the Spleen lead to Phlegm which accumulates in the breast. Disharmony of the Directing and Penetrating Vessels with Emptiness (of Blood and Essence) below and Fullness above leads to accumulation in the breast. Stagnant Qi can turn into Fire after a long period of time and this, in turn, may become Toxic-Heat. Fire and ToxicHeat injure Yin and lead to Liver and Kidney deficiency. In terms of channels, the Directing and Penetrating Vessels are the most important ones in the development of breast lumps. Both Directing and Penetrating Vessels arise from the space between the kidneys, flow through the uterus and connect upward with the breasts (see Fig. 59.1).
Figure 59.1 Connection among Directing and Penetrating Vessels, Uterus and breasts.
The stagnation of Liver-Qi that is nearly always the beginning stage of breast lump development is closely related to the Kidneys and this relationship takes place within the Directing and Penetrating Vessels. When the Kidneys are weak, the Directing and Penetrating Vessels are also weak in the Lower Burner: when Kidney-Qi is deficient, the Liver may lose its free
flow and the combination of these two factors upsets the normal functioning of the Directing and Penetrating Vessels. This results in Emptiness below and Fullness above in these two vessels. Thus, the treatment principle must be based on tonifying the Kidneys and consolidating the Directing and Penetrating Vessels below, and moving Qi, eliminating stagnation and subduing rebellious Qi above. The Directing and Penetrating Vessels also influence the formation of
breast lumps in other ways, through the Gao (
) and Huang
( ) structures. Gao literally means ‘fat’ while Huang means ‘membranes’: the Source points for these two structures are both on the Directing Vessel. Chapter 1 of the Spiritual Axis mentions the Source points as being the following: • P-7 Daling for the Heart. • LU-9 Taiyuan for the Lungs. • KI-3 Taixi for the Kidneys. • SP-3 Taibai for the Spleen. • LIV-3 Taichong for the Liver. • Ren-15 Jiuwei for Gao.
• Ren-6 Qihai for Huang. The Spiritual Axis says literally: “The Source of Gao comes out at Jiuwei, one point. The Source of Huang comes out at Bo Yang, one point.”11 All Chinese texts and dictionaries say that Bo Yang is Ren-6 Qihai, but some people think it is Ren-8 Shenque. However, note that an alternative name for Ren-6 Qihai is ‘Xia Huang’, i.e. ‘Lower Membranes’: this would seem to confirm that the point Bo Yang mentioned in Chapter 1 of the Spiritual Axis is indeed Ren-6 Qihai (see also Ch. 7). Gao (‘fat’) may refer to adipose tissue. An interesting aspect of this is that old Daoist texts on embryology say that in the first month, the fetus (or, more precisely, blastocyst) is just ‘Gao’ say that the fetus in the second month is ‘Gao’). Huang literally means ‘membranes’ and it refers to tissues surrounding and connecting the viscera. Chapter 40 of the Simple Questions mentions Huang: Some people are affected by swelling of the large joints and abdominal pain around the umbilicus: what is the cause of this disease? [the Yellow Emperor asks] Chi Po answers: This disease is called Hardness of the Viscera and is due to Wind. When this overflows to the Large Intestine it reaches the Huang Membranes, the Source of the Huang Membranes is below the umbilicus and this causes pain around the umbilicus.12 The Classic of Categories (1624) says: “The gaps running up and down the abdomen in between the muscles of abdominal cavity are where the Huang Membranes are situated”.13 This last passage clearly seems to indicate that the Huang membranes are the connective tissue in the abdominal cavity that encapsulates and connects the viscera. Thus, Gao and Huang represent a whole range of connective tissue including adipose tissue and abdominal connective tissue. They cover the whole body with a layer immediately below the skin and an inner layer wrapping and anchoring the organs, muscles and bones. In other words, Gao and Huang are all the structures that are not skin, muscles, sinews, blood vessels, bones or internal organs. When we refer to the tissues of the
body related to the five main Yin organs, we normally include skin (Lungs), muscles (Spleen), sinews (Liver), bones (Kidneys) and vessels (Heart); however, if these were the only tissues, the organs would be situated in a vacuum unconnected to each other or to surrounding structures. We know from modern medicine that the connective tissue does indeed connect, i.e. it connects various structures of the body. In the abdominal cavity, Gao corresponds to adipose tissue and Huang to the connective tissue and the capsules surrounding the organs (Fig. 59.2). There are other types of connective tissues such as the tendons, which pertain to the ‘sinews’.
Figure 59.2 Ren-15, Source point of Gao, and Ren-6, Source point of Huang. With reference to the two points Ren-15 and Ren-6 (or Ren-8), these are the Source of Gao and Huang, which means that these points and the whole Directing Vessel on the abdomen are embryologically related to the development of abdominal connective tissue. Using these points can therefore act at a deep energetic level to regulate and equalize tensions and weaknesses in the ‘membranes’ of the abdomen and thorax. In relation to the breast, this is rich in adipose tissue and connective tissue, the latter in the
form of compartments that house the glandular lobules (see Fig. 59.3). Thus, both the Directing and Penetrating Vessels exert an important influence on the breast through the Gao and Huang structures (as well as in other ways). Figure 59.4 illustrates the relation between these two vessels and breast structures.
Figure 59.3 Adipose and connective tissue in breast.
Figure 59.4 Relation between Directing and Penetrating Vessels and breast structures.
A stagnation of Qi in the Directing and Penetrating Vessels, and especially in the latter, will therefore induce a state of tension and congestion in the Gao and Huang structures of the breast and obstruct the channels, vessels and Connecting channels of the breast: all these are related to the Penetrating Vessel because this vessel governs all Connecting channels (as it is the Sea of the Twelve Channels) and the blood vessels (as it is the Sea of Blood). Long-term stagnation of Qi will eventually lead to accumulation of Phlegm and stasis of Blood, both important factors in the pathogenesis of breast lumps. The Huang structures (and therefore the Directing and Penetrating Vessels) are also involved in the pathogenesis of breast cancer, even though this is a carcinoma, i.e. cancer of the epithelial tissue. In fact, in recent years researchers have suggested that some of the non-glandular supporting cells within the breast (made of connective tissue and therefore Huang) may influence the growth of cancer cells. These cells form part of the supporting structure of the breast and produce some chemical messengers called growth factors which seem to ‘communicate’ chemically with breast cancer cells to influence both their growth and their ability to spread.14 A number of herbs have a particular action in removing obstructions from the Connecting channels of the breast: an expression which attempts to translate the concise but descriptive Chinese terms tong ru luo (
), literally ‘penetrating the breasts Luo (channels)’. All these herbs will have an action in moving Qi and Blood in the Penetrating Vessel because of the
relation between this channel and the Connecting channels and blood vessels. The main herbs that have this function are: • Ju Luo Fibra Citri rubrum • Lu Lu Tong Fructus Liquidambaris • Chuan Shan Jia Squama Manitis • Mu Tong Caulis Akebia • Si Gua Luo Retinervus Luffae fructus • Lou Lu Radix Rhapontici • Tong Cao Medulla Tetrapanacis. It is interesting to note that some of these herb names contain the words Luo for Connecting channels and Tong for ‘removing obstructions’. Moreover, the structure of these herbs when dried resembles a network of channels running in all directions, just as the network of Connecting channels does. In some of them, the structure even resembles the network of the breasts with its lobules, milk ducts and connective tissue compartments. In particular, Ju Luo Fibra Citri rubrum, i.e. the soft fibrous tissue lining the inside of the rind in tangerines, bears a close resemblance to the connective tissue inside the breast, and the whole fruit may be taken to represent the breast itself (see Fig. 59.5).
Figure 59.5 Ju Luo and Si Gua Luo resembling the breast connective tissues. The main pathogenic conditions in breast lumps are therefore: • stagnation of Qi • stasis of Blood • Phlegm • Toxic-Heat • Liver and Kidney deficiency. The last two are more common in older women. However, every case is characterized by deficiency in its initial stages and by simultaneous excess and deficiency in its middle to late stages. Since each case is characterized by both a deficiency and an excess, the crucial question is whether to tonify the body’s Qi (bu zheng), eliminate pathogenic factors (gong xie) or do both simultaneously. Generally speaking, one tonifies the body’s Qi and eliminates pathogenic factors simultaneously but always with the emphasis on one or the other. This means that, when using herbal medicine especially, one has to have a clear idea in mind as to the chosen treatment principle and consequent chosen formula. Although every formula is modified to take into account tonifying the body’s Qi or eliminating pathogenic factors, the choice of where to put the emphasis is still crucial. In the initial stages, the treatment principle usually adopted is to tonify the body’s Qi and especially the Liver and Kidneys. Thus, for example, if a woman presents with a very small lump that has been detected by mammography and there are no prominent symptoms of a breast pathology in a Chinese sense (no obvious swelling, redness, heat and, most of all, no palpable lump), the emphasis of the treatment should probably be on tonifying the body’s Qi; however, whatever tonifying formula is chosen, it should always be modified to include herbs that eliminate pathogenic factors
and move Qi or resolve Phlegm or both. If, on the contrary, a woman presents with an obvious lump or lumps in the breast which have been proven to be benign in nature and the breast is swollen, hot and tender, then the treatment principle should be to eliminate pathogenic factors primarily by moving Qi, invigorating Blood, resolving Phlegm, removing obstructions from the breast’s Connecting channels or resolving Toxic-Heat. Again, whatever eliminating formula is chosen, it should be modified with the addition of some herbs to tonify the body’s Qi and, in particular, the Liver and Kidneys. With acupuncture, the distinction between tonifying the body’s Qi and eliminating pathogenic factors is less clear cut but it does, nevertheless, exist both in the choice of points and in the choice of needling technique. With regard to the choice of points, tonifying the body’s Qi implies choosing tonic points such as KI-3 Taixi, Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-13 Qixue and BL-23 Shenshu for the Kidneys, and LIV-8 Ququan, SP-6 Sanyinjiao, BL-18 Ganshu and Ren-4 Guanyuan for the Liver. If Blood needs to be tonified, one would use points such as LIV-8 Ququan, SP-6 Sanyinjao, ST36 Zusanli, BL-17 Geshu and Ren-4 Guanyuan. With regard to eliminating pathogenic factors, one would use points such as SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-9 Shuifen, ST-28 Shuidao, ST-40 Fenglong and BL-22 Sanjiaoshu to resolve Dampness and Phlegm; points such as Ren-6 Qihai, SP-10 Xuehai, LIV-3 Taichong, KI-14 Siman, T.B.-6 Zhigou, P-6 Neiguan, LIV-14 Qimen and BL-18 Ganshu to move Qi and invigorate Blood; and points such as L.I.-11 Quchi, Ren-12 Zhongwan, SP-10 Xuehai, LIV-2 Xingjian, P-8 Laogong or G.B.-41 Zulinqi to resolve Toxic-Heat. In terms of needling technique, this should obviously be reinforcing to tonify the body’s Qi and reducing to eliminate pathogenic factors.
Diagnosis Palpation is essential, not to replace the diagnosis of an expert gynecologist, but because it gives us therapeutic guidelines: • Lump relatively soft: Phlegm. • Lump hard: stasis of Blood and/or Toxic-Heat. • Lump with distinct edges: Phlegm. • Lump with indistinct edges: Toxic-Heat. • Mobile on palpation: Phlegm. • Not mobile on palpation: stasis of Blood and/or Toxic-Heat. • Redness: Fire or Toxic-Heat. • Whiteness of skin: Phlegm. • Purple skin: stasis of Blood. • Purulent discharge from nipple: Toxic-Heat. • Yellow discharge from nipple: Damp-Heat. • Clear discharge from nipples: Dampness. • Bloody discharge: Toxic-Heat injured Blood-Connecting channels, Blood-Heat. Table 59.1 summarizes the different types of breast lumps, with their symptoms, tongue, pulse, treatment principle and prescription.
Table 59.1 Comparison of different types of breast lumps
Channels It is useful at this point to review the channels coursing over the breasts (Fig. 59.6).
Figure 59.6 Channels affecting the breast.
Main channels The Stomach channel goes over the breast and many of its points are
important for the breast, e.g. ST-18 Rugen, ST-12 Qupen, ST-36 Zusanli, ST-41 Jiexi. It affects the breast as a whole, and also via the Penetrating Vessel which connects to the Stomach at ST-30 Qichong. The production of breast milk after childbirth is a transformation of Blood from the Sea of Blood of the Penetrating Vessel into milk. The Liver channel goes over the sides of the breast and specifically influences the nipple. Liver points which affect the breast are LIV-3 Taichong and LIV-14 Qimen. Extraordinary Vessels The Penetrating Vessel scatters over the chest and has an important influence on the breast also because it represents the channel connection between the Uterus (where it starts) and the breasts. In other words, the Penetrating Vessel is the channel embodiment of the Western hormonal connection between the ovaries/uterus and the breasts. The pathology of the Penetrating Vessel has a great bearing on the formation of breast lumps. When there is a disharmony of this vessel in the Lower Burner (with Blood deficiency or Kidney deficiency), very often Qi rebels upwards to disturb the chest and cause stagnation of Qi in the chest and breasts. This is a major factor in the development of breast lumps. Muscle channels The Gall Bladder muscle channel goes over the breast. In fact, G.B.-41 Zulinqi is an important point for the breast. The Stomach muscle channel goes over the breast. Both the Pericardium and Heart muscle channels go over the breast: this highlights the physiological connection between emotional factors affecting the Heart and Pericardium and breast lumps. It should be remembered that stagnation of Qi may affect the Heart in the chest.
Identification of patterns and treatment I will discuss the prescriptions according to patterns first and then those according to symptoms and signs. The patterns discussed are: • stagnation of Liver-Qi • Spleen-Yang deficiency with Phlegm • Directing and Penetrating Vessel disharmony • stagnant Liver-Qi turned into Fire • Toxic-Heat • Liver- and Kidney-Yin deficiency, Principle of treatment Breast lumps are always characterized by excess and deficiency and the treatment should therefore aim to expel pathogenic factors and tonify the body’s Qi. In the beginning stages, the emphasis should be on tonifying the body’s Qi, and in the middle to late stages on expelling pathogenic factors. In any case, resolving stagnation is always important. Dr Gao says: In the treatment of breast lumps … no matter whether there is Deficiency or Excess, chronic or acute condition, Heat or Cold, or even whether the main chosen treatment method is to support Upright Qi or attack pathogenic factors, moving Qi and removing obstruction from the Connecting channels is the main treatment principle … [when this is done] stagnation is resolved, accumulation is dispersed and hardness softened.
To expel pathogenic factors means to move Qi, eliminate stagnation, eliminate Blood stasis, resolve Phlegm, drain Fire, resolve Toxin and soften hardness, as required. To tonify involves tonifying the Spleen, Liver and Kidneys and nourishing the Blood and Essence, as required.
Stagnation of Liver-Qi
Clinical manifestations Irregular periods, breast distension before periods or related to emotional state, pain in breast and nipple, dislike of having them covered, small nodules, not hard, not adhering to skin and deeper tissues, i.e. they can be moved, border not clearly defined, sighing, mental depression, irritability. Tongue: normal coloured or slightly Red sides. Pulse: Wiry. Treatment principle Pacify the Liver, move Qi, eliminate stagnation, invigorate Blood, remove obstructions from the Connecting channels, dissipate nodules. Acupuncture T.B.-6 Zhigou, G.B.-34 Yanglingquan, G.B.-41 Zulinqi, LIV-3 Taichong, P6 Neiguan, G.B.-21 Jianjing, BL-51 Huangmen, BL-18 Ganshu, LIV-14 Qimen, ST-18 Rugen, LIV-8 Ququan, SP-6 Sanyinjiao. All with reducing or even method except for LIV-8 and SP-6 which should be reinforced. Explanation
– T.B.-6 and G.B.-34 move Qi, eliminate stagnation and pacify the Liver. T.B.-6 affects the lateral side of the body (the Lesser Yang channels’ area of influence) and therefore the sides of the body. G.B.-34 affects the costal region, i.e. the ribs just under the breast.
– G.B.-41 moves Qi and resolves Dampness: it specifically affects the breast itself. – LIV-3 moves Qi, eliminates stagnation and pacifies the Liver. – P-6 pacifies the Liver, calms the Mind and settles the Ethereal Soul. It affects the chest area and therefore the breast. – G.B.-21 promotes the descending of Qi and affects the breasts. – BL-51 is the points where the Triple Burner’s Qi emerges from in between the kidneys and ascends to the chest and breasts: it therefore moves Qi and eliminates stagnation in the breast area. – BL-18 and LIV-14, Back-Transporting and Front-Collecting points respectively, move Qi, eliminate stagnation and pacify the Liver. – ST-18 is a local point for the breast. – LIV-8 and SP-6 nourish Liver-Blood and are used if there is LiverBlood deficiency. Prescription of points from Dr Guo Cheng Jie 15
S.I.-11 Tianzong, G.B.-21 Jianjing, BL-18 Ganshu, ST-15 Wuyi, Ren-17 Shanzhong, P-6 Neiguan. Explanation
– S.I.-11 affects the breasts. – G.B.-21 moves Liver-Qi and makes Qi descend. It also has an effect on the breasts (it is sometimes used for agalactia).
– BL-18 pacifies the Liver and moves Qi. – ST-15 is a local point for breast problems. – Ren-17 moves Qi in the chest and breast area. – P-6 pacifies the Liver, moves Qi and affects the chest and breast area. Herbal treatment Eight formulae are discussed below, all based on stagnation of Liver-Qi. They all, however, address other patterns which are mainly stasis of Blood, Phlegm or Toxic-Heat. a Prescription
– RU HE NEI XIAO TANG – Breast Kernel Inner-Dissolving Decoction Explanation
– Chai Hu (or Qing Pi), Xiang Fu and Ju He move Qi, eliminate stasis and pacify the Liver. Qing Pi specifically affects the breast. – Yu Jin and Chi Shao invigorate Blood and eliminate stasis. Yu Jin specifically affects the breast. – Dang Gui nourishes Liver-Blood which will help to pacify the Liver. – Shan Ci Gu, Xia Ku Cao and Lou Lu resolve Toxic-Heat and dissipate
nodules. Xia Ku Cao and Lou Lu specifically affect the breast. – Si Gua Luo invigorates Blood, eliminates stasis and removes obstructions from the Connecting channels: it specifically affects the breast. – Gan Cao harmonizes. This formula is suitable if, in addition to Qi stagnation, there is also some Blood stasis and Toxic-Heat. This would manifest with an inflammatory swelling of the breasts which become hot and painful. The tongue presentation appropriate to this formula is a body that is Red on the sides and with a sticky, yellow coating. b Prescription
– JIA WEI XIAO YAO SAN – Variation of Free and Easy Wanderer Powder Explanation
– Chai Hu, Qing Pi, Chen Pi, Xiang Fu and Ju He move Qi, eliminate stagnation and pacify the Liver. Qing Pi specifically affects the breast. – Yu Jin invigorates Blood, eliminates stasis and affects the breast. – Gua Lou and Ban Xia resolve Phlegm; Gua Lou specifically affects the breast. – Dang Gui and Bai Shao nourish Liver-Blood which helps to pacify the Liver. This formula is suitable if there is some Phlegm, manifesting with fairly large lumps which are relatively soft, very swollen and tender breasts. This
pattern is more likely to occur in an overweight woman. The tongue presentation appropriate to this formula is a Swollen body with a sticky coating. c Prescription
– QING GAN JIE YU TANG – Clearing the Liver Eliminating Stagnation Decoction Explanation
– Bai Shao and Dang Gui nourish Liver-Blood which helps to pacify the Liver. – Chuan Xiong invigorates Blood and eliminates stasis. – Shan Zhi Zi and Mu Dan Pi clear Heat and cool Blood. – Chai Hu moves Qi, eliminates stagnation and pacifies the Liver. This formula is suitable if there is some Heat deriving from Qi stagnation. The tongue presentation appropriate to this formula is a Red body with redder sides. d Prescription
– CHAI HU SHU GAN TANG – Bupleurum Pacifying the Liver Decoction
Explanation This formula, already explained, moves Qi, eliminates stagnation and pacifies the Liver: it is specific for pain from Qi stagnation. It is therefore suitable if the breasts are distended and painful. e Prescription
– SHEN XIAO GUA LOU SAN – Trichosantes Spirit-Effect Powder Explanation
– Gua Lou resolves Phlegm and affects the breast. – Dang Gui nourishes Liver-Blood which helps to pacify the Liver. – Gan Cao is in the formula not to harmonize but to resolve Toxic-Heat (this is evident from its dosage). – Ru Xiang and Mo Yao invigorate Blood and eliminate stasis. This formula is suitable if there is stasis of Blood as well as stagnation of Qi. It is therefore applicable if the breasts are painful, the lumps are hard and the tongue is Purple. f Prescription
– XIAO YAO SAN Variation (I)
– Free and Easy Wanderer Powder Variation (I) Explanation
– Gua Lou resolves Phlegm and affects the breast. – Xia Ku Cao resolves Toxic-Heat and also affects the breast. – Hai Zao resolves Phlegm and dissolves masses. – Qing Pi and Xiang Fu move Qi, eliminate stagnation and pacify the Liver. – Huang Yao Zi resolves Phlegm and dissolves masses. It should not be used if the liver function is abnormal. This formula is suitable when the breast lumps (from Phlegm) are large and relatively soft. g Prescription
– XIAO YAO SAN Variation (II) – Free and Easy Wanderer Powder Variation (II) Explanation
– Chai Hu and Qing Pi move Qi, eliminate stagnation and pacify the Liver. – Bai Shao and Dang Gui nourish Liver-Blood which helps to pacify the Liver. – Chi Shao, Dan Shen, Yu Jin, Chuan Shan Jia, E Zhu and Yi Mu Cao
invigorate Blood and eliminate stasis. Chuan Shan Jia and Yu Jin specifically affect the breast. – Gua Lou and Hai Zao resolve Phlegm and soften masses. – Lou Lu resolves Toxic-Heat and dissipates nodules: it specifically affects the breast. This formula is suitable for complex conditions characterized by Phlegm, stasis of Blood and Toxic-Heat. It is therefore applicable if the breasts are painful and very swollen, the lumps hard and the tongue ReddishPurple with a sticky, yellow coating. h Prescription
– XIAO YAO SAN Variation (Dr Shan Dao Wei, Nanjing) – Free and Easy Wanderer Powder Variation Explanation
– Chai Hu, Chen Pi and Qing Pi move Qi, eliminate stagnation and pacify the Liver. – Dang Gui and Bai Shao nourish Liver-Blood which helps to pacify the Liver. – Yu Jin invigorates Blood and eliminates stasis: it specifically affects the breast. – Fu Ling resolves Dampness to help to resolve Phlegm. – Xia Ku Cao drains Fire and resolves Toxic-Heat: it specifically affects
the breast. – Zhe Bei Mu resolves Phlegm and softens masses. – Yu Zhu nourishes Stomach-Yin. This formula is suitable if there is Phlegm, Toxic-Heat and the beginning of Yin deficiency: Toxic-Heat can injure Yin over a long period of time. The tongue presentation appropriate to this formula is therefore a Red and Swollen body with a sticky but rootless coating, possibly peeled in the centre. Women’s Treasure remedies
– FREEING THE MOON This remedy pacifies the Liver, moves Qi, eliminates stagnation, tonifies Spleen-Qi and nourishes Liver-Blood. The tongue presentation appropriate to this remedy is a body with slightly Pale sides. – FREEING CONSTRAINT This remedy pacifies the Liver, moves Qi, eliminates stagnation, invigorates Blood, eliminates stasis, calms the Mind and settles the Ethereal Soul. The tongue presentation appropriate to this remedy is a body with Red or slightly Purple sides. Table 59.2 compares and contrasts the formulae for breast lumps from Qi stagnation. As they are all for Qi stagnation, they are distinguished by the accompanying patterns; Qi stagnation is not therefore listed, it being assumed that they all address this pattern. Table 59.2 Comparison of formulae for breast lumps from Qi stagnation
Summary Stagnation of Liver-Qi
Clinical manifestations
Irregular periods, breast distension before periods or related to emotional state, pain in breast and nipple, dislike of having them covered, small nodules, not hard, not adhering to skin and deeper tissues, i.e. they can be moved, border not clearly defined, sighing, mental depression, irritability. Tongue: normal coloured or slightly Red sides. Pulse: Wiry. Treatment principle
Pacify the Liver, move Qi, eliminate stagnation, invigorate Blood, remove obstructions from the Connecting channels, dissipate nodules. Acupuncture
T.B.-6 Zhigou, G.B.-34 Yanglingquan, G.B.-41 Zulinqi, LIV-3 Taichong, P6 Neiguan, G.B.-21 Jianjing, BL-51 Huangmen, BL-18 Ganshu, LIV-14 Qimen, ST-18 Rugen, LIV-8 Ququan, SP-6 Sanyinjiao. All with reducing or even method except for LIV-8 and SP-6 which should be reinforced. Herbal treatment
Pre scriptions
• RU HE NEI XIAO TANG Breast Kernel Inner-Dissolving Decoction • JIA WEI XIAO YAO SAN Variation of Free and Easy Wanderer Powder • QING GAN JIE YU TANG Clearing the Liver Eliminating Stagnation Decoction • CHAI HU SHU GAN TANG Bupleurum Pacifying the Liver Decoction • SHEN XIAO GUA LOU SAN Trichosantes Spirit-Effect Powder
• XIAO YAO SAN Variation (I) Free and Easy Wanderer Powder Variation (I) • XIAO YAO SAN Variation (II) Free and Easy Wanderer Powder Variation (II) • XIAO YAO SAN Variation (Dr Shan Dao Wei, Nanjing) Free and Easy Wanderer Powder Variation Wome n’s Tre asure remedies
• FREEING THE MOON • FREEING CONSTRAINT
Spleen-Yang deficiency with Phlegm
Clinical manifestations Breast lumps relatively soft, in the beginning like an egg, no pain but in severe cases the breasts may feel tender to the touch, feeling of heaviness, a feeling of oppression of the chest, tiredness, feeling cold, loose stools. Tongue: Pale, Swollen and wet. Pulse: Deep, Weak, Slippery. Treatment principle Warm Yang, strengthen the Spleen, resolve Phlegm, dissipate accumulation. Acupuncture BL-20 Pishu, BL-21 Weishu, Ren-12 Zhongwan, ST-36 Zusanli, SP-3 Taibai, SP-6 Sanyinjiao, Ren-9 Shuifen, SP-9 Yinlingquan, ST-40 Fenglong, BL-22 Sanjiaoshu. Reinforcing method on the first six points to tonify the Spleen; reducing or even method on the others. Moxa should be used. Explanation
– BL-20, BL-21, Ren-12, ST-36, SP-3 and SP-6 tonify the Spleen. Warming needle on ST-36 and SP-3 warms the Yang. – Ren-9, SP-9 and BL-22 resolve Dampness. – ST-40 resolves Phlegm. Herbal treatment
Prescription
– SHI WEI LIU QI YIN – Ten Ingredients Coursing Qi Decoction Explanation
– Rou Gui warms the Yang, warms the Uterus and scatters Cold. – Huang Qi and Ren Shen tonify Qi and strengthen the Original Qi. – Bai Zhi reduces swelling. – Jie Geng directs the formula to the Upper Burner. – Wu Yao and Zhi Ke move Qi, eliminate stagnation and pacify the Liver. – Hou Po and Bing Lang fragrantly resolve Dampness. – Dang Gui and Bai Shao nourish Liver-Blood which helps to pacify the Liver. – Chuan Xiong and E Zhu invigorate Blood and eliminate stasis. – Fang Feng and Zi Su Ye resolve Dampness and harmonize the Stomach. – Mu Tong dries Dampness and removes obstructions from the Connecting channels. Please note that the use of this herb is illegal and it should therefore be replaced by Tong Cao Medulla Tetrapanacis.
– Tu Fu Ling and Zhe Bei Mu resolve Toxic-Heat and Phlegm. – Gan Cao harmonizes. Although this formula tonifies Spleen-Yang and resolves Phlegm, it has a complex action, also invigorating Blood, moving Qi and resolving Dampness. It also helps to resolve Phlegm by draining Dampness and harmonizing the Centre. Its action is specifically directed at the Upper Burner, and thus the combination of these actions makes it suitable to treat breast lumps occurring against a background of Spleen-Yang deficiency but also other patterns such as Phlegm, Qi stagnation, Dampness and Toxic-Heat. Summary Spleen-Yang deficiency with Phlegm
Clinical manife stations
Breast lumps relatively soft, in the beginning like an egg, no pain but in severe cases the breasts may feel tender to the touch, feeling of heaviness, a feeling of oppression of the chest, tiredness, feeling cold, loose stools. Tongue: Pale, Swollen and wet. Pulse: Deep, Weak, Slippery. Tre atme nt principle
Warm Yang, strengthen the Spleen, resolve Phlegm, dissipate accumulation. Acupuncture
BL-20 Pishu, BL-21 Weishu, Ren-12 Zhongwan, ST-36 Zusanli, SP-3 Taibai, SP-6 Sanyinjiao, Ren-9 Shuifen, SP-9 Yinlingquan, ST-40 Fenglong, BL-22 Sanjiaoshu. Reinforcing method on the first six points to tonify the Spleen; reducing or even method on the others. Moxa should be used. He rbal tre atme nt
Prescription
• SHI WEI LIU QI YIN Ten Ingredients Coursing Qi Decoction
Directing and Penetrating Vessel (Ren and Chong Mai) disharmony
Clinical manifestations Swollen breasts, distension and pain of breasts before or during period, swelling goes down after period, late cycle, infertility, small, hard lump which is difficult to move, sometimes discharge from the nipple, a feeling of tightness of the chest, anxiety, abdominal pain, painful periods, weariness, sore back, cold limbs, feeling cold in lower abdomen. Tongue: Pale. Pulse: Fine-Wiry. This pattern is due to a Kidney deficiency affecting the Directing and Penetrating Vessels and resulting in rebellious Qi in the Penetrating Vessel, reflected by the abdominal pain, feeling of tightness of the chest and anxiety. The lumps in the breasts are also due to the imbalance within the Penetrating Vessel, with a deficiency (of the Kidneys) below and a stagnation above: since the Penetrating Vessel runs over the breasts, lumps develop. The other symptoms accompanying infertility (sore back, tiredness, cold feeling and pale tongue) are all due to Kidney deficiency. Treatment principle Regulate and ‘fill’ the Directing and Penetrating Vessels, warm the breast Connecting channels and remove obstructions from them. Acupuncture SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), KI-13 Qixue, Ren-4 Guanyuan, KI-14 Siman, LIV-3 Taichong, SP-6 Sanyinjiao, KI-3 Taixi, T.B.-6 Zhigou. All with reducing or even method except for SP-6, Ren-4, KI-13 and KI-3 which should be reinforced. Moxa can be used. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel, subdue rebellious Qi and strengthen the Uterus. – Ren-4 and KI-13 nourish the Kidneys, strengthen the Uterus and reinforce the Directing and Penetrating Vessels. – KI-14, a point of the Penetrating Vessel, moves Qi and eliminates stagnation in the Lower Burner. – LIV-3 moves Qi and eliminates stagnation. It also regulates the Penetrating Vessel. – SP-6 and KI-3 tonifies the Kidneys and consolidate the root of the Penetrating Vessel. – T.B.-6 moves Qi, eliminates stagnation and pacifies the Liver. Herbal treatment
a Prescription
– JIA WEI YANG HE TANG – Variation of Yang-Harmonizing Decoction Explanation
– Gan Jiang and Rou Gui warm the Yang and the Uterus and expel Cold.
– Ma Huang and Bai Jie Zi warm the channels and remove obstructions from the Connecting channels. Note the small dosage of Ma Huang which indicates that it is used here not to stimulate the diffusing and descending of Lung-Qi but to remove obstructions from the Connecting channels. – Lu Jiao Jiao nourishes the Governing Vessel and Blood. It is especially suited to women as it tonifies Yang without drying while also nourishing Blood. – Shu Di Huang tonifies the Kidneys, nourishes the Essence and strengthens the Directing and Penetrating Vessels. – Xiang Fu, Qing Pi, Chen Pi and Yu Jin move Qi, eliminate stagnation, pacify the Liver and subdue rebellious Qi in the Penetrating Vessel. b Prescription
– LU PU TANG – Cornu Cervi-Taraxacum Decoction Explanation
– Lu Jiao tonifies Kidney-Yang and strengthens the Governing Vessel. – Pu Gong Ying and Shan Ci Gu resolve Toxic-Heat and dissipate nodules: they specifically affect the breast. This formula is suitable if there is a deficiency of Kidney-Yang together with Toxic-Heat in the breast manifesting with hot, painful and swollen breasts. The tongue would be Pale but with a yellow coating. c Prescription
– ER XIAN TANG and XIAO YAO SAN Variation – Two Immortals Decoction and Free and Easy Wanderer Powder Variation Explanation The first six herbs constitute the formula Er Xian Wan, already explained, which nourishes both Kidney-Yin and Kidney-Yang and clears pathological Minister Fire. The next seven herbs constitute the formula Xiao Yao San, without Dang Gui as it is already in the formula Er Xian Tang. – Gua Lou, Hai Zao and Huang Yao Zi resolve Phlegm, soften masses and dissipate nodules. Do not use Huang Yao Zi if the liver function is abnormal: in any case, do not use it uninterruptedly but only for 2–3 weeks at a time followed by a break of 2–3 weeks. – Wang Bu Liu Xing invigorates Blood and specifically affects the breasts. Women’s Treasure remedy
– PENETRATING VESSEL This remedy tonifies the Kidneys, nourishes Blood, strengthens the Directing and Penetrating Vessels and subdues rebellious Qi in the Penetrating Vessel. Since this vessel affects the breasts, this remedy can alleviate stagnation of Qi in the breasts as well as tonifying the Kidneys and Blood. Summary
Directing and Penetrating Vessel (Ren and Chong Mai) disharmony
Clinical manifestations
Swollen breasts, distension and pain of breasts before or during period, swelling goes down after period, late cycle, infertility, small, hard lump which is difficult to move, sometimes discharge from the nipple, a feeling of tightness of the chest, anxiety, abdominal pain, painful periods, weariness, sore back, cold limbs, feeling cold in lower abdomen. Tongue: Pale. Pulse: Fine-Wiry. Treatment principle
Regulate and ‘fill’ the Directing and Penetrating Vessels, warm the breast Connecting channels and remove obstructions from them. Acupuncture
SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), KI-13 Qixue, Ren-4 Guanyuan, KI-14 Siman, LIV-3 Taichong, SP-6 Sanyinjiao, KI-3 Taixi, T.B.-6 Zhigou. All with reducing or even method except for SP-6, Ren-4, KI-13 and KI-3 which should be reinforced. Moxa can be used. Herbal treatment
Pre scriptions
• JIA WEI YANG HE TANG Variation of Yang-Harmonizing Decoction • LU PU TANG Cornu Cervi-Taraxacum Decoction • ER XIAN TANG and XIAO YAO SAN Variation Two Immortals Decoction and Free and Easy Wanderer Powder Variation
Women’s Treasure remedy
• PENETRATING VESSEL
Stagnant Liver-Qi turned into Fire
Clinical manifestations Large breast lump like a heap, hard, adhering to skin, inverted nipple, orange-skin effect, purple skin, blood vessels showing, irritability, dry mouth, bitter taste, headaches, red face, dark urine, constipation. Tongue: Red, with redder sides and a dry, yellow coating. Pulse: Wiry and Rapid. Treatment principle Clear the Liver, drain Fire, eliminate stagnation, resolve Phlegm and ToxicHeat. Acupuncture LIV-3 Taichong, T.B.-6 Zhigou, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), LIV-14 Qimen, LIV-2 Xingjian, L.I.-11 Quchi, SP-6 Sanyinjiao, ST-18 Rugen, G.B.-41 Zulinqi. All with reducing or even method. Explanation
– LIV-3, LIV-14 and T.B.-6 move Qi, eliminate stagnation and pacify the Liver. – SP-4 and P-6 regulate the Penetrating Vessel and subdue rebellious Qi. – LIV-2 drains Liver-Fire.
– L.I.-11 clears Heat and drains Fire. – SP-6 nourishes Yin. – ST-18 is a local point for the breast. – G.B.-41 resolves Damp-Heat and specifically affects the breast. Herbal treatment
Prescription
– QING GAN JIE YU TANG Variation – Clearing the Liver and Eliminating Stagnation Decoction Variation Explanation The first six herbs constitute the formula Qing Gan Jie Yu Tang which has already been explained above under the pattern of Liver-Qi stagnation. – Sheng Di Huang nourishes the Kidneys and the Directing and Penetrating Vessels. – Chen Pi, Ban Xia and Zhe Bei Mu resolve Phlegm and soften masses. – Fu Shen and Yuan Zhi calm the Mind. – Zi Su Ye harmonizes the Stomach and helps to resolve Phlegm. It also affects the chest and breast area.
– Mu Tong is used here to remove obstructions from the Connecting channels. Please note that the use of Mu Tong is illegal and it should therefore be replaced by Tong Cao Medulla Tetrapanacis. – Xiang Fu moves Qi and eliminates stagnation. – Ban Zhi Lian and Bai Hua She She Cao resolve Toxic-Heat. – Gan Cao harmonizes. Summary Stagnant Liver-Qi turned into Fire
Clinical manife stations
Large breast lump like a heap, hard, adhering to skin, inverted nipple, orange-skin effect, purple skin, blood vessels showing, irritability, dry mouth, bitter taste, headaches, red face, dark urine, constipation. Tongue: Red, with redder sides and a dry, yellow coating. Pulse: Wiry and Rapid. Tre atme nt principle
Clear the Liver, drain Fire, eliminate stagnation, resolve Phlegm and ToxicHeat. Acupuncture
LIV-3 Taichong, T.B.-6 Zhigou, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), LIV-14 Qimen, LIV-2 Xingjian, L.I.-11 Quchi, SP-6 Sanyinjiao, ST-18 Rugen, G.B.-41 Zulinqi. All with reducing or even method. He rbal tre atme nt
Prescription
• QING GAN JIE YU TANG Variation Clearing the Liver and Eliminating Stagnation Decoction Variation
Toxic-Heat
Clinical manifestations Longstanding illness, fluid inside breast, lump inside it, discharge of yellow or bloody fluid, foul smelling, painful, dry mouth, thirst, dark urine, bitter taste, red eyes, insomnia. Tongue: Red, with redder sides, Red points and a thick, sticky, dry, yellow coating. Pulse: Wiry, Slippery, Rapid, Overflowing. This pattern is usually due to Liver-Fire turning into Toxic-Heat. Treatment principle Drain Fire, clear the Liver, resolve Toxin, move Qi, invigorate Blood, eliminate stasis. Acupuncture LIV-2 Xingjian, L.I.-11 Quchi, SP-10 Xuehai, Ren-12 Zhongwan, L.I.-4 Hegu, P-5 Jianshi, G.B.-41 Zulinqi, ST-18 Rugen, S.I.-1 Shaoze. All with reducing method. Explanation
– LIV-2 clears Liver-Fire. – L.I.-11 and SP-10 resolve Toxic-Heat and cool and invigorate Blood. – Ren-12 helps to resolve Toxic-Heat by resolving Phlegm. – L.I.-4 and P-5 clear Heat and cool Blood. P-5 also helps to resolve
Toxic-Heat by resolving Phlegm. – G.B.-41 resolves Damp-Heat from the breast and specifically affects the breast. – ST-18 is a local point for the breast. – S.I.-1 is an empirical point for congestion in the breast: it should be bled. Prescription
– WU WEI XIAO DU YIN and XUE FU ZHU YU TANG – Five-Ingredient Dissolving Toxin Decoction and Blood Mansion Eliminating Stasis Decoction Explanation The first five herbs constitute the formula Wu Wei Xiao Du Yin: all its ingredients resolve Toxic-Heat and the formula is generally used for carbuncles and boils with redness, swelling, pain and purulent discharges. It is therefore suitable for breast lumps from Toxic-Heat with swelling, heat and tenderness of the breast, hard lumps and a purulent discharge from the nipple. The formula Xue Fu Zhu Yu Tang, already explained, invigorates Blood and eliminates stasis from the Upper Burner. Thus, combined with the previous formula, it can resolve Toxic-Heat and eliminate stasis of Blood from the breast. Summary Toxic-Heat
Clinical manife stations
Longstanding illness, fluid inside breast, lump inside it, discharge of yellow or bloody fluid, foul smelling, painful, dry mouth, thirst, dark urine, bitter taste, red eyes, insomnia. Tongue: Red, with redder sides, Red points and a thick, sticky, dry, yellow coating. Pulse: Wiry, Slippery, Rapid, Overflowing. Tre atme nt principle
Drain Fire, clear the Liver, resolve Toxin, move Qi, invigorate Blood, eliminate stasis. Acupuncture
LIV-2 Xingjian, L.I.-11 Quchi, SP-10 Xuehai, Ren-12 Zhongwan, L.I.-4 Hegu, P-5 Jianshi, G.B.-41 Zulinqi, ST-18 Rugen, S.I.-1 Shaoze. All with reducing method. He rbal tre atme nt
Prescription
• WU WEI XIAO DU YIN and XUE FU ZHU YU TANG Five-Ingredient Dissolving Toxin Decoction and Blood Mansion Eliminating Stasis Decoction
Liver- and Kidney-Yin deficiency
Clinical manifestations Ulcers on nipple, yellow fluid or blood oozing from nipple, breast lumps for a long time, loss of weight, dark complexion, weariness, weak and sore back and knees, irregular periods, dizziness, tinnitus, exhaustion, night sweating. Tongue: without coating; Red, if there is Empty-Heat. Pulse: Floating-Empty or Fine-Rapid. This pattern is seen in older women with chronic breast lumps. In such a pattern, the pathogenic factor has turned into Toxin, Liver and Kidneys are deficient, Blood and Essence exhausted, Spleen-Qi is weak, the Upright Qi is depleted, and Toxin may spread to the internal organs. Treatment principle Nourish Liver and Kidneys, tonify Qi and Blood, resolve Phlegm and Toxin, soften hardness. Acupuncture LIV-8 Ququan, SP-6 Sanyinjiao, Ren-4 Guanyuan, KI-3 Taixi, BL-23 Shenshu, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu, SP-9 Sanyinjiao, Ren-9 Shuifen, BL-22 Sanyinjiao, ST-40 Fenglong. Reinforcing method on the points that nourish Liver and Kidneys, even method on the others. No moxa. Explanation
– LIV-8, SP-6 and Ren-4 nourish the Liver. – KI-3 and BL-23 tonify the Kidneys. – LU-7 and KI-6 regulate the Directing Vessel and nourish the Kidneys. – Ren-12, ST-36 and BL-20 tonify the Spleen. – SP-9, Ren-9 and BL-22 resolve Dampness which helps to resolve Phlegm. – ST-40 resolves Phlegm. Herbal treatment
a Prescription
– XIANG BEI YANG RONG TANG – Cyperus-Fritillaria Nourishing and Flourishing Decoction Explanation
– Xiang Fu moves Qi, eliminates stagnation and pacifies the Liver. – Zhe Bei Mu resolves Phlegm and softens masses. – Ren Shen and Bai Zhu tonify Qi and the Original Qi. – Fu Ling and Chen Pi resolve Dampness.
– Shu Di Huang, Chuan Xiong, Bai Shao and Dang Gui constitute the formula Si Wu Tang Four Substances Decoction which nourishes Blood. – Jie Geng directs the formula to the Upper Burner and therefore breast and also resolves Toxin. – Gan Cao, Sheng Jiang and Da Zao harmonize. – Pu Gong Ying, Ban Zhi Lian and Bai Hua She She Cao resolve ToxicHeat; Pu Gong Ying affects the breast. b Prescription
– QI JU DI HUANG WAN – Lycium-Chrysanthemum-Rehmannia Pill Explanation This formula, already explained, nourishes Liver- and Kidney-Yin, but as it stands does not address the pathogenic factors giving rise to the breast lumps. It should therefore be modified by the addition of herbs such as Qing Pi Pericarpium Citri reticulatae viride, Dan Shen Radix Salviae miltiorrhizae, Pu Gong Ying Herba Taraxaci, Bai Hua She She Cao Herba Hedyotis diffusae and Yi Yi Ren Semen Coicis to move Qi, invigorate Blood, resolve Toxic-Heat and soften masses. Summary Liver- and Kidney-Yin deficiency
Clinical manife stations
Ulcers on nipple, yellow fluid or blood oozing from nipple, breast lumps for a long time, loss of weight, dark complexion, weariness, weak and sore back and knees, irregular periods, dizziness, tinnitus, exhaustion, night sweating. Tongue: without coating; Red, if there is Empty-Heat. Pulse: Floating-Empty or Fine-Rapid. Tre atme nt principle
Nourish Liver and Kidneys, tonify Qi and Blood, resolve Phlegm and Toxin, soften hardness. Acupuncture
LIV-8 Ququan, SP-6 Sanyinjiao, Ren-4 Guanyuan, KI-3 Taixi, BL-23 Shenshu, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-12 Zhongwan, ST-36 Zusanli, BL-20 Pishu, SP-9 Sanyinjiao, Ren-9 Shuifen, BL-22 Sanyinjiao, ST-40 Fenglong. Reinforcing method on the points that nourish Liver and Kidneys, even method on the others. No moxa. He rbal tre atme nt
Prescriptions
• XIANG BEI YANG RONG TANG Cyperus-Fritillaria Nourishing and Flourishing Decoction • QI JU DI HUANG WAN Lycium-Chrysanthemum-Rehmannia Pill
Other herbs and formulae according to symptoms and signs The following prescriptions take into account the treatment given according to the main symptoms and signs appearing in breast lumps, and they can be used either as they are or, with variation, in addition to the chosen formula.
Softening
Herbs Yi Yi Ren Semen Coicis, Zhe Bei Mu Bulbus Fritillariae thunbergii, Bie Jia Carapax Trionicis, Mu Li Concha Ostreae, Hai Zao Sargassum, Kun Bu Thallus Eckloniae. Beginning stage of lump, swelling of breast, breast hard, not painful (stasis of Blood)
Herbs Jiang Can Bombyx batryticatus, Qing Pi Pericarpium Citri reticulatae viride, Wang Bu Liu Xing Semen Vaccariae, Chuan Shan Jia Squama Manitis. Skin broken, oozing pus and blood (Toxic-Heat)
Herbs Bai Hua She She Cao Herba Hedyotis diffusae, Jin Yin Hua Flos Lonicerae, Pu Gong Ying Herba Taraxaci, Zi Cao Radix Lithospermi. Nipple oozing fluid, foul-smelling pus (Damp-Heat)
Herbs Tu Fu Ling Rhizoma Smilacis glabrae, Ju Hua Flos Chrysanthemi, Gan Cao Radix Glycyrrhizae, Zhe Bei Mu Bulbus Fritillariae thunbergii, Yi Yi Ren Semen Coicis. Qi deficiency, weariness, weakness of limbs
Herbs Dang Shen Radix Codonopsis, Huang Qi Radix Astragali, Bai Zhu Rhizoma Atractylodis macrocephalae, Zhi Gan Cao Radix Glycyrrhizae preparata. Large, (relatively) soft lump (Phlegm)
Prescription
– GUA LOU XIAO YAO SAN – Trichosanthes Free and Easy Wanderer Powder Lump grows bigger, mobile, bloody discharge from nipple, fever, pain (Toxic-Heat)
Prescription
– LOU JU CI GU TANG – Trichosanthes-Chrysanthemum-Shancigu Decoction
Prognosis and prevention The factors determining which women are most at risk of breast lumps are: • beginning of menopause • hormone replacement therapy • nulliparous • bottled-up emotional problems • signs of stagnation of Qi and Blood and tongue Purple on sides. Therefore preventive measures include: • dealing with emotions, with psychotherapy if necessary • using acupuncture to eliminate stagnation and resolve Phlegm • in diet, avoiding dairy and greasy foods and sweets • with herbs: eliminating stagnation, resolving Phlegm, tonifying the Spleen, calming the Mind, regulating the Directing and Penetrating Vessels. The following are herbal treatments that can be used in women at risk of breast lumps according to the above risk factors and tongue picture (Purple on chest/breast areas, see Fig. 5.6).
Herbal treatment
Stagnation of Qi from emotional problems Pre-menstrual distension of breasts, nodules, Red tongue, Wiry pulse. Prescription
– YUE JU WAN Variation – Gardenia-Ligusticum Pill Variation Stasis of Blood from emotional problems Distension and pain of breast before periods, nodules, Purple tongue. Prescription
– YUE JU WAN Variation (increase Chuan Xiong) – Gardenia-Ligusticum Pill Variation Stagnation of Lung-Qi from emotional problems Sighing, a feeling of tightness or oppression of the chest, sadness, grief, Pale tongue.
Prescription
– BAN XIA HOU PO TANG Variation – Pinellia-Magnolia Decoction Variation Liver-Qi stagnation with Phlegm Breasts very swollen before periods, soft lump. Prescription
– GUA LOU XIAO YAO SAN – Trichosanthes Free and Easy Wanderer Powder Phlegm in breasts: pumpkin seeds and stems (stems as a tincture). Liver-Qi stagnation with Heat Pre-menstrual distension of breasts, irritability, depression, slightly manic. a Prescription
– QING ZHI SI WU TANG – Citrus-Gardenia Four Substances Decoction b Prescription
– DAN ZHI XIAO YAO SAN – Moutan-Gardenia Free and Easy Wanderer Powder
Acupuncture
– Regulate the Directing and Penetrating Vessels, calm the Mind, settle the Ethereal Soul and Corporeal Soul, move Liver-Qi, nourish Liver-Blood. – LU-7 Lieque and KI-6 Zhaohai to regulate the Directing Vessel. – SP-4 Gongsun and P-6 Neiguan to regulate the Penetrating Vessel. – G.B.-21 Jianjing, LIV-14 Qimen, LIV-3 Taichong, G.B.-41 Zulinqi, G.B.-34 Yanglingquan, ST-18 Rugen as distal, local and adjacent points for the breasts. – Ren-4 Guanyuan, KI-13 Qixue to nourish Blood and tonify the Directing and Penetrating Vessels. – KI-14 Siman, KI-16 Huangshu LIV-3 Taichong, Ren-18 Yutang and KI-25 Shencang to subdue rebellious Qi in the Penetrating Vessel. – Ren-15 Jiuwei, P-7 Daling, P-6 Neiguan, BL-23 Shenshu, BL-52 Zhishi, BL-47 Hunmen, BL-42 Pohu to calm the Mind and settle the Ethereal Soul and Corporeal Soul. As for prognosis, Chinese medicine can help to dissolve breast lumps if they are small: if they are numerous or rather large, it may be difficult to dissolve them. However, Chinese medicine can make a positive contribution to a woman’s breast condition in practically every case, even if the lumps are not dissolved: it can reduce the size of the lumps, make the breast less swollen and tender, eliminate any discharges that there might be from the nipple, treat pre-menstrual tension, regulate the periods and prevent complications. Thus, it is always worthwhile treating a woman with a benign breast pathology. Herbal treatment is more effective than acupuncture and the most difficult pattern to help is that from Toxic-Heat.
Western view From a Western point of view, the most important distinction to be made when faced by a woman with a breast lump is that between a benign and a malignant lump. Benign tumours do not spread beyond their site of origin and are usually harmless. Malignant tumours are cancerous which means that they are able to overcome the normal controls that stop cells in one area invading other tissues. If left unchecked, they will invade and destroy surrounding tissue and may eventually spread through the rest of the body. It is practically impossible to distinguish a benign from a malignant breast lump simply from palpation: thus, a woman presenting with a breast lump should never be treated with Chinese medicine without referral to a gynecologist. Statistics and the age of the patient can provide a very rough guideline as to the nature of a breast lump: in fact, in a woman over 55, a solitary breast lump is likely to be cancerous; in a woman under 30, it is likely to be a fibroadenoma; and in the ages between 30 and 55, it is most likely to be a cyst. Figure 59.7 clearly shows the relative frequency of fibroadenomas, cysts and breast cancer in relation to age.
Figure 59.7 Frequency distribution of breast lumps with age. (Reproduced with kind permission from A McPherson, 1995 Women’s Problems in General Practice, Oxford University Press, Oxford, p. 31.)
The main symptoms of breast cancer are: • lump in the breast • change in size or shape of the breast • pain • indrawing or inversion of the nipple • rash around the nipple • bleeding or discharge from the nipple • dimpling of the skin of the breast (peau d’orange, or ‘orange-skin’ effect) • lump in the axilla • prominent veins on the breast • swelling of the skin • symptoms of secondary tumours elsewhere.16 Many of the above symptoms may, of course, occur also in benign breast disease. Leaving aside the lump or lumps, a discharge from the nipple, a rash around the nipple or nipple retraction, for example, may occur also in duct ectasia. A nipple discharge may also be caused by epithelial hyperplasia. A yellow or blood-stained discharge may also occur in duct papilloma. A greenish or yellow discharge may indicate mastitis, while a milky discharge may be caused by an adverse drug reaction (provided, of course, that the woman is not breastfeeding). A swelling of the lymph glands in the axilla may occur also in fat necrosis which follows a trauma to the breast. It is important to remember that if a woman has been suffering from a benign breast condition for some time and she develops a new lump, this should not be automatically assumed to be a development of the same benign
breast condition; benign and malignant breast conditions may coexist. The three most common benign breast conditions are cysts, fibroadenoma and papilloma. The first two belong to a group of benign breast conditions now called anomalies of normal development and involution (ANDI). Thus, the most common benign breast conditions are: • cysts • fibroadenoma • papilloma • breast pain and nodularity • duct ectasia • epithelial hyperplasia • lipomas • mastitis • galactocele • fat necrosis. Cysts Cysts, also called fibrocystic disease, are the commonest benign condition of the breast. It is estimated that 50% of women will have a cyst at some time or another in their life. Tied as women’s bodies are to cycles, it has been noticed that this condition tends to be at its worst for women in the northern hemisphere in the months between December and May when the ovaries are most active. It also affects the left breast more than the right. Cyst are most common in the 40–50 age group: they are usually
multiple and occur more frequently in the upper, outer quadrant of the breast (Liver channel in Chinese medicine). Fibrocystic disease is caused either by the breasts preparing for milk production too enthusiastically during the first half of the monthly cycle and/or failing to drain properly or blocking the accumulated fluid during the second half of the cycle. This production of excess fluid and the failure to drain it away properly causes the swelling. In some cases, the blockages can lead to the growth of one or more large fluidfilled cysts and in others to the growth of numerous small cysts. On palpation, granular masses with many small lumps with distinct margins may be felt (Phlegm with Qi stagnation in Chinese medicine). Cysts are more common in the last decade of a woman’s reproductive life. From the Chinese perspective, cysts are a typical mass from Phlegm. Fibroadenoma Fibroadenoma is the second most common benign breast disease after fibrocystic disease and accounts for about 12% of all palpable breast lump cases. It is more common in young women 20–25 years old. This condition manifests with single or multiple nodules, which are round or oval with distinct margins and a smooth surface. The nodules are painless, rubbery and mobile: in fact, they can be so mobile that they are difficult to feel as they slip under the fingers (Phlegm in Chinese medicine). Fibroadenomas are benign tumours of the fibrous and glandular tissue within a breast lobule. The lumps usually grow very slowly and finally shrink. From the point of view of Chinese medicine, fibroadenomas are usually caused by Blood stasis. Papilloma A duct papilloma is a small, benign growth of one of the milk ducts just under the nipple. It is so small that usually no lump can be felt; it is often discovered when pressure on the duct causes a yellow or blood-stained discharge from
the nipple. Papillomas are more common in older women; although benign, they can be a pre-cancerous condition and become malignant. The discharge is unilateral and should not be confused with a slight, milky, bilateral discharge which may occur in many other conditions. Pressure around the nipple will usually elicit a discharge and this indicates the location of the tumour. From the Chinese perspective, a papilloma is often due to Damp-Heat. Breast pain and nodularity Breast pain and nodularity form part of the ANDI classification of benign breast disease. A pre-menstrual breast tenderness and nodularity is very common and it is usually resolved with the onset of the period. In a very mild form, this can be considered as a normal response to hormonal cycles. In more severe forms, this problem may be due to the contraceptive pill or hormone replacement therapy. Mastalgia (breast pain) may also be unrelated to the menstrual cycle; this form occurs more frequently in older women. Mastalgia is probably due to abnormalities in the pulsatile secretions of gonadotropins and/or prolactin. From the Chinese perspective, breast pain and nodularity are usually due Qi stagnation or a combination of Qi stagnation and Phlegm. Duct ectasia This condition usually occurs only in older women, usually around the menopause. The milk ducts become inflamed and fill with a sticky, yellow, sometimes blood-stained secretion which is discharged from the nipple. Usually both breasts are affected and the area around the nipple may become red and itchy. From the Chinese point of view, duct ectasia is usually due to DampHeat or to Toxic-Heat.
Epithelial hyperplasia Epithelial hyperplasia is an excessive growth of the cells lining the milk ducts. It is more common around the time of menopause and its symptoms are lumpiness or a nipple discharge. Lipomas Lipomas are benign tumours of fat tissue. They may occur anywhere in the body. In the breast, they present with a fairly large and very soft lump under the skin. From the Chinese perspective, a lipoma is a classic type of mass from Phlegm. Mastitis Mastitis is an acute inflammation of the breast in reaction to trauma, infection or irritation. The breast becomes red, hot, swollen and painful (symptoms of Toxic-Heat in Chinese medicine). By far the most common cause of mastitis is an infection during breastfeeding. Galactocele A galactocele is a type of cyst that is due to the blockage of one of the ducts which becomes swollen with milk. Galactoceles are more common during pregnancy. Fat necrosis This occurs after a trauma to the breast that causes necrosis of fat cells. It manifests with a hard, irregular lump (stasis of Blood in Chinese medicine)
and sometimes also a lump under the axilla. Figure 59.8 summarizes the main conditions causing the three main symptoms of breast lump, nipple discharge and breast pain.
Figure 59.8 Main conditions in breast lump, nipple discharge and breast pain. Table 59.3 compares and differentiates cysts, fibroadenoma, breast pain and nodularity, and carcinoma. Table 59.3 Comparison of cysts, fibroadenoma, breast pain and nodularity, and carcinoma
End notes 1. Chinese Medicine Research Institute of the Guangzhou College of Traditional Chinese Medicine 1980 Concise Dictionary of Chinese Medicine (Jian Ming Zhong Yi Ci Dian
), People’s Health Publishing House, Beijing, p. 543..
2. Cited in Li Ai 1989 Essentials of Cancer Clinical Syndromes (Zhong Ai Lin Zheng Bei Yao
), People’s Health Publishing House, Beijing, p. 259..
3. Ibid., p. 259..
4. Ibid., p. 259..
5. Ibid., p. 259..
6. Ibid., p. 259..
7. Zhang Yuan Kai (ed.) 1985 Medical Collection of Four Families from Meng He (Meng He Si Jia Yi Ji
), Jiangsu Science Publishing House, Nanjing, p. 420..
8. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p. 120. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
9. Cited in Essentials of Cancer Clinical Syndromes, p. 259..
10. Ibid, p. 259..
11. 1981 Spiritual Axis (Ling Shu Jing
), People’s Health Publishing House, Beijing, p. 4. First published c. 100 BC..
12. 1979 The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen
), People’s Health Publishing House, Beijing, p. 225. First published c. 100 BC..
13. Zhang Jing Yue 1982 Classic of Categories (Lei Jing
), People’s Health Publishing Company, Beijing, p. 561. The Classic of Categories was first published in
1624..
14. Baum M, Saunders C, Meredith S 1994 Breast Cancer, Oxford University Press, Oxford, p. 128..
15. Wang Xue Tai (chief ed.) 1991 Medical Records of Famous Contemporary Chinese Acupuncturists (Zhong Guo Dang Dai Zhen Jiu Ming Jia Yi An
), Jilin Science and Technology Press, Jilin, p. 574..
16. Breast Cancer, pp 21–22..
CHAPTER 60 Abdominal Masses
AETIOLOGY 794 PATHOLOGY 794 IDENTIFICATION OF PATTERNS AND TREATMENT 794 QI MASSES 795 Liver-Qi stagnation 795 Retention of food and Phlegm 796 BLOOD MASSES 798 Stagnation of Qi and Blood 798 Stasis of Blood knotted in the Interior 799 Deficiency of Upright Qi and stasis of Blood 802 PROGNOSIS AND PREVENTION 803 WESTERN VIEW 804 APPENDIX I: OVARIAN CYSTS 805 Aetiology and pathology 805 Herbal treatment 806 APPENDIX II: CERVICAL DYSPLASIA 807 Treatment 809
Abdominal
masses
are
called
Ji
Ju
(
). Ji indicates actual abdominal masses which are immovable; if there is an associated pain, its location is fixed. These masses are due to stasis of Blood. I shall call them ‘Blood masses’. Ju indicates abdominal masses which come and go, do not have a fixed location and are movable; if there is an associated pain, it too comes and goes and changes location. Such masses are due to stagnation of Qi. I shall call them ‘Qi masses’. Actual abdominal lumps therefore pertain to the category of abdominal masses and specifically Ji masses, i.e. Blood masses. Another name for abdominal masses was Zheng Jia (
), Zheng being equivalent to Ji, i.e. actual, fixed masses, and Jia to Ju, i.e. non-substantial masses from stagnation of Qi. Zheng Jia is normally used in referring to abdominal masses that generally occur only in women; but they do occur in men as well, though rarely. Chapter 60 of the Simple Questions says: “Diseases of the Directing Vessel … in women are masses below the waist.”1 In this context, the Simple Questions uses the term Jia-Ju, i.e. non-substantial masses from Qi stagnation. The term Ji Ju appears in the Classic of Difficulties which clearly distinguishes the two types: Ji masses pertain to Yin and Ju masses to Yang … When Qi accumulates it gives rise to Ji masses, when it gathers it gives rise to Ju masses. Ji masses arise from the Yin organs and Ju masses from
the Fu organs. Ji masses have a fixed location and pain, and have boundaries above and below, and edges to the right and left [i.e. they have clearly defined borders]. Ju masses seem to start from nowhere, without a boundary above and below and with a moving pain.2 The Essential Prescriptions of the Golden Cabinet by Zhang Zhong Jing says: Ji masses arise from the Yin organs and they cannot be moved; Ju masses arise from the Yang organs, they come and go, the pain has no fixed location, and they are easier to treat.3 The General Treatise on the Aetiology and Symptoms of Diseases (AD 610) says: Abdominal masses are due to cold and heat not being regulated [i.e. exposure to extremes of weather], irregular diet and stagnation of the Qi of the Yin organs. If they do not move they are called Zheng; if they are movable they are called Jia. ‘Jia’ implies the meaning of ‘false’: this is because these masses can come and go and are not actual masses.4 Since the time of the Tang dynasty, eight types of women’s abdominal masses have been described, i.e. yellow, green, dry, blood, fat, fox, snake and turtle mass.
Aetiology
Emotional strain Emotional strain is the most common cause of the formation of abdominal masses. Anger, especially when repressed, frustration, resentment, hatred, worry and guilt can all lead to stagnation of Liver-Qi and, in the long run, to stasis of Liver-Blood. The Liver channel plays an important role in the movement of Qi in the lower abdomen and, in women, Liver-Blood plays a paramount role in the circulation of Blood in this area. Irregular diet Diet is another important aetiological factor in the formation of abdominal masses. Irregular eating or the excessive consumption of cold and raw foods may lead to the formation of Cold in the lower abdomen. Cold contracts and naturally interferes with the circulation of Qi and, especially, Blood; it may lead to stasis of Blood. Excessive consumption of greasy foods, on the other hand, impairs the Spleen and may lead to the formation of Dampness and Phlegm, which can settle in the lower abdomen and bring about abdominal masses. There is also a close interaction between Phlegm and stasis of Blood so that one may lead to or aggravate the other. External pathogenic factors External pathogenic factors are less important in the aetiology of abdominal masses. The most important pathogenic factor is external Cold which can invade the lower abdomen and impair the circulation of Blood eventually leading to stasis of Blood. Chapter 66 of the Spiritual Axis says: “Ji masses
are due to Cold.”5 External Dampness may invade the channels of the legs and then creep up them to settle in the lower abdomen where, in the long run, it transforms into Phlegm and may give rise to abdominal masses.
Pathology As for pathology, abdominal masses are always characterized by either stagnation of Qi or stasis of Blood, the former being non-substantial and the latter substantial masses. In addition to stagnation, there may also be Phlegm. However, in all cases of abdominal masses there is always an underlying deficiency of Qi. Deficient Qi fails to transport and transform and, leading to stagnation of Qi and Blood, it allows masses to form. Masses from stagnation of Qi come and go, are movable on palpation and change location. If there is pain, the pain has no fixed location and is accompanied by a pronounced feeling of distension. Masses from stasis of Blood are fixed in location, they are not movable on palpation and feel quite hard. If there is pain, it is fixed and stabbing in character. Masses from Phlegm feel soft on palpation and have a fixed location. There is usually no pain.
Identification of patterns and treatment The treatment of abdominal masses is always based on moving Qi and Blood. However, there are other factors to take into account depending on the stage of the disease. In the beginning stages of the condition, the pathogenic factor (stagnation of Qi or stasis of Blood) is relatively weak and the body’s Qi relatively strong. In the middle stages, the body’s Qi is weakening and the pathogenic factor becoming more prominent. In the late stages, the pathogenic factor is very prominent and the masses very developed while the body’s Qi is very weak. Thus, irrespective of the pathogenic factor involved, the principle of treatment must be guided by the stage of the condition: • In the beginning stages, primarily resolve the pathogenic factor, i.e. move Qi, invigorate Blood and resolve Phlegm. • In the middle stages, resolve the pathogenic factor and tonify the body’s Qi simultaneously. • In the late stages, primarily tonify the body’s Qi and secondarily resolve the pathogenic factor. Also, when moving Qi in Qi masses, the treatment principle is to move Qi primarily and invigorate Blood secondarily. In Blood masses, the treatment principle is to invigorate Blood, eliminate stasis, ‘break’ Blood primarily and move Qi secondarily. Thus, the formulae given below are only a guideline. The approach adopted should be chosen according to the pattern of the disease, but the formulae must be modified in every case according to its stage. Furthermore, all prescriptions indicated below should be modified with the addition of ‘softening’ herbs, i.e. herbs which soften masses: this is particularly necessary for masses from stasis of Blood or Phlegm. Softening herbs are:
• Yi Yi Ren Semen Coicis • Zhe Bei Mu Bulbus Fritillariae thunbergii • Hai Zao Sargassum • Kun Bu Thallus Eckloniae • Chuan Shan Jia Squama Manitis • Xia Ku Cao Spica Prunellae • Gui Ban Plastrum Testudinis • Mu Li Concha Ostreae • Jiang Can Bombyx batryticatus • Bie Jia Carapax Trionycis • Wa Leng Zi Concha Arcae • Hai Dai Thallus Laminariae. As for the relative application of acupuncture and herbal medicine, especially for Blood masses, the herbal treatment is primary in relation to acupuncture. The patterns discussed are: Qi masses
• Liver-Qi stagnation. • Retention of food and Phlegm. Blood masses
• Stagnation of Qi and Blood. • Stasis of Blood knotted in the Interior. • Deficiency of Upright Qi and stasis of Blood.
Qi masses
Liver-Qi stagnation
Clinical manifestations
Movable abdominal masses which come and go, abdominal distension and pain which come and go with the masses, a feeling of discomfort in the hypochondrium, depression, moodiness, irritability, alternation of constipation and diarrhoea. Tongue: the body colour may be normal or slightly Red on the sides. Pulse: Wiry. Treatment principle
Pacify the Liver, eliminate stagnation, move Qi and dissolve masses. Acupuncture
G.B.-34 Yanglingquan, Ren-6 Qihai, LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-14 Siman, Ren-6 Qihai. Reducing or even method. Explanation
– G.B.-34 and Ren-6, in combination, move Liver-Qi in the lower abdomen.
– LIV-3 moves Liver-Qi. – P-6 indirectly moves Liver-Qi and calms the Mind. – T.B.-6 moves Liver-Qi. – SP-6 moves Qi and soothes the Liver. Specifically, it treats the lower abdomen. – LU-7 and KI-6 are used in women to open the Directing Vessel and move Qi in the lower abdomen. The Directing Vessel is specific for abdominal masses. – KI-14 moves Qi and Blood in the lower abdomen. – Ren-6 moves Qi in the lower abdomen. Herbal treatment
a Prescription
– XIAO YAO SAN – Free and Easy Wanderer Powder Explanation
This formula, which has already been explained, moves Liver-Qi in the lower abdomen. Modifications
• In order to enhance the formula’s moving-Qi effect, add Xiang Fu Rhizoma Cyperi and Mu Xiang Radix Aucklandiae. • If the stagnation and masses are very pronounced, add Yan Hu Suo Rhizoma Corydalis and Yu Jin Radix Curcumae. • In an old person, add Dang Shen Radix Codonopsis or Ren Shen Radix Ginseng. • If, in addition to stagnation of Qi, there is some Dampness and Phlegm (a very common situation), increase the dosage of Fu Ling, reduce that of Dang Gui and add Sha Ren Fructus Amomi, Cang Zhu Rhizoma Atractylodis and Huang Bo Cortex Phellodendri. b Prescription
– XIANG LENG WAN – Aucklandia-Sparganium Pill Explanation
– Mu Xiang, Zhi Ke, Chuan Lian Zi and Qing Pi move Qi and eliminate stagnation. – Ding Xiang and Xiao Hui Xiang warm the channels and scatter Cold in the abdomen. – San Leng and E Zhu invigorate Blood, eliminate stasis and ‘break’ Blood. The present formula differs from the previous one in three respects: it is
much stronger in its action and better at dissolving masses, it invigorates Blood and it scatters Cold. It is therefore especially indicated when Qi stagnation is associated with Cold and the tongue is Pale and the pulse is Tight. Modifications
• If the periods are late and scanty, add Dang Gui Radix Angelicae sinensis and Chuan Xiong Rhizoma Chuanxiong. • If there is lower abdominal pain and a feeling of masses, remove Ding Xiang and add Li Zhi He Semen Litchi. • If the abdominal pain is accompanied by a white vaginal discharge, add Pu Gong Ying Herba Taraxaci. Women’s Treasure remedy
– FREEING THE MOON This remedy pacifies the Liver, moves Qi, eliminates stagnation, tonifies Spleen-Qi, nourishes Liver-Blood and settles the Ethereal Soul. The tongue presentation appropriate to this remedy is a body with slightly Pale sides. Summary Liver-Qi stagnation
Clinical manife stations
Movable abdominal masses which come and go, abdominal distension and pain which come and go with the masses, a feeling of discomfort in the
hypochondrium, depression, moodiness, irritability, alternation of constipation and diarrhoea. Tongue: the body colour may be normal or slightly Red on the sides. Pulse: Wiry. Tre atme nt principle
Pacify the Liver, eliminate stagnation, move Qi and dissolve masses. Acupuncture
G.B.-34 Yanglingquan, Ren-6 Qihai, LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-14 Siman, Ren-6 Qihai. Reducing or even method. He rbal tre atme nt
Prescriptions
• XIAO YAO SAN Free and Easy Wanderer Powder • XIANG LENG WAN Aucklandia-Sparganium Pill Women’s Treasure re me dy
• FREEING THE MOON
Retention of food and Phlegm
Clinical manifestations
Soft abdominal masses, which may be strip-like in shape, abdominal distension, constipation or diarrhoea, poor appetite, nausea and a feeling of fullness. Tongue: Swollen, with a sticky coating which is thicker on the root.
Pulse: Slippery. Treatment principle
Resolve food retention, regulate the bowels, move Qi and resolve Phlegm. Acupuncture
Ren-12 Zhongwan, BL-20 Pishu, Ren-10 Xiawan, Ren-6 Qihai, L.I.-4 Hegu, ST-40 Fenglong, ST-36 Zusanli, BL-21 Weishu, ST-34 Liangqiu, SP6 Sanyinjiao. Reducing or even method, except on Ren-12 and BL-20 which should be reinforced. Explanation
– Ren-12 and BL-20 tonify the Spleen to resolve Phlegm and promote transformation of food. – Ren-10 promotes the descending of Stomach-Qi. – Ren-6 moves Qi in the lower abdomen. – L.I.-4 regulates the ascending and descending of Qi in the Stomach. – ST-40 resolves Phlegm and promotes the descending of Stomach-Qi. – ST-36 promotes the descending of Stomach-Qi and relieves constipation. If there is diarrhoea, replace this with ST-37 Shangjuxu. – BL-21 and ST-34, Back-Transporting and Accumulation points respectively, promote the descending of Stomach-Qi.
– SP-6 resolves Dampness and moves Qi in the lower abdomen. Herbal treatment
a Prescription
– LIU MO TANG – Six Ground-Herbs Decoction Explanation
This formula moves Qi and resolves food retention in the lower abdomen. It is particularly used if there is constipation. – Mu Xiang, Wu Yao and Chen Xiang regulate Qi, eliminate stagnation and make Qi descend. – Da Huang, Bing Lang and Zhi Shi move downwards and make Qi descend. Modifications
• If there is diarrhoea, remove Da Huang and add Bai Zhu Rhizoma Atractylodis macrocephalae and Sha Ren Fructus Amomi. • To enhance the Phlegm-resolving effect of this formula, add Ban Xia Rhizoma Pinelliae preparatum, Fu Ling Poria, Chen Pi Pericarpium Citri reticulatae and Zhe Bei Mu Bulbus Fritillariae thunbergii.
• If the retention of food is pronounced, add Ping Wei San Balancing the Stomach Powder plus Shan Zha Fructus Crataegi and Shen Qu Massa medicata fermentata. • If there is deficiency of Qi (which is always present in chronic conditions), use Xiang Sha Liu Jun Zi Tang Aucklandia-Amomum Six Gentlemen Decoction, some herbs to move Qi in the lower abdomen, such as Xiang Fu Rhizoma Cyperi, and some to resolve Phlegm and lumps, such as Zhe Bei Mu Bulbus Fritillariae thunbergii. b Prescription
– CANG FU DAO TAN WAN Variation – Atractylodes-Cyperus Conducting Phlegm Pill Variation Explanation
– Fu Ling, Chen Pi, Ban Xia and Dan Nan Xing resolve Dampness and Phlegm. Ban Xia was added to the original prescription. – Xiang Fu and Zhi Ke move Qi and eliminate stagnation which will help to resolve Phlegm. – Shen Qu and Sheng Jiang promote digestion and dissolve food accumulation, which will help to resolve Phlegm. – Gan Cao harmonizes. c Prescription
– KAI YU ZHENG YUAN SAN – Opening Stagnation Upright Original [Qi] Powder Explanation
– Bai Zhu tonifies Qi and dries Dampness. – Chen Pi, Fu Ling and Sha Ren resolve Dampness. – Qing Pi and Xiang Fu move Qi and eliminate stagnation. – Shan Zha, Shen Qu and Mai Ya dissolve food accumulation and help to resolve Phlegm. – Hai Fen and Jie Geng resolve Phlegm and soften and dissolve masses. If Hai Fen is unavailable, it can be replaced with Mu Li Concha Ostreae. – Yan Hu Suo moves Qi and invigorates Blood. Summary Re te ntion of food and Phle gm
Clinical manifestations
Soft abdominal masses, which may be strip-like in shape, abdominal distension, constipation or diarrhoea, poor appetite, nausea and a feeling of fullness. Tongue: Swollen, with a sticky coating which is thicker on the root. Pulse: Slippery. Treatment principle
Resolve food retention, regulate the bowels, move Qi and resolve Phlegm.
Acupuncture
Ren-12 Zhongwan, BL-20 Pishu, Ren-10 Xiawan, Ren-6 Qihai, L.I.-4 Hegu, ST-40 Fenglong, ST-36 Zusanli, BL-21 Weishu, ST-34 Liangqiu, SP6 Sanyinjiao. Reducing or even method, except on Ren-12 and BL-20 which should be reinforced. Herbal treatment
Prescriptions • LIU MO TANG Six Ground-Herbs Decoction • CANG FU DAO TAN WAN Variation Atractylodes-Cyperus Conducting Phlegm Pill Variation • KAI YU ZHENG YUAN SAN Opening Stagnation Upright Original [Qi] Powder
Blood masses
Stagnation of Qi and Blood
Clinical manifestations
Hard and immovable abdominal masses, abdominal distension and pain, late periods. Tongue: Purple. Pulse: Wiry. Treatment principle
Move Qi, invigorate Blood, remove obstructions from the Connecting channels and dissolve masses. Acupuncture
G.B.-34 Yanglingquan, Ren-6 Qihai, LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-10 Xuehai, BL-17 Geshu. Reducing or even method. Explanation
– G.B.-34 and Ren-6 in combination, move Liver-Qi in the lower abdomen. – LIV-3 moves Liver-Qi and Liver-Blood.
– P-6 indirectly moves Liver-Qi and calms the Mind. – T.B.-6 moves Liver-Qi. – SP-6 moves Blood and soothes the Liver. Specifically, it treats the lower abdomen. – LU-7 and KI-6 are used in women to open the Directing Vessel and move Qi in the lower abdomen. The Directing Vessel is specific for abdominal masses. – SP-10 and BL-17 invigorate Blood. Herbal treatment
Prescription
– JIN LING ZI SAN and SHI XIAO SAN – Toosendan Powder and Breaking into a Smile Powder Explanation
The first formula (composed of the first two herbs) moves Liver-Qi and Liver-Blood and the second one invigorates Blood and stops pain in the lower abdomen. b Prescription
– DA QI QI TANG
– Big Seven Qi Decoction Explanation
This formula is selected if the stagnation of Qi and Blood in the lower abdomen derives from, or is associated with, Cold in the abdomen. – Qing Pi, Chen Pi, Xiang Fu, Jie Geng and Huo Xiang move Qi and harmonize the Stomach. – Rou Gui and Yi Zhi Ren warm the Lower Burner and scatter Cold. – San Leng and E Zhu ‘break’ Blood and dissolve masses. – Gan Cao, Sheng Jiang and Da Zao harmonize. Women’s Treasure remedy
– FREEING CONSTRAINT This remedy pacifies the Liver, moves Qi, eliminates stagnation, invigorates Blood, eliminates stasis and settles the Ethereal Soul. The tongue presentation appropriate to this remedy is a body with Red or Purple sides. Summary Stagnation of Qi and Blood
Clinical manife stations
Hard and immovable abdominal masses, abdominal distension and pain, late periods. Tongue: Purple. Pulse: Wiry. Tre atme nt principle
Move Qi, invigorate Blood, remove obstructions from the Connecting channels and dissolve masses. Acupuncture
G.B.-34 Yanglingquan, Ren-6 Qihai, LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-10 Xuehai, BL-17 Geshu. Reducing or even method. He rbal tre atme nt
Prescriptions
• JIN LING ZI SAN and SHI XIAO SAN Toosendan Powder and Breaking into a Smile Powder • DA QI QI TANG Big Seven Qi Decoction Women’s Treasure re me dy
• FREEING CONSTRAINT
Stasis of Blood knotted in the Interior
Clinical manifestations
Hard, immovable and painful masses in the abdomen, dark and withered complexion, dry skin, feeling cold, amenorrhoea, painful periods, late periods. Tongue: Purple. Pulse: Choppy. This is a condition of severe and chronic stasis of Blood with obvious masses. The dark and withered complexion reflects stasis of Blood and the
cold feeling is due not to internal Cold, but to poor circulation of Blood. The skin is dry because stagnant Blood is pooled in the lower abdomen and does not moisten and nourish the skin. Treatment principle
‘Break’ Blood, eliminate stasis, soften hardness, dissolve masses, regulate Spleen and Stomach. Acupuncture
G.B.-34 Yanglingquan, Ren-6 Qihai, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, BL-17 Geshu, ST-29 Guilai, LIV-3 Taichong, SP-6 Sanyinjiao, LIV-8 Ququan, ST-36 Zusanli and BL-20 Pishu. Reducing or even method, except on LIV-8, ST-36 and BL-20 which should be reinforced. Explanation
– G.B.-34 and Ren-6 move Qi and Blood in the abdomen. – SP-4 and P-6 open the Penetrating Vessel and regulate Blood as this Extraordinary Vessel is the Sea of Blood and regulates all Blood-Connecting channels. – SP-10 and BL-17 invigorate Blood. – ST-29 invigorates Blood in the lower abdomen. – LIV-3 and SP-6 invigorate Liver-Blood. – LIV-8, ST-36 and BL-20 nourish Blood.
Herbal treatment
a Prescription
– GE XIA ZHU YU TANG – Eliminating Stasis below the Diaphragm Decoction Explanation
This formula is specific to invigorate Blood, eliminate stasis, stop pain and dissolve masses in the lower abdomen. – Dang Gui, Chi Shao, Chuan Xiong, Hong Hua and Tao Ren (a modified version of Tao Hong Si Wu Tang Persica-Carthamus Four Substances Decoction) invigorate Liver-Blood. – Wu Ling Zhi and Yan Hu Suo ‘break’ Blood, eliminate stasis, stop pain and dissolve masses. – Zhi Ke, Xiang Fu and Wu Yao move Qi which helps to invigorate Blood. – Dan Pi clears any Liver-Heat which may derive from the hot herbs within the formula. – Gan Cao harmonizes and stops pain. b Prescription
– GUI ZHI FU LING WAN
– Ramulus Cinnamomi-Poria Pill Explanation
– Gui Zhi and Fu Ling in combination penetrate the channels and blood vessels of the Lower Burner so as to allow the Blood-invigorating herbs to reach that area. – Chi Shao, Mu Dan Pi and Tao Ren invigorate Blood, eliminate stasis and dissolve masses. Modifications
The following variations apply to both the above formulae. • To enhance the mass-dissolving effect, add San Leng Rhizoma Sparganii, E Zhu Rhizoma Curcumae and Ze Lan Herba Lycopi, herbs which ‘break’ Blood and dissolve masses. • To soften hardness, a method of treatment which is necessary to dissolve masses, add one or two of the following herbs according to symptoms and signs: Zhe Bei Mu Bulbus Fritillariae thunbergii, Bie Jia Carapax Trionycis, Mu Li Concha Ostreae, Chuan Shan Jia Squama Manitis, Yi Yi Ren Semen Coicis, Xia Ku Cao Spica Prunellae, Hai Zao Sargassum or Kun Bu Thallus Eckloniae. • If there is a deficiency of Blood, eliminate Yan Hu Suo, do not use Blood-‘breaking’ herbs, increase Dang Gui and add Shu Di Huang Radix Rehmanniae preparata. • If the periods are heavy, add Shi Xiao San Breaking into a Smile Powder.
• If there is a vaginal discharge, add Yi Yi Ren Semen Coicis and Bai Zhi Radix Angelicae dahuricae. • If there is severe abdominal pain, add Yan Hu Suo Rhizoma Corydalis and Ze Lan Herba Lycopi. c Prescription
– EMPIRICAL PRESCRIPTION Explanation
– Dang Gui, Chi Shao, Tao Ren and Hong Hua invigorate Blood and eliminate stasis. – San Leng, Di Bie Chong and E Zhu ‘break’ Blood and dissolve masses. – Su Mu invigorates Blood and dissolves swelling. – Shi Jian Chuan resolves Phlegm and dissolves swelling. – Shan Zha dissolves food accumulation and promotes digestion. It is added to counteract the strong action of the herbs that ‘break’ Blood. Modifications
• If there is also Phlegm, add Fu Ling Poria, Cang Zhu Rhizoma Atractylodis, Chen Pi Pericarpium Citri reticulatae, Zhe Bei Mu Bulbus Fritillariae thunbergii and Hai Zao Sargassum. • If there are pronounced signs of deficiency, add Dang Shen Radix
Codonopsis and Huang Qi Radix Astragali. • If there are Cold signs, add Xiao Hui Xiang Fructus Foeniculi. • If there are signs of Yin deficiency, add Gui Ban Plastrum Testudinis, Bie Jia Carapax Trionycis and Sheng Di Huang Radix Rehmanniae. Table 60.1 compares and contrasts the above three formulae. Table 60.1 Comparison of formulae for abdominal masses from Blood stasis
Women’s Treasure remedy
– HARMONIZING THE MOON This remedy is a variation of the formula Gui Zhi Fu Ling Wan Ramulus Cinnamomi-Poria Pill which invigorates Blood, eliminates stasis and dissolves masses. The tongue presentation appropriate to this remedy is a Purple body. Summary Stasis of Blood knotted in the Interior
Clinical manife stations
Hard, immovable and painful masses in the abdomen, dark and withered complexion, dry skin, feeling cold, amenorrhoea, painful periods, late periods. Tongue: Purple. Pulse: Choppy. Tre atme nt principle
‘Break’ Blood, eliminate stasis, soften hardness, dissolve masses, regulate Spleen and Stomach. Acupuncture
G.B.-34 Yanglingquan, Ren-6 Qihai, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, BL-17 Geshu, ST-29 Guilai, LIV-3 Taichong, SP-6 Sanyinjiao, LIV-8 Ququan, ST-36 Zusanli and BL-20 Pishu. Reducing or even method, except on LIV-8, ST-36 and BL-20 which should be reinforced. He rbal tre atme nt
Prescriptions
• GE XIA ZHU YU TANG Eliminating Stasis below the Diaphragm Decoction • GUI ZHI FU LING WAN Ramulus Cinnamomi-Poria Pill • EMPIRICAL PRESCRIPTION Women’s Treasure re me dy
• HARMONIZING THE MOON
Case history
A 45-year-old woman had been suffering from a myoma in the uterus which was about 2 cm in diameter. Her lower abdomen was generally distended and her periods were rather heavy, with dark, clotted blood. Apart from this, she was in good health. Her tongue was Purple on the sides (Plate 11) and her pulse was slightly Firm (i.e. Wiry at the deep level). Diagnosis
This myoma was due to stasis of Blood of the Liver: this is confirmed by the Purple colour on the sides of her tongue and the dark colour of her menstrual blood. Treatment principle
The treatment principle followed was to move Liver-Blood and eliminate stasis in the uterus. This patient was treated only with herbs. Herbal treatment
The formula used was a variation of Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction: • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Chi Shao Radix Paeoniae rubra 6 g • Hong Hua Flos Carthami 6 g • Tao Ren Semen Persicae 6 g • Wu Ling Zhi Faeces Trogopteri 4 g • Yan Hu Suo Rhizoma Corydalis 6 g • Xiang Fu Rhizoma Cyperi 3 g
• Zhi Ke Fructus Aurantii 6 g • Wu Yao Radix Linderae 6 g • Mu Dan Pi Cortex Moutan 6 g • Gan Cao Radix Glycyrrhizae 3 g • Yi Yi Ren Semen Coicis 20 g • E Zhu Rhizoma Curcumae 9 g Explanation
All the herbs but the last two form the Ge Xia Zhu Yu Tang with the dosages of some of the herbs reduced. • Yi Yi Ren was added to soften the mass. • E Zhu was added to ‘break’ Blood.
This formula was given for 9 months, with slight variations, and produced a dispersal of the myoma. Case history A 27-year-old woman had been diagnosed as having a large cyst on one ovary (7.5 cm in diameter), a myoma between the uterus and the ovary, and endometriosis. This caused her some abdominal pain and discomfort. The abdomen felt hard on palpation. Her periods were painful, sometimes heavy and sometimes scanty, sometimes stopping and starting, and the menstrual blood was dark with clots. She had an excessive vaginal discharge, yellow in colour. Her tongue was Pale-Purple, Swollen and with a sticky coating all over which was yellow on the root (Plate 12). Her pulse was Slippery, slightly Firm (Wiry at the deep level), Deep, and Weak on both Rear positions. Diagnosis
The ovarian cyst and myoma were due to stasis of Blood, but there was also Damp-Heat in the Lower Burner contributing to the stagnation in that area. Underlying these two conditions, there was also a deficiency of the Kidneys. Treatment principle
This patient’s condition was very complex due to the presence of endometriosis, ovarian cyst and uterine myoma. The ovarian cyst was too large to be dissolved with herbal treatment but she did not want an operation. I therefore agreed to treat her in order first of all to tonify the general body condition, second to treat the endometriosis, and third to attempt to shrink the cyst. The treatment principle was to move Liver-Blood, eliminate stasis in the Uterus, resolve Damp-Heat and tonify the Kidneys. She was treated only with herbs. Herbal treatment
The formula used was a variation of the two formulae Gui Zhi Fu Ling Wan Ramulus Cinnamomi-Poria Pill and Si Miao San Four Wonderful Powder: • Gui Zhi Ramulus Cinnamomi 6 g • Fu Ling Poria 9 g • Chi Shao Radix Paeoniae rubra 6 g • Mu Dan Pi Cortex Moutan 6 g • Tao Ren Semen Persicae 6 g • Huang Bo Cortex Phellodendri 6 g • Cang Zhu Rhizoma Atractylodis 6 g • Yi Yi Ren Semen Coicis 10 g
• Chuan Niu Xi Radix Cyathulae 6 g • Dang Gui Radix Angelicae sinensis 6 g • E Zhu Rhizoma Curcumae 4 g • Tu Si Zi Semen Cuscutae 6 g • Lu Lu Tong Fructus Liquidambaris 4 g Explanation
The first nine herbs constitute the two root formulae. • Dang Gui was added to nourish and move Blood. • E Zhu strongly moves Blood and dissolves masses. • Tu Si Zi was added to tonify Kidney-Yang. • Lu Lu Tong moves Qi and Blood, resolves Dampness and dissolves masses. It is specific for ovarian cysts.
This formula was used, with some variations, for about 9 months. After this time, her condition improved insofar as her periods were more regular, not painful and the blood was not clotted. The ovarian cyst also was reduced in size. Afterwards, the prescription was changed, introducing more tonifying herbs such as Bai Zhu Rhizoma Atractylodis macrocephalae and Dang Shen Radix Codonopsis. Deficiency of Upright Qi and stasis of Blood
Clinical manifestations
Hard and painful masses, sallow complexion, loss of weight, loss of appetite,
exhaustion. Tongue: Purple. Pulse: Fine and Choppy. This is a chronic condition of severe Blood stasis which has led to the formation of masses with an underlying deficiency of the body’s Qi. From the point of view of Western medicine, it could correspond to carcinoma. Treatment principle
Strongly tonify Qi and Blood, move Blood and eliminate stasis. Acupuncture
Ren-4 Guanyuan, Ren-6 Qihai, Ren-8 Shenque, BL-23 Shenshu, BL-20 Pishu, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-10 Xuehai, BL-17 Geshu. Even method on the last two points and reinforcing method on all the others. Moxa should be used on Ren-4, Ren-6 or Ren-8. Explanation
– Ren-4 nourishes Blood and Yin and tonifies the Original Qi. – Ren-6 tonifies Qi. – Ren-8 tonifies the Original Qi and Essence. – BL-23, BL-20, ST-36, SP-6 and KI-3 tonify Spleen and Kidneys. – LU-7 and KI-6 open the Directing Vessel, move Qi in the abdomen and dissolve abdominal masses. – SP-10 and BL-17 invigorate Blood.
Herbal treatment
Prescription
– BA ZHEN TANG and HUA JI WAN – Eight Precious Decoction and Resolving Blood Masses Pill Explanation
The first eight herbs constitute the Eight Precious Decoction which tonifies Qi and Blood. – San Leng, E Zhu, Wu Ling Zhi and Su Mu invigorate Blood, eliminate stasis and dissolve masses. The first two herbs are stronger and they ‘break’ Blood. – Xiang Fu and Bing Lang move Qi to help to move Blood. – Xiong Huang opens the orifices and helps to dissolve masses. This is a toxic substance and it can be omitted: it is listed here as it is in the original prescription. It could be replaced with Shi Chang Pu Rhizoma Acori tatarinowii (6 g). – Wa Leng Zi, A Wei and Hai Fu Shi soften hardness and dissolve masses. Modifications
• If there is Yin deficiency, add Sheng Di Huang Radix Rehmanniae and Bei Sha Shen Radix Glehniae.
Women’s Treasure remedies
– PRECIOUS SEA and STIR FIELD OF ELIXIR The first remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. It has been modified with the addition of Kidney tonics. The second remedy is a variation of the formula Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction which invigorates Blood and eliminates stasis. The tongue presentation appropriate to these two remedies is a Bluish-Purple body. Summary Deficiency of Upright Qi and stasis of Blood
Clinical manife stations
Hard and painful masses, sallow complexion, loss of weight, loss of appetite, exhaustion. Tongue: Purple. Pulse: Fine and Choppy. Tre atme nt principle
Strongly tonify Qi and Blood, move Blood and eliminate stasis. Acupuncture
Ren-4 Guanyuan, Ren-6 Qihai, Ren-8 Shenque, BL-23 Shenshu, BL-20 Pishu, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-10 Xuehai, BL-17 Geshu. Even method on the last two points and reinforcing method on all the others. Moxa should be used on Ren-4, Ren-6 or Ren-8. He rbal tre atme nt
Prescription
• BA ZHEN TANG and HUA JI WAN Eight Precious Decoction and Resolving Blood Masses Pill Women’s Treasure re me die s
• PRECIOUS SEA • STIR FIELD OF ELIXIR
Prognosis and prevention The subject of prognosis in abdominal masses cannot be separated from that of Western diagnosis. In the case of abdominal masses perhaps more than in any other, a Western diagnosis is essential. Although Chinese medicine can be effective in treating masses, we should never treat them blindly without first establishing what they really are. As explained below, from a Western perspective masses can be due to many different pathologies: enlarged organs, cysts, myomas (‘fibroids’), spastic colon, masses of faeces or malignant tumours. The treatment and prognosis in each of these cases will obviously differ enormously. Furthermore, in addition to the above types of masses, one should add those that are non-substantial, i.e. due to Qi stagnation. First of all, to make a prognosis from a Chinese perspective, we must differentiate between masses due to Qi and masses due to Blood accumulation: the former are much easier to disperse. Acupuncture can be used to disperse Qi masses but Blood masses are better treated with both acupuncture and herbal medicine. From a Western perspective, to mention the most common causes of masses, those due to a spasm in the colon or to masses of faeces are the easiest to resolve. Ovarian cysts and uterine myomas can be dispersed only if they are very small (not more than 2 cm in diameter). There are three types of myomas: subserous (on the outside wall of the uterus), interstitial (within the wall of the uterus) and submucous (on the inside of the uterus, see below). The interstitial myomas are the easiest (or better, the least difficult) to disperse, and the subserous ones the most difficult (see Ch. 67). As for malignant tumours of the abdomen, Chinese herbs must be used in conjunction with Western treatment. The prognosis varies according to the organ involved and the stage of the carcinoma: however, the differentiation and treatment outlined in this chapter do not apply to malignant tumours as their treatment needs a different approach. Of all malignant tumours, lymphomas respond best to treatment with Chinese herbs. Finally, masses due to enlargement of organs can be dispersed by a
combination of both acupuncture and herbs. In all the above cases, treatment will necessarily take a long time and patience is required from both the practitioner and the woman. As for prevention, any patient who is prone to abdominal masses or has been cured of one should follow certain precautions: first of all, avoid the excessive consumption of cold energy foods, and especially cold drinks, as these tend to lead to stasis in the lower abdomen (an important recommendation especially in countries such as the USA where people tend to consume large quantities of iced drinks). During the menstrual period and after childbirth, women should carefully avoid exposure to cold or dampness (e.g. wearing a wet swimming suit on a windy beach, sitting on damp grass, etc.). Women who practise meditation concentrating the breath in the lower abdomen should do so in a standing rather than sitting position: this practice in a sitting position tends to increase or cause stagnation in the lower abdomen in women. Moderate exercise is vital to keep Qi moving in the lower abdomen. Even just brisk walking in the open air (although not in a city centre!) is an effective exercise. Tai Ji Quan is an excellent exercise to remove or prevent stagnation in the lower abdomen, and it is particularly suited to those over 40. Finally, women should take care not to catch cold after sexual activity and also to avoid sex during the periods: both these activities lead to stasis of Blood in the lower abdomen.
Western view Masses which are sufficiently large or sufficiently close to the abdominal wall cause increased resistance to palpation. Obviously, only Blood masses may correspond to actual abdominal masses from the point of view of Western medicine. Qi masses, by their very nature, are not actual, physical masses. From a Western diagnostic perspective, it is very important to establish whether a mass is in the abdominal wall or the abdominal cavity. This distinction can be easily made with a simple test. With the patient supine, ask her to raise the head in order to tense the abdominal muscles. If the mass is in the abdominal cavity, it will be shielded by the tensed muscles and will cease to be palpable. If the mass is in the abdominal wall, it will still be felt through the tensed abdominal muscles. Myoma
A myoma is a solid, well-defined benign growth in the myometrium. Myomas are by far the most common tumours of the uterus: it is estimated that 20% of all women over 35 years harbour them.6 Often called fibroids, this is a misnomer as they are composed of smooth muscle tissue. Myomas vary in size ranging from microscopic to enormous proportions. They may be single or, more frequently, multiple. There are different types of myomas (Fig. 60.1): • Submucous myomas grow from the endometrium on the inner wall of the uterus. If they have a pedicle they are called pedunculated. • Interstitial myomas grow within the muscular wall of the uterus. • Subserous myomas grow on the outer wall of the uterus, underneath the peritoneum.
Figure 60.1 Types of myoma. Small myomas are often symptomless. When they reach a certain size they become palpable and, if large, the mass can be seen bulging from the abdomen. Excessive uterine bleeding is a common consequence of myomas: this is due to expansion of the endometrium from pressure of the myoma with consequent increased amount of endometrial tissue. Myomas do not usually cause pain; however, if there is torsion of their pedicle they may cause dysmenorrhoea. Large myomas may press on the bladder and cause urinary symptoms such as bladder irritability, increased frequency or dysuria. Myomas are discussed in Chapter 67. Ovarian cysts
Ovarian cysts may be physiological (called functional): they occur when an enlarged follicle fails to rupture. A functional ovarian cyst resolves by itself and requires no treatment. Neoplastic cysts are new growths not arising from normal physiological processes. There are very many types of neoplastic cysts and their classification is extremely complex. The reader is therefore referred to one of the gynecology textbooks mentioned in the bibliography. Polycystic ovary disease
Polycystic ovary disease is characterized by the presence of numerous small cystic follicles varying in size but seldom exceeding 0.5 cm in diameter. There is failure of the ovarian enzyme systems which are necessary for the normal production of oestrogens. The patient is usually obese and complains of amenorrhoea, infertility and hirsutism (excessive body hair growth). Polycystic ovary syndrome is discussed in Chapter 66.
Endometriosis
Endometriosis does not usually cause an abdominal mass, but it can do so when there is a build up of scar tissue and displacement of the uterus. Endometriosis is discussed in Chapter 65. Carcinoma of the cervix
Carcinoma of the cervix causes an abdominal mass only when it is invasive and it has grown beyond the limits of the cervix. The earliest sign of cervical carcinoma is vaginal bleeding, at first irregular and brought on by coitus, micturition or defaecation. Later, the bleeding may become continuous. When the growth ulcerates and becomes infected, a think, blood-stained discharge appears, later becoming offensive. The median age of onset of invasive cervical cancer is 45 years. Endometrial carcinoma
The peak incidence of endometrial carcinoma is at 61 years and 75% of cases occur after the menopause. Various risk factors have been identified, all of which relate to excessive exposure of the endometrium to oestrogen; these include obesity, late menopause, polycystic ovary syndrome, oestrogen-secreting ovarian tumours and exogenous oestrogen administration (as in the contraceptive pill and hormone replacement therapy). An abdominal mass (usually with pain) is a late symptom of endometrial carcinoma. In the initial stages, the most common sign is vaginal bleeding usually occurring after the menopause. At first the bleeding is slight and intermittent; later it may become continuous and heavy. In pre-menopausal women, there is irregular inter-menstrual bleeding. In the early stages there may be a watery discharge which may later become offensive.
Appendix I: ovarian cysts Ovarian cysts fall under the category of ‘Abdominal Masses’ (zheng jia
). The oldest description of a pathology resembling ovarian cysts is in Chapter 57 of the Spiritual Axis which describes an abdominal mass called ‘Intestines Deep Mass’ (chang
tan
): External Cold engages in a fight with the Defensive Qi, Qi cannot flourish and accumulations develop inside forming a nodule: a perverse Qi rises and decayed flesh forms. In the beginning the lump is the size of an egg; gradually it increases in size until it becomes the same size as the abdomen of a woman at full term’s pregnancy. After some years, the lump feels hard on pressure but it is moveable; it fluctuates with the menstrual periods.7
Aetiology and pathology The aetiology of ovarian cysts is often attributed to invasion of external pathogenic factors suffered during the period or soon after childbirth, both times when the genital system is in a vulnerable state and prone to be invaded by such pathogens.
This cause of disease is usually combined with emotional stress leading to stagnation of Qi and Blood and with dietary irregularity (excessive consumption of sugar and greasy foods) leading to Spleen-Qi deficiency and Phlegm. The pathology of ovarian cysts is always characterized by a combination of Phlegm, Dampness and stasis of Blood. Thus, the principle of treatment is to resolve Phlegm and Dampness, invigorate Blood, eliminate stasis, soften hardness and dissolve. The dosages and approach to treatment should be adapted according to whether the woman has periods or not. If the woman suffers from amenorrhoea, most Chinese doctors recommend using a rather vigorous approach with fairly large doses. If the woman has periods, one should distinguish whether these are heavy or scanty. If the periods are heavy, in addition to the treatment principles mentioned above, one should tonify Qi, consolidate the Directing and Penetrating Vessels and cool Blood; if the periods are scanty, one should tonify Qi and nourish Blood. Herbal treatment
a Prescription
– EMPIRICAL PRESCRIPTION by Dr Huang Tao Qiang8 Explanation
Please note that the dosages given are those used by Dr Shen Zhong Li: I would personally recommend reducing by at least half if not more. I should also add that Huang Yao Zi is slightly toxic and should be used only for a few weeks at a time with breaks of a 4–5 weeks in between; furthermore, it should not be used if the patient has a history of liver disease such as hepatitis
A, B or C or liver cirrhosis. – Sheng Di Huang, Dang Gui and Bai Shao nourish Blood. – Chi Shao and Liu Ji Nu invigorate Blood and eliminate stasis. Liu Ji Nu ‘breaks’ Blood. – Ban Zhi Lian, Hong Teng, Gan Qi, Xia Ku Cao and Bai Jiang Cao resolve Toxic-Heat. Ban Zhi Lian also dissolves masses and has an anticarcinogenic effect. Xia Ku Cao also softens masses. – Huang Yao Zi resolves Phlegm, dissolves nodules and softens masses. – Hai Zao and Ji Nei Jin soften masses. – Gan Cao harmonizes. Modifications
• If there is Qi deficiency, add Huang Qi Radix Astragali and Dang Shen Radix Codonopsis. Qi tonics are often added according to the principle that ‘tonifying the Upright Qi automatically expels pathogenic factors’. • If there is Yin deficiency, add Bei Sha Shen Radix Glehniae, Gui Ban Plastrum Testudinis and Huang Jing Rhizoma Polygonati. • If there is Liver-Fire, add Mu Dan Pi Cortex Moutan. • If there are loose stools, add Mu Xiang Radix Aucklandiae and Shan Yao Radix Dioscoreae. • If there is insomnia, add Bai Zi Ren Semen Platycladi and Ye Jiao Teng Caulis Polygoni multiflori.
• If there are palpitations, add San Qi Radix Notoginseng and Yuan Zhi Radix Polygalae. • If there is backache, add Gou Ji Rhizoma Cibotii. • If the periods are heavy and have clots, add Qian Cao Gen Radix Rubiae. • If the periods are scanty, add San Leng Rhizoma Sparganii and E Zhu Rhizoma Curcumae. • If there is abdominal pain, add Xiang Fu Rhizoma Cyperi and Yi Mu Cao Herba Leonuri. • If there is tubal inflammation or obstruction, add Ban Bian Lian Herba Lobeliae chinensisi. Dr Shen Zhong Li specifically advises against using insects (such as Di Bie Chong Eupolyphaga or Shui Zhi Hirudo) to ‘break’ Blood as they are too powerful and may injure the body’s Qi and Blood. b Prescription
– EMPIRICAL PRESCRIPTION by Dr Yao Shi An9 Explanation
– Huang Qi tonifies Qi and expels pus. – San Leng and E Zhu ‘break’ Blood and dissolve masses. – Zao Jiao Ci resolves Toxic-Heat, expels pus and invigorates Blood.
– Hai Zao, Kun Bu and Xia Ku Cao soften masses. Xia Ku Cao also resolves Toxic-Heat. – Bai Jie Zi resolves Phlegm. – Shui Zhi ‘breaks’ Blood and dissolves masses. The above dosages are from the original formula by Dr Yao. I would personally reduce them by at least half. This formula differs from the previous one in so far as it also strongly tonifies Qi with a high dose of Huang Qi: this is used according to the principle that ‘tonifying the Upright Qi automatically expels pathogenic factors’. Modifications
• If there is Damp-Heat, add Da Huang Radix et Rhizoma Rhei, Bai Hua She She Cao Herba Hedyotis diffusae and Hong Teng Caulis Sargentodoxae. • If there is Damp-Cold, add Gui Zhi Ramulus Cinnamomi, Lu Jiao Cornu Cervi and Wu Zhu Yu Fructus Evodiae. Dr Yao suggests giving this prescription for 1 month and then checking the results with an ultrasound scan: if necessary, continue for another month. c Prescription
– GUI ZHI FU LING WAN Variation10 – Ramulus Cinnamomi-Poria Pill Variation Explanation
The first five herbs constitute the formula Gui Zhi Fu Ling Wan which invigorates Blood, eliminates stasis and dissolves masses. – Huang Yao Zi resolves Phlegm and softens masses. – Ji Nei Jin softens masses. – Shui Zhi ‘breaks’ Blood and dissolves masses also by promoting the transformation of Water. – Li Zhi He and Wu Yao move Qi, eliminate stagnation, warm the menses and direct the formula to the Liver channel. As was the case for the previous two prescriptions, the dosages of this prescription are those indicated by Dr Wang Hui Lan: I would personally reduce them by at least half. The emphasis of this formula is invigorating Blood and moving Qi. Table 60.2 illustrates the differences between the above three formulae. Table 60.2 Comparison of formulae for ovarian cysts
Appendix II: cervical dysplasia Cervical dysplasia is characterized by three abnormalities: a disorderly maturation or a lack of differentiation of the squamous epithelial cells; nuclear abnormalities; and increased mitotic activity. This condition’s incidence is in direct correlation with the age of onset of sexual intercourse and the number of sexual partners, i.e. the younger the age of regular intercourse and the higher the number of partners, the higher the risk of developing cervical dysplasia. The relationship between cervical squamous pre-cancer and sexual intercourse is beyond doubt as the condition is virtually unknown in celibate women. The exposed area of columnar epithelium on the ectocervix is called the transformation zone because, over many years, the columnar cells are replaced by squamous epithelium by a process of metaplasia. The risk of developing cervical cancer or pre-cancer is increased if the transformation zone is exposed to a sexually transmitted carcinogen at a time of maximum cellular activity during adolescence. This fact is in complete agreement with the Chinese view that sexual activity at an early age is very detrimental to the Directing and Penetrating Vessels because the Uterus and these vessels are in a vulnerable state at such an age. Cervical dysplasia in its various stages, carcinoma in situ and invasive carcinoma of the cervix are now recognized as a continuum of the same disease. There are three stages of severity of cervical intra-epithelial neoplasia (CIN): • CIN 1 corresponds to mild dysplasia. • CIN 2 to moderate dysplasia. • CIN 3 to severe dysplasia and carcinoma in situ. Figure 60.2 illustrates the normal cervical epithelium together with its changes in stages CIN 1, 2 and 3.
Figure 60.2 Cervical epithelial changes in CIN.
(Reproduced with permission from Govan, McKay Hart and Callander 1993 Gynaecology Illustrated, 4th edn, Churchill Livingstone, Edinburgh, pp 208–209.)
After these three, the next stage would be invasive carcinoma which has a very poor prognosis: its main sign is vaginal bleeding brought on by coitus, micturition or defaecation. The bleeding later becomes continuous, and when the growth ulcerates there is a blood-stained discharge. The staging of invasive cervical carcinoma is as follows: • Stage 0: CIN 3 (carcinoma in situ). • Stage IA: micro-invasive carcinoma. • Stage IB: invasive carcinoma confined to cervix. • Stage IIA: tumour extending to the upper third of the vagina. • Stage IIB: tumour extending to the parametrium. • Stage IIIA: tumour involving the lower third of the vagina. • Stage IIIB: tumour extending to the pelvic wall. • Stage IVA: tumour involving the bladder or rectum. • Stage IVB: tumour spread to liver or lung. Although the above terminology stresses the continuing nature of the process leading from CIN 1 to carcinoma, in cervical dysplasia this is not an inexorable progression from one stage to the next: for example, it is quite possible for cases of CIN 1 to revert to normal. Furthermore, many cases of CIN, regardless of the grade, never progress to the next stage. From a Chinese perspective, whether a case of CIN progresses through the various stages or remains stationary (or even reverts to normal) depends on the state of that person’s Upright Qi. Cancer and Upright Qi are like the two sides of a pair of scales: when one goes up, the other goes
down. Thus, anything that makes the body’s Qi go up (with treatment and healthy lifestyle) will make cancer reverse or stay stationary. CIN is diagnosed through the Papanicolaou (Pap) smear, while colposcopy allows the accurate localization of the abnormal epithelium. Treatment may consist in any of the following procedures: • Laser treatment. • Cryotherapy. • Cold coagulation. • Electrocoagulation diathermy. • Cone biopsy. Whichever treatment is adopted, the aim is to destroy the transformation zone entirely to a depth of 6 mm. Cone biopsy involves the excision of a cylinder of tissue from the cervix so that the entire transformation zone is excised: this procedure is both diagnostic and therapeutic. From the point of view of Chinese medicine, this condition would have been diagnosed in the old times only at its invasive stage, i.e. when it manifests with vaginal bleeding and, later, a blood-stained, offensive discharge, by which time the carcinoma is already quite advanced and probably not treatable with Chinese medicine. Thus, to treat cervical dysplasia we must obviously rely on a Western diagnosis with the Pap smear test. As for its aetiology, this has already been mentioned above: it is often due to onset of regular sexual intercourse at too early an age which injures the Directing and Penetrating Vessels. Adolescence is a very vulnerable time in the life of a girl and any cause of disease at this age has serious consequences. In fact, other causes of disease may play a contributory role. Invasion of external Dampness easily invades the gynecological system in women and may form the basis for the development of dysplasia or cancer.
Emotional problems at puberty time also have a very deep influence on a girl’s life: they may cause stagnation of Qi in the Liver which easily affects the genital system in women. After some time, Qi stagnation may turn into Blood stasis and cause masses. Thus, the pathology is characterized first and foremost by a deficiency of the Upright Qi and a weakness of the Directing and Penetrating Vessels; in addition, there may be stagnation of Qi, stasis of Blood or Damp-Heat. Treatment As for the treatment, there are no specific formulae for CIN in its three stages: it is sufficient simply to identify the main patterns and treat the woman accordingly. There will always be an underlying deficiency that may involve the Liver and/or Kidneys: this may be a deficiency of Qi, Yang, Blood or Yin. In addition, there may be pathogenic factors and particularly Dampness and/or Liver-Qi stagnation. If deficiency predominates, one should tonify Qi, Yang, Blood or Yin primarily and modify the formula with herbs to resolve Dampness or move Qi according to the case. If Fullness predominates, one should start with a formula that resolves Dampness or moves Liver-Qi and modify it with the addition of tonic herbs. Acupuncture
Acupuncture is effective in treating cervical dysplasia and the main points would be: – LU-7 Lieque on the right and KI-6 Zhaohai on the left to regulate the Directing Vessel. – Ren-4 Guanyuan to nourish Blood, tonify the Kidneys and strengthen the Uterus (reinforcing method). – Ren-3 Zhongji and Xia Liao BL-34 to resolve Dampness from the
genital system (reducing or even method). – BL-53 Baohuang to resolve Dampness from the cervix (reducing or even method). – BL-20 Pishu and BL-23 to tonify Spleen and Kidneys and nourish Blood (reinforcing method). – BL-18 to tonify the Liver (reinforcing method). – LIV-5 Ligou to move Liver-Qi in the genital area (reducing or even method). – SP-9 Yinlingquan, SP-6 Sanyinjiao and BL-22 to resolve Dampness from the Lower Burner (reducing or even method). Moxa can be used if there is deficiency of Qi, Yang or Blood. Herbal treatment
Normally, to treat benign or malignant tumours, one needs to use some herbs that ‘break’ Blood, some that dissolve masses, some that resolve Phlegm and some that resolve Toxic-Heat, according to the case. However, in the case of CIN 1 and CIN 2, there is no tumour but only cell changes that may later give rise to a tumour: thus, in these cases, there is no need to resolve Phlegm, ‘break’ Blood, dissolve masses or resolve Toxic-Heat. In such cases, I would simply add one or two anti-cancer herbs to one of the following formulae: • Deficiency of Qi: Liu Jun Zi Tang Six Gentlemen Decoction or Shen Ling Bai Zhu San Ginseng-Poria-Atractylodes Powder (Three Treasures remedy: Central Mansion). • Deficiency of Blood: Ba Zhen Tang Eight Precious Decoction (Women’s Treasure remedy: Precious Sea).
• Deficiency of Kidney-Yang: You Gui Wan Restoring the Right [Kidney] Pill (Three Treasures remedy: Strengthen the Root; Women’s Treasure remedy: Unicorn Pearl). • Deficiency of Kidney-Yin: Zuo Gui Wan Restoring the Left [Kidney] Pill (Three Treasures remedy: Nourish the Root; Women’s Treasure remedy: Growing Jade). • Stagnation of Liver-Qi: Xiao Yao San Free and Easy Wanderer Powder (Women’s Treasure remedy: Freeing the Moon or Freeing Constraint). • Damp-Heat in the Lower Burner: Si Miao San Four Wonderful Powder (Women’s Treasure remedy: Drain the Jade Valley). To each of these formulae I would add one herb with an anti-cancer effect such as Bai Hua She Cao Herba Hedyotis diffusae or Ban Zhi Lian Herba Scutellariae barbatae (6 g). The Journal of Traditional Chinese Medicine reports the treatment of 30 cases of CIN 2 and 3 with a follow up over 10 years.11 The formula used was the following: Prescription
– EMPIRICAL PRESCRIPTION by Dr Tian Jing Feng Modifications
• If there is Liver-Qi stagnation, remove Huang Qi and add Chai Hu Radix Bupleuri, Yu Jin Radix Curcumae and Bai Shao Radix Paeoniae alba. • If there is Liver- and Kidney-Yin deficiency, add Nu Zhen Zi Fructus Ligustri lucidi and Gou Qi Zi Fructus Lycii.
• If there is Empty-Heat, add Huang Bo Cortex Phellodendri and Zhi Mu Rhizoma Anemarrhenae. • If there is Damp-Heat, add Tu Fu Ling Rhizoma Smilacis glabrae, Pu Gong Ying Herba Taraxaci and Yi Yi Ren Semen Coicis. • If there is Spleen and Heart deficiency, remove Bai Jiang Cao and add Dang Shen Radix Codonopsis, Long Yan Rou Arillus Longan and Fu Ling Poria. • If there is vaginal bleeding, add San Qi Radix Notoginseng and E Jiao Colla Corii asini. • If there is lower abdominal pain, add Yan Hu Suo Rhizoma Corydalis and Xiang Fu Rhizoma Cyperi. • If there is backache, add Xu Duan Radix Dipsaci and Gou Ji Rhizoma Cibotii. • If there is constipation, add honey. • If the urine is dark, add Qu Mai Herba Dianthi and Bian Xu Herba Polygoni avicularis. As can be seen from an analysis of the ingredients, this formula resolves Toxic-Heat and ‘breaks’ Blood and, as such, it is probably better for CIN 3 rather than CIN 2. External use
Prescription
– SAN HUANG SAN
– Three Yellows Powder Explanation
Boil the herbs in about 1 pint of water for 30 minutes, strain, let cool until lukewarm and use as a vaginal douche by the means of a small rubber pump. Both acupuncture and herbal medicine, singly or in combination, give good results in cervical dysplasia, usually within 6 months of treatment. End notes 1. 1979 The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen
), People’s Health Publishing House, Beijing, p. 320. First published c. 100 BC..
2. Nanjing College of Traditional Chinese Medicine 1979 A Revised Explanation of the Classic of Difficulties (Nan Jing Jiao Shi
), People’s Health Publishing House, Beijing, p. 122. First published c. 100 BC..
3. He Ren 1979 A Popular Guide to the Essential Prescriptions of the Golden Cabinet (Jin Gui Yao Lue Tong Su Jiang Hua
), Shanghai Science Publishing House, Shanghai, p. 83. The Essential Prescriptions of the Golden Cabinet itself was written by Zhang Zhong Jing and first published c. AD 220..
4. Chao Yuan Fang AD 610 General Treatise on the Aetiology and Symptomatology of Diseases (Zhu Bing Yuan Hou Zong Lun), cited in Zhang Bo Yu 1986 Chinese Internal Medicine (Zhong Yi Nei Ke Xue
), Shanghai Science and Technology Press, Shanghai, p. 187..
5. 1981 Spiritual Axis (Ling Shu Jing
), People’s Health Publishing House, Beijing, first published c. 100 BC, p. 122..
6. Jones H W, Seegar Jones G 1980 Gynaecology, Williams and Wilkins, Baltimore, p. 245..
7. Spiritual Axis, p. 106..
8. Huang Tao Qiang 1989 The Experience of Dr Shen Zhong Li in Treating Ovarian Cysts (Shen Zhong Li Zhi Liao Luan Chao Nang Zhong de Jing Yan), Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi
) 30(6): 15..
9. Yao Shi An 1996 What Should One Pay Attention to when Treating Ovarian Cysts with Chinese Medicine? (Zhong Yi Zhi Liao Luan Chao Nang Zhong Ying Zhu Yi Shen Me?), Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi) 37(2): 119..
10. Wang Hui Lan 1994 Clinical Observation on Augmented Gui Zhi Fu Ling Wan in the Treatment of Ovarian Cysts (Gui Zhi Fu Ling Wan Jia Wei Zhi Liao Luan Chao Nang Zhong Lin Chuang Guan Cha), Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi) 35(6): 355..
11. Tian Jing Feng 1989 The Treatment with Chinese Herbs of 30 Cases of Cervical Dysplasia at stage CIN 2 and 3 – Ten Years Observation of Results (Zhong Yi Yao Zhi Liao II, III Qi Gong Jing Ai 30 Li – 10 Nian Liao Xiao Guan Cha), Journal of Chinese Medicine (Zhong Yi Za Zhi) 30(9): 30..
CHAPTER 61 Excessive Vaginal Discharge
AETIOLOGY AND PATHOLOGY 814 IDENTIFICATION OF PATTERNS AND TREATMENT 815 Spleen deficiency 815 Kidney-Yang deficiency 817 Kidney-Yin deficiency 818 Damp-Heat 820 Toxic-Heat 822 Liver-Qi stagnation 823 Ancient acupuncture prescriptions for excessive vaginal discharge 824 Prescriptions by Fu Qing Zhu 825 PROGNOSIS AND PREVENTION 825 WESTERN VIEW 825 Vaginal
discharge
is
called
dai
xia
(
) in Chinese medicine, literally meaning ‘disease below the Girdle Vessel’. In old times, this term actually
referred to all women’s diseases and it was therefore equivalent to ‘gynecology’, and the term dai xia yi meant ‘gynecologist’. Since the Sui dynasty (AD 581–618), this term has come to mean only ‘excessive vaginal discharge’. A slight vaginal discharge that increases in volume and viscosity at midcycle is physiological and does not constitute a disease. If the discharge is excessive or other than colourless, or if its consistency is other than thin, and if it has an offensive smell, it then constitutes a pathological condition: thus, a pathological vaginal discharge implies a change in amount, colour, consistency or smell. In Chinese medicine, the physiological vaginal discharge is produced, stored and secreted by the Kidneys; transformed and distributed by the Spleen; governed by the Directing Vessel (Du Mai); and controlled by the Girdle Vessel (Dai Mai). Excessive Vaginal Discharge as a Chinese disease category has always had a predominant and important place in Chinese gynecology, compared with Western gynecology. The reason for this is probably that, in the absence of modern diagnostic means, the ancient Chinese doctors relied on the appearance of a vaginal discharge not only for diagnosis but also prognosis. In Western medicine, we know that an excessive vaginal discharge in most cases reflects a local pathology of the lower genital tract (such as vaginitis from Candida or Trichomonas infection). We also know that, in a few cases, an excessive vaginal discharge may be a symptom of uterine carcinoma and Western gynecology has the means to diagnose this. In the old times, Chinese gynecologists would not have known that an excessive vaginal discharge from local vaginitis and one from uterine cancer had different pathologies: they did know, however, that some types of vaginal discharges are more serious and indicate a poor prognosis. For example, they differentiated between a vaginal discharge from Damp-Heat and one from Toxic-Heat, the latter denoting a worse prognosis. The ancient gynecologists also knew, for example, that a bloody discharge with pus occurring after the menopause indicates a very poor prognosis: this ties in completely with Western medicine as such a discharge often indicates the
possible presence of uterine carcinoma. In conclusion, the careful and detailed observation of the pathology of vaginal discharge developed over centuries gave the ancient Chinese gynecologist very good diagnostic and prognostic means to differentiate between serious and mild conditions.
Aetiology and pathology
Irregular diet, excessive physical work Excessive consumption of dairy foods, greasy foods and sugar often leads to the formation of Dampness: in women, this easily infuses downwards to the genital system to cause a vaginal discharge. Even if the patient does not consume excessive amounts of dairy or greasy foods, eating irregularly also leads to the formation of Dampness. Excessive physical work weakens the Spleen which then fails to transform and transport fluids properly: these accumulate into Dampness, infuse to the genital system and cause an excessive vaginal discharge. After some years, Spleen-Yang deficiency leads to Kidney-Yang deficiency, so that the Kidneys cannot store and hold fluids, which leak out in the form of vaginal discharge. Emotional strain Worry, anger, irritation, frustration, guilt and resentment may all lead to stagnation of Liver-Qi; stagnant Liver-Qi invades the Spleen and impairs its transformation and transportation of fluids, leading to the accumulation of Dampness. When combined with Liver-Qi stagnation, Dampness may settle in the Liver channel which curls around the genitalia and causes an excessive vaginal discharge. Overwork Overwork for several years without adequate rest leads to Liver- and Kidney-Yin deficiency and to weakness of the Directing and Girdle Vessels which cannot hold Yin fluids: this causes an excessive vaginal discharge.
Invasion of external Dampness External Dampness may invade the leg channels and flow up to settle in the genital system and cause an excessive vaginal discharge. Women are particularly prone to invasion of Dampness especially after childbirth and after each period. After some time, Dampness often combines with Heat to form Damp-Heat. Invasion of external Dampness leads to excessive vaginal discharge especially when there is a concurrent aetiological factor such as irregular diet. After some time, Damp-Heat may turn into Toxic-Heat which is a more serious type of pathogenic factor and one that is often accompanied by a poor prognosis. A pathological vaginal discharge must be differentiated in term of amount, colour, consistency and odour. Amount
A profuse discharge is usually due to a deficiency of the Kidneys, while a white, sticky discharge usually reflects a Spleen deficiency. Colour
As for colour, four colours are usually distinguished: white, yellow, red and green. A white discharge indicates Cold; yellow, red, or green discharges indicate Heat. Consistency
A dilute, watery discharge indicates Cold or deficiency and a thick, sticky one denotes Heat or Dampness. A profuse red discharge, whether dilute or
sticky, indicates deficiency of Yin with Damp-Heat. Odour
An odour in general indicates Heat, as does a leathery smell, but a fishy smell may indicate Cold. Thus, to differentiate between deficiency and excess, a light-coloured, thin, watery discharge without odour indicates deficiency (or Cold), while a dark, thick, dense discharge with an offensive odour indicates Fullness (or Heat). It is often difficult to judge the colour of a discharge because a white discharge usually stains the briefs yellow. Red vaginal discharge should be differentiated from mid-cycle menstrual bleeding. A red vaginal discharge is sticky and usually smelly and it does not occur with periodicity. Mid-cycle menstrual bleeding occurs with regularity at monthly intervals, is not sticky or turbid, and generally does not have an offensive odour. In terms of channels, vaginal discharges involve the Spleen, Liver and Kidney channels and, of the Extraordinary Vessels, the Directing and Girdle Vessels (Ren and Dai Mai). In fact, most authors say that the term dai in dai xia, meaning vaginal discharge, is related to the name of the Girdle Vessel, i.e. Dai Mai. When the Girdle Vessel is slack, Qi sinks and Dampness infuses downwards to the genital system causing a vaginal discharge: for this reason, vaginal discharges are a major indication for the use of this vessel. In this type of pathology, the Girdle Vessel is closely connected to the Directing Vessel as the former harmonizes the ascending and descending of Qi which affects the latter: for this reason, a pathology of the Girdle Vessel (being too slack) causes Qi to sink in the Directing Vessel with symptoms of a persistent vaginal discharge. The sinking of Qi in the Girdle Vessel is related to a Kidney deficiency, while the formation of Dampness is due to a Spleen deficiency. Fu Qing Zhu says: Excessive vaginal discharge is a Dampness pattern. It is called ‘dai’
due to the inability of the Girdle [Dai] Vessel to bind. The Girdle Vessel communicates with the Directing and Governing vessels and if these are diseased, the Girdle Vessel also is … The Girdle Vessel may be injured not only by falls, sprains or contusions, but also by excessive sexual activity or by excessive drinking of alcohol to the point of complete drunkenness.1 The points used are its opening points G.B.-41 Zulinqi (on the right) and T.B.-5 Waiguan (on the left), and G.B.-26 Daimai, G.B.-27 Wushu and G.B.-28 Weidao.
Identification of patterns and treatment The main deficiency pathology centres around Spleen or Kidney deficiency (which may be of Kidney-Yang or Kidney-Yin); the main Full pathology is Damp-Heat or Toxic-Heat. Thus, the treatment principle in deficiency conditions of the Spleen is to tonify, raise (Qi) and dry (Dampness); in deficiency conditions of the Kidneys, it is to tonify the Kidneys and consolidate the Directing Vessel. For Full conditions from Damp-Heat, the treatment principle is to clear (Heat) and transform (Water). For Toxic-Heat, the treatment principle is to drain (Fire) and resolve (Toxin). Toxic-Heat or Damp-Heat are often accompanied by infestation of
what the ancient Chinese called ‘parasites’ (chong ). ‘Parasites’ can cause various diseases in Chinese medicine: apart from the obvious intestinal parasites, tuberculosis (TB) of the lungs and certain types of vaginal discharges are caused by ‘parasites’. As for TB of the lungs, called
zhai
(
)
or
lao
zhai
(
), the ancient Chinese doctors had perceptively understood that it was caused by some pathogenic living organisms which they called ‘parasites’, i.e. chong or lao chong. For example, Zhu Dan Xi (1281–1358) says: “In some syndromes there are parasites inside the Yin organs that bite the heart and lungs: this is called zhai disease.”2 The ancient Chinese doctors had also understood that such ‘parasites’ could be infectious. The Formulae to Aid the Living (1237) says: Lao Zhai [i.e. tuberculosis] is a serious disease. Those who suffer from it can transmit it to each other; they can have it for many years and all the family members may die of it.3 In the case of vaginal discharges, according to the old doctors, some are caused by parasites (chong): again, the ancient Chinese doctors were very perceptive because we know from modern medicine that fungal or bacterial infections, spread through sexual contact, cause most vaginal discharges. In such cases, the treatment principle is to ‘kill parasites’ (sha
chong ), i.e. eliminate bacteria or fungi with herbs that have an anti-bacterial or anti-fungal effect and the majority of which also kill parasites. From a Western perspective, a vaginal discharge associated with abdominal pain may indicate pelvic inflammatory disease and most of the
formulae for Toxic-Heat are particularly suitable to treat this condition. The patterns discussed are: • Spleen deficiency • Kidney-Yang deficiency • Kidney-Yin deficiency • Damp-Heat • Toxic-Heat • Liver-Qi stagnation.
Spleen deficiency
Clinical manifestations Excessive vaginal discharge that is white or slightly yellow, sticky, without smell and persistent, dull complexion, tiredness, depression, cold limbs, loose stools. Tongue: Pale with a sticky, white coating. Pulse: Weak and slightly Slippery. This pattern is characterized not only by deficiency of Spleen-Qi or Spleen-Yang but also by sinking of Spleen-Qi: the persistent vaginal discharge, besides being a symptom of Dampness, is also a symptom of Spleen-Qi sinking. Treatment principle Strengthen the Spleen, tonify Qi, raise Yang, resolve Dampness. Acupuncture Ren-12 Zhongwan, ST-36 Zusanli, SP-3 Taibai, SP-6 Sanyinjiao, SP-9 Yinlingquan, BL-22 Sanjiaoshu, Du-20 Baihui, Ren-6 Qihai, Ren-3 Zhongji, BL-32 Ciliao, BL-20 Pishu. All with reinforcing method except for SP-9 and SP-6 which should be needled with even method. Moxa is applicable. Explanation
– Ren-12, ST-36, SP-3 and BL-20 tonify Spleen-Qi or Spleen-Yang. Warming needle on ST-36 should be applied.
– SP-6 and SP-9 resolve Dampness from the Lower Burner. – BL-22 promotes the transformation of fluids in the Lower Burner and helps to resolve Dampness. – Du-20 raises Qi. It can be used with a moxa stick. – Ren-6 tonifies Qi in general. – Ren-3 and BL-32 resolve Dampness from the genital system. Herbal treatment
a Prescription
– WAN DAI TANG – Ending Vaginal Discharge Decoction Explanation This formula from Fu Qing Zhu’s Gynaecology is for white vaginal discharge.4 The dosages indicated are from the original textbook: I would personally reduce them by at least half. The formula is designed to tonify the Spleen strongly, resolve Dampness and pacify the Liver so that it does not overact on the Spleen and also so that it consolidates the Girdle Vessel. – Bai Zhu, Shan Yao and Ren Shen tonify Spleen-Qi and Stomach-Qi. – Bai Shao nourishes Blood, pacifies the Liver and, being astringent, will ‘absorb’ discharges.
– Cang Zhu, Che Qian Zi and Chen Pi resolve Dampness. – Jing Jie, charred, stops bleeding and discharges. – Chai Hu moves Liver-Qi. – Gan Cao harmonizes. b Prescription
– YI HUANG TANG – Change Yellow Decoction Explanation This formula from Fu Qing Zhu’s Gynaecology is for yellow vaginal discharge with Spleen deficiency and Damp-Heat.5 – Shan Yao tonifies the Spleen and Stomach. – Qian Shi is astringent and stops discharges. – Huang Bo and Che Qian Zi resolve Damp-Heat. – Bai Guo directs the other herbs to the Directing Vessel, as explained by Fu Qing Zhu. Modifications
• If there is backache and symptoms of Kidney-Yang deficiency, add Du Zhong Cortex Eucommiae and Tu Si Zi Semen Cuscutae.
• If there is abdominal pain, add Xiang Fu Rhizoma Cyperi and Ai Ye Folium Artemisiae argyi. • If the condition is chronic and the discharge a constant trickle, add Lu Jiao Shuang Cornu Cervi degelatinatum, Wu Zei Gu Endoconcha Sepiae, Qian Shi Semen Euryales, Long Gu Fossilia Ossis mastodi (fried) and Mu Li Concha Ostreae (fried). Three Treasures remedy
– TONIFY QI AND EASE THE MUSCLES This remedy is a variation of the formula Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction which tonifies and raises Qi. It is well suited to this condition of vaginal discharge from Qi deficiency and Dampness because it contains herbs that resolve Dampness. The tongue presentation appropriate to this remedy is a Pale body with a sticky, white coating. Summary Spleen deficiency
Clinical manifestations
Excessive vaginal discharge that is white or slightly yellow, sticky, without smell and persistent, dull complexion, tiredness, depression, cold limbs, loose stools. Tongue: Pale with a sticky, white coating. Pulse: Weak and slightly Slippery. Treatment principle
Strengthen the Spleen, tonify Qi, raise Yang, resolve Dampness. Acupuncture
Ren-12 Zhongwan, ST-36 Zusanli, SP-3 Taibai, SP-6 Sanyinjiao, SP-9 Yinlingquan, BL-22 Sanjiaoshu, Du-20 Baihui, Ren-6 Qihai, Ren-3 Zhongji, BL-32 Ciliao, BL-20 Pishu. All with reinforcing method except for SP-9 and SP-6 which should be needled with even method. Moxa is applicable. Herbal treatment
Pre scriptions
• WAN DAI TANG Ending Vaginal Discharge Decoction • YI HUANG TANG Change Yellow Decoction Three Treasures remedy
• TONIFY QI AND EASE THE MUSCLES
Kidney-Yang deficiency
Clinical manifestations Profuse, white and dilute vaginal discharge resembling water or egg white, dizziness, tiredness, backache, frequent, pale urination, feeling cold. Tongue: Pale and wet. Pulse: Deep, Weak. Treatment principle Tonify and warm the Kidneys, consolidate the Directing Vessel, stop discharge. Acupuncture BL-23 Shenshu, Ren-4 Guanyuan, KI-13 Qixue, G.B. 26 Daimai, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, Du-20 Baihui. All with reinforcing method; moxa must be used. Explanation
– BL-23, with moxa cones, tonifies Kidney-Yang. – Ren-4 and KI-13, with moxa cones, tonify Kidney-Yang and the Original Qi and consolidate the Penetrating Vessel. – G.B.-26 consolidates the Girdle Vessel to stop vaginal discharge. – ST-36, SP-6 and KI-3 tonify the Kidneys and Qi in general.
– Du-20 raises Qi. This is necessary to stop the vaginal discharge: a persistent, profuse vaginal discharge with the above symptoms indicates not only deficiency of Kidney-Yang but also sinking of Kidney-Qi in a way similar to and with the same pathology as the sinking of Spleen-Qi. Herbal treatment
a Prescription
– NEI BU WAN – Inner Tonification Pill Explanation
– Lu Rong, Tu Si Zi, Rou Cong Rong and Sha Yuan Zi tonify and warm the Kidneys and consolidate the Essence. – Huang Qi tonifies and raises Qi. – Sang Piao Xiao is astringent and stops discharges. – Rou Gui and Fu Zi warm the Kidneys and the Uterus. – Bai Ji Li is probably included to regulate the ascending and descending of Qi in combination with Huang Qi. In fact, Huang Qi raises pure Qi while Bai Ji Li subdues ascending Yang: thus the combination of these two actions regulates the ascending and descending of Qi and therefore stops sinking of Qi.
– Zi Wan is probably included to regulate Qi in the chest so as to facilitate the ascending and descending of Qi between the Lower and Upper Burners. Modifications
• If the patient has loose stools, remove Rou Cong Rong and add Bu Gu Zhi Fructus Psoraleae. b. Prescription
– WU ZI YAN ZONG WAN Variation – Five-Seed Developing Ancestors Pill Variation Explanation The first five herbs constitute the formula Wu Zi Yan Zong Wan which tonifies Kidney-Yang and consolidates the Essence. The dosages indicated are from the original source and are obviously those for a batch of pills. The dosages indicated of the last two herbs are daily dosages for a decoction. – Tu Si Zi tonifies Kidney-Yang and consolidates the Essence. – Wu Wei Zi, an astringent herb, nourishes and consolidates the Essence. – Gou Qi Zi tonifies the Kidneys and the Essence. – Fu Pen Zi, also astringent, tonifies Kidney-Yang and stops discharges. – Che Qian Zi is added to clear any Heat deriving from tonification of Yang.
– Qian Shi, another astringent, is added to stop discharges. – Ba Ji Tian tonifies Kidney-Yang. Compared with the previous formula, the present one is more astringing than tonifying, while the former is much warmer in nature and its emphasis is on tonifying and warming the Kidneys. Another difference is that the former prescription, Nei Bu Wan, tonifies the Governing Vessel, while the latter, Wu Zi Yan Zong Wan, tonifies the Directing Vessel. Nei Bu Wan is therefore indicated when there are pronounced symptoms of Kidney-Yang deficiency, with backache, and of interior Cold. c Prescription
– EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai6 Explanation
– Ba Ji Tian and Sang Ji Sheng tonify the Kidneys. – Gui Zhi warms Yang. – Huang Qi tonifies Spleen-Qi. – Qiang Huo and Fang Feng resolve Dampness. – Bai Shao harmonizes the Liver. – Ban Xia and Chen Pi harmonize the Centre. – Fu Ling and Fu Shen resolve Dampness. – Zhi Gan Cao harmonizes.
Three Treasures remedy
– STRENGTHEN THE ROOT This remedy is a variation of the formula You Gui Wan Restoring the Right [Kidney] Pill which tonifies and warms the Kidneys and strengthens the Governing Vessel. It is somewhat similar in action to the above formula Nei Bu Wan Inner Tonification Pill. The tongue presentation appropriate to this remedy is a Pale and wet body. Summary Kidney-Yang deficiency
Clinical manifestations
Profuse, white and dilute vaginal discharge resembling water or egg white, dizziness, tiredness, backache, frequent, pale urination, feeling cold. Tongue: Pale and wet. Pulse: Deep, Weak. Treatment principle
Tonify and warm the Kidneys, consolidate the Directing Vessel, stop discharge. Acupuncture
BL-23 Shenshu, Ren-4 Guanyuan, KI-13 Qixue, G.B.-26 Daimai, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, Du-20 Baihui. All with reinforcing method; moxa must be used.
Herbal treatment
Pre scriptions
• NEI BU WAN Inner Tonification Pill • WU ZI YAN ZONG WAN Variation Five-Seed Developing Ancestors Pill Variation • EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai Three Treasures remedy
• STRENGTHEN THE ROOT
Kidney-Yin deficiency
Clinical manifestations White vaginal discharge that is dilute in consistency and without odour, dizziness, tinnitus, five-palm heat, a feeling of heat in the evening. Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty. Treatment principle Nourish Yin, strengthen the Kidneys, clear Heat, consolidate the Essence. Acupuncture Ren-4 Guanyuan, KI-13 Qixue, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-6 Sanyinjiao, KI-3 Taixi, Du-20 Baihui. All with reinforcing method, no moxa. Explanation
– Ren-4 and KI-13 nourish the Kidneys, strengthen the Directing Vessel and consolidate the Essence. – LU-7 and KI-6 regulate the Directing Vessel and nourish Kidney-Yin. – SP-6 and KI-3 nourish the Kidneys. – Du-20 raises Qi. This point is added for the same reasons as for the previous two patterns, i.e. to raise Qi, stop Qi from sinking and stop discharges. In this case, it combines well with the opening points of the
Directing Vessel, LU-7 and KI-6, to balance all the Yin points with a Yang one. Herbal treatment
a Prescription
– ZUO GUI WAN – Restoring the Left [Kidney] Pill Explanation This formula, already explained, nourishes Kidney-Yin. b Prescription
– ZHI BO DI HUANG WAN Variation – Anemarrhena-Phellodendron-Rehmannia Pill Variation Explanation The first eight herbs constitute the formula Zhi Bo Di Huang Tang, already explained, which nourishes Kidney-Yin and resolves Damp-Heat. – Qian Shi and Jin Ying Zi are two astringent herbs that stop discharges and consolidate the Essence.
c Prescription
– EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai7 Explanation This formula is for vaginal discharge from Kidney-Yin deficiency with EmptyHeat and Damp-Heat infusing downwards. It is therefore suitable when the tongue is Red and without coating in the centre, but with a thin, sticky yellow coating on the root. – Dang Gui and Chai Hu pacify and regulate the Liver. – Mu Li, Nu Zhen Zi, Shu Di Huang and Bai Shao nourish Yin. – Chi Xiao Dou, Ren Dong Teng, Ze Xie and Che Qian Zi drain DampHeat. – Mu Dan Pi clears Empty-Heat. – Huai Niu Xi conducts Dampness downwards. – Gan Cao harmonizes. d Prescription
– BU GAN YI SHEN TANG8 – Tonifying the Liver and Benefiting the Kidneys Decoction Explanation
The first six herbs constitute the formula Liu Wei Di Huang Wan SixIngredient Rehmannia Pill which nourishes Liver- and Kidney-Yin. – Huang Bo resolves Damp-Heat from the Lower Burner. – Bai Shao nourishes Yin. – Wu Wei Zi nourishes Yin. – Shen Qu promotes digestion. Three Treasures remedy
– NOURISH THE ROOT This remedy is a variation of the formula Zuo Gui Wan Restoring the Left [Kidney] Pill which nourishes Kidney-Yin. It is well suited to treat vaginal discharge from Kidney-Yin deficiency because it contains Lu Jiao Shuang, an ‘absorbent’ herb, and Shan Zhu Yu which is astringent. Summary Kidney-Yin deficiency
Clinical manifestations
White vaginal discharge that is dilute in consistency and without odour, dizziness, tinnitus, five-palm heat, a feeling of heat in the evening. Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty. Treatment principle
Nourish Yin, strengthen the Kidneys, clear Heat, consolidate the Essence. Acupuncture
Ren-4 Guanyuan, KI-13 Qixue, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-6 Sanyinjiao, KI-3 Taixi, Du-20 Baihui. All with reinforcing method, no moxa. Herbal treatment
Pre scriptions
• ZUO GUI WAN Restoring the Left [Kidney] Pill • ZHI BO DI HUANG WAN Variation Anemarrhena-Phellodendron-Rehmannia Pill Variation • EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai • BU GAN YI SHEN TANG Tonifying the Liver and Benefiting the Kidneys Decoction Three Treasures remedy
• NOURISH THE ROOT
Damp-Heat
Clinical manifestations Profuse yellow or brown discharge that is sticky in consistency and with an odour, loose stools. Tongue: sticky, yellow coating on the root with Red spots. Pulse: Slippery. Treatment principle Clear Heat, resolve Dampness. Acupuncture G.B.-41 Zulinqi (on the right) and T.B.-5 Waiguan (on the left), Ren-3 Zhongji, Ren-2 Qugu, G.B.-26 Daimai, SP-9 Yinlingquan, SP-6 Sanyinjiao, BL-33 Zhongliao, BL-22 Sanjiaoshu, BL-53 Baohuang, BL-30 Baihuanshu. All with reducing or even method, no moxa. Explanation
– G.B.-41 and T.B.-5 regulate the Girdle Vessel which stops vaginal discharges. A persistent vaginal discharge, especially one from Damp-Heat, is considered to be due to a ‘slackening’ of the Girdle Vessel which allows Dampness to infuse downwards. – G.B.-26 stops vaginal discharges and consolidates the Girdle Vessel. Ideally, the needling sensation should propagate towards the lower abdomen and even the genitals.
– Ren-3 and Ren-2 regulate the Directing Vessel and resolve Dampness. – SP-9 and SP-6 resolve Dampness from the Lower Burner. – BL-33 resolves Dampness and treats genital problems. – BL-22 promotes the transformation of fluids in the Lower Burner and helps to resolve Dampness. – BL-53 treats genital problems. – BL-30 drains Damp-Heat from the lower genital system. Herbal treatment
a Prescription
– BI XIE SHEN SHI TANG – Dioscorea Draining Dampness Decoction Explanation
– Bi Xie, Yi Yi Ren, Ze Xie, Fu Ling, Tong Cao, Hua Shi and Huang Bo drain Damp-Heat from the Lower Burner and the genito-urinary system. – Mu Dan Pi clears Heat from the Liver channel. b Prescription
– MIE DI ZHI YANG TANG9 – Killing Trichomonas and Stopping Itching Decoction Explanation This formula, almost the same as the previous one, is proposed by Dr Cong Chun Yun as specific for the treatment of infections from Trichomonas vaginalis. The dosages indicated are those proposed by Dr Cong, which I would personally reduce proportionally. – Bi Xie, Huang Bo, Yi Yi Ren, Fu Ling, Ze Xie, Cang Zhu and Hua Shi drain Dampness from the Lower Burner. – Mu Dan Pi clears Heat from the Liver channel. – Zhi Mu clears Empty-Heat in the Lower Burner. – He Shi kills parasites. c Prescription
– ZHI DAI WAN – Stopping Vaginal Discharge Pill Explanation
– Zhu Ling, Fu Ling and Ze Xie resolve Dampness.
– Che Qian Zi, Yin Chen Hao, Huang Bo and Shan Zhi Zi resolve DampHeat. – Chi Shao and Mu Dan Pi invigorate Blood and clear Heat. They also treat Liver channel Heat which might be causing the vaginal discharge. – Niu Xi is a messenger herb to direct the formula to the Lower Burner. d Prescription
– LONG DAN XIE GAN TANG – Gentiana Draining the Liver Decoction Explanation This formula, already explained, drains Liver-Fire and resolves Damp-Heat from the Upper and Lower Burners. It is suitable when there are pronounced signs of Liver-Fire and the Damp-Heat in the genital system is related to the Liver channel. Thus, the main manifestations indicating the use of this formula are headaches, red eyes, red face, irritability, thirst, dark urine, constipation, a Red tongue with redder sides and a sticky, yellow coating, and a Wiry pulse. e Prescription
– YI HUANG TANG – Change Yellow Decoction Explanation
This formula, already explained, is used if Damp-Heat is accompanied by Spleen and Kidney deficiency. Table 61.1 illustrates the differences among the above four formulae (considering a and b as one). Table 61.1 Comparison and differences among formulae for vaginal discharge from Damp-Heat
External treatment
a Prescription
– Ku Shen Radix Sophorae flavescentis 30 g – Wei Ling Xian Radix Clematidis 15 g
– Dang Gui Radix Angelicae sinensis 15 g (‘tail’ only) – She Chuang Zi Fructus Cnidii 90 g – Jin Yin Hua Flos Lonicerae 90 g Explanation
– Ku Shen drains Dampness and has an anti-fungal and anti-Trichomonas effect. – Wei Ling Xian expels Wind-Damp. – Dang Gui invigorates Blood. – She Chuang Zi kills parasites. – Jin Yin Hua resolves Toxic-Heat. These herbs should be boiled for half an hour in 3–4 pints of water and the resulting liquid divided into three equal doses, to be used one per day. One dose is then diluted in cold water and is either applied to the vagina or poured into a shallow bath in which the woman should sit for 20 minutes. This external prescription is given by Dr Cong Chun Yun as a treatment for infection from Trichomonas vaginalis.10 b Prescription
– Jin Yin Hua Flos Lonicerae 90 g – Huo Xiang Herba Pogostemonis 60 g – She Chuang Zi Fructus Cnidii 90 g
– Tu Fu Ling Rhizoma Smilacis glabrae 90 g Explanation
– Jin Yin Hua and Tu Fu Ling resolve Toxic-Heat. – Huo Xiang resolves Dampness. – She Chuang Zi kills parasites. The above herbs are prepared in the same way as the previous formula except that the above dosages are for 1 week’s treatment, in which case the strained liquid should be kept in the fridge. This formula is proposed by Dr Cong Chun Yun as a treatment for infection from Candida.11 Women’s Treasure remedy
– DRAIN THE JADE VALLEY This remedy drains Dampness from the genital system and has an antifungal and anti-bacterial action. The tongue presentation appropriate to this remedy is a sticky, yellow coating that is thicker on the root. Three Treasures remedy
– DRAIN FIRE This remedy is a variation of the formula Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction: it drains Damp-Heat from the Lower Burner and specifically from the Liver channel in the genitals area. It is suitable for a sticky, yellow vaginal discharge occurring against a background of other Liver-Fire symptoms such as thirst, dry mouth, constipation and
dark urine. The tongue presentation appropriate to this remedy is a Red body with redder sides and with a yellow coating on the root with Red spots. Summary Damp-Heat
Clinical manifestations
Profuse yellow or brown discharge that is sticky in consistency and with an odour, loose stools. Tongue: sticky, yellow coating on the root with Red spots. Pulse: Slippery. Treatment principle
Clear Heat, resolve Dampness. Acupuncture
G.B.-41 Zulinqi (on the right) and T.B.-5 Waiguan (on the left), Ren-3 Zhongji, Ren-2 Qugu, G.B.-26 Daimai, SP-9 Yinlingquan, SP-6 Sanyinjiao, BL-33 Zhongliao, BL-22 Sanjiaoshu, BL-53 Baohuang, BL-30 Baihuanshu. All with reducing or even method, no moxa. Herbal treatment
Pre scriptions
• BI XIE SHEN SHI TANG Dioscorea Draining Dampness Decoction • MIE DI ZHI YANG TANG Killing Trichomonas and Stopping Itching
Decoction • ZHI DAI WAN Stopping Vaginal Discharge Pill • LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction • YI HUANG TANG Change Yellow Decoction Women’s Treasure remedy
• DRAIN THE JADE VALLEY Three Treasures remedy
• DRAIN FIRE
Toxic-Heat
Clinical manifestations Profuse yellow, blood-stained or five-colour discharge that is sticky in consistency and with an odour, a feeling of heat, thirst, dark urine. Tongue: Red with a sticky, yellow or brown coating with Red spots. Pulse: Slippery and Rapid. Treatment principle Clear Heat, resolve Toxin, resolve Dampness, stop discharge. Acupuncture L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-3 Zhongji, Ren-2 Qugu, SP-10 Xuehai, KI-2 Rangu, LIV-3 Taichong. All with reducing or even method, no moxa. Explanation
– L.I.-11 clears Heat and resolves Toxin. – SP-9 and SP-6 resolve Dampness from the Lower Burner. – Ren-3 and Ren-2 resolve Dampness from the genital system. – SP-10, KI-2 and LIV-3 cool Blood. Herbal treatment
a Prescription
– WU WEI XIAO DU YIN Variation – Five-Ingredient Dissolving Toxin Decoction Variation Explanation All the ingredients of this formula resolve Toxic-Heat. This formula can treat acute or chronic pelvic inflammatory disease. b. Prescription
– ZHI MEI JING YIN SAI JI12 – Anti-fungal Vaginal Cleansing Formula Explanation All the ingredients of this formula have an anti-parasitic and anti-fungal effect. This formula is best taken as a powder. c Prescription
– PEN QIANG JIE DU TANG13
– Pelvic Eliminating Toxins Decoction Explanation
– Hong Teng, Bai Jiang Cao, Pu Gong Ying and Tu Fu Ling resolve ToxicHeat. – Dan Shen, Mu Dan Pi and Chi Shao invigorate Blood and eliminate stasis. – Yi Yi Ren drains Damp-Heat and resolves Toxic-Heat. – Chuan Lian Zi moves Qi and eliminates stagnation. – Gan Cao resolves Toxic-Heat. This formula is suitable to treat chronic pelvic inflammatory disease from Toxic-Heat and stasis of Blood. d Prescription
– PEN QIANG LING14 – Pelvis Efficacious [Formula] Explanation
– Dang Gui nourishes and invigorates Blood. – Chi Shao, Dan Shen, Yan Hu Suo and San Leng invigorate Blood and eliminate stasis.
– Xiang Fu and Wu Yao move Qi and eliminate stagnation. – Hong Teng, Bai Jiang Cao and Gan Cao resolve Toxic-Heat. This formula, like the previous one, is suitable to treat chronic pelvic inflammatory disease. It is similar to the previous formula, but it puts the emphasis on invigorating Blood rather than on resolving Toxic-Heat. External treatment
Prescription
– She Chuang Zi Fructus Cnidii 15 g – Ku Shen Radix Sophorae flavescentis 15 g – Bai Bu Radix Stemonae 15g, Di Fu Zi Fructus Kochiae 15 g – Bai Xian Pi Cortex Dictami 15 g – Ming Fan Alumen 10 g Boil these ingredients for half an hour, strain and pour into a shallow bath for the patient to sit in for 15 minutes. Women’s Treasure remedy
– DRAIN THE JADE VALLEY This remedy, already mentioned under the previous pattern, drains Dampness and resolves Phlegm from the genital system. The tongue presentation appropriate to this remedy is a sticky, yellow coating that is
thicker on the root. Summary Toxic-Heat
Clinical manifestations
Profuse yellow, blood-stained or five-colour discharge that is sticky in consistency and with an odour, a feeling of heat, thirst, dark urine. Tongue: Red with a sticky, yellow or brown coating with Red spots. Pulse: Slippery and Rapid. Treatment principle
Clear Heat, resolve Toxin, resolve Dampness, stop discharge. Acupuncture
L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-3 Zhongji, Ren-2 Qugu, SP-10 Xuehai, KI-2 Rangu, LIV-3 Taichong. All with reducing or even method, no moxa. Herbal treatment
Pre scriptions
• WU WEI XIAO DU YIN Variation Five-Ingredient Dissolving Toxin Decoction Variation • ZHI MEI JING YIN SAI JI Anti-fungal Vaginal Cleansing Formula
• PEN QIANG JIE DU TANG Pelvic Eliminating Toxins Decoction • PEN QIANG LING Pelvis Efficacious [Formula] Women’s Treasure remedy
• DRAIN THE JADE VALLEY
Liver-Qi stagnation
Clinical manifestations Profuse white or yellow, sticky vaginal discharge without odour, hypochondrial pain, irritability, depression. Tongue: slightly Red on the sides. Pulse: Wiry. This discharge is due partly to stagnant Liver-Qi invading the Spleen and impairing its transportation and transformation function, and partly to stagnation of the Liver channel in the genital system. Treatment principle Pacify the Liver, move Qi, eliminate stagnation, strengthen the Spleen. Acupuncture T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, LIV-5 Ligou, SP-6 Sanyinjiao, ST-36 Zusanli, SP-9 Yinlingquan, BL-20 Pishu, BL-18 Ganshu, G.B.-26 Daimai, G.B.-41 Zulinqi (on the right) and T.B.-5 Waiguan (on the left). All with reducing or even method except for BL-20, ST-36 and SP-6 which should be needled with reinforcing method. Explanation
– T.B.-6, G.B.-34 and LIV-3 pacify the Liver, move Qi and eliminate stagnation. – LIV-5 pacifies the Liver and eliminates stagnation from the Liver channel
in the genital system. – BL-20, ST-36 and SP-6 tonify the Spleen. – SP-9 resolves Dampness from the genital system. – BL-18 moves Liver-Qi. – G.B.-41 and T.B.-5 regulate the Girdle Vessel and resolve Damp-Heat. – G.B.-26 consolidates the Girdle Vessel to stop vaginal discharges. Herbal treatment
Prescription
– XIAO YAO SAN Variation – Free and Easy Wanderer Powder Variation Explanation The first eight herbs constitute the formula Xiao Yao San which pacifies the Liver, moves Qi, eliminates stagnation, nourishes Blood and tonifies SpleenQi. – Yi Yi Ren and Bian Dou resolve Dampness. – Xiang Fu moves Qi and eliminates stagnation. Women’s Treasure remedy
– FREEING THE MOON This remedy pacifies the Liver, moves Qi, eliminates stagnation, tonifies Spleen-Qi, resolves Dampness and nourishes Liver-Blood. The tongue presentation appropriate to this remedy is a body that is slightly Pale on the sides. Summary Liver-Qi stagnation
Clinical manifestations
Profuse white or yellow, sticky vaginal discharge without odour, hypochondrial pain, irritability, depression. Tongue: slightly Red on the sides. Pulse: Wiry. Treatment principle
Pacify the Liver, move Qi, eliminate stagnation, strengthen the Spleen. Acupuncture
T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, LIV-5 Ligou, SP-6 Sanyinjiao, ST-36 Zusanli, SP-9 Yinlingquan, BL-20 Pishu, BL-18 Ganshu, G.B.-26 Daimai, G.B.-41 Zulinqi (on the right) and T.B.-5 Waiguan (on the left). All with reducing or even method except for BL-20, ST-36 and SP-6 which should be needled with reinforcing method. Herbal treatment
Pre scription
• XIAO YAO SAN Variation Free and Easy Wanderer Powder Variation Women’s Treasure remedy
• FREEING THE MOON
Ancient acupuncture prescriptions for excessive vaginal discharge
1. From the ABC of Acupuncture, Zhen Jiu Jia Yi Jing (AD 259): • For white vaginal discharge with infertility: BL-31 Shangliao.15 • For red and white vaginal discharge with a feeling of distension below the heart: BL-32 Ciliao.16 • For red vaginal discharge that is white at times, retention of urine from Qi stagnation and scanty periods: BL-33 Zhongliao.17 • For greenish vaginal discharge or incessant red vaginal discharge, with itching and pain of the vagina extending to the hypogastrium and inability to bend forward or backward: BL-34 Xialiao.18 2. G.B.-26 Daimai, Ren-4 Guanyuan, Ren-6 Qihai, SP-6 Sanyinjiao, BL30 Baihuanshu, P-5 Jianshi (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601).19 3. For red and white vaginal discharge: G.B.-26 Daimai, Ren-4 Guanyuan, Ren-6 Qihai, SP-6 Sanyinjiao, BL-30 Baihuanshu, P-5 Jianshi (Miraculous Classic, Shen Ying Jing, 1425). 4. For red and white vaginal discharge: Ren-2 Qugu (seven moxa cones), LIV-3 Taichong, Ren-4 Guanyuan, KI-7 Fuliu, SP-6 Sanyinjiao and ST-25 Tianshu (100 moxa cones) (Collection of Acupuncture and Moxibustion, Zhen Jiu Ji Cheng, 1874). 5. For red and white vaginal discharge: Du-4 Mingmen, Ren-14 Shenjue and Ren-3 Zhongji, all with seven moxa cones (Illustrated Supplement to the Classic of Categories, Lei Jing Tu Yi, 1624).
Prescriptions by Fu Qing Zhu The formulae used by Fu Qing Zhu for vaginal discharge are as follows. – WAN DAI TANG20 – Ending Vaginal Discharge Decoction (see above) This is for white vaginal discharge due to Dampness and Spleen deficiency. – JIA JIAN XIAO YAO SAN21 – Modified Free and Easy Wanderer Powder – YI HUANG TANG – Change Yellow Decoction (see above) This formula is for yellow vaginal discharge from Damp-Heat with a background of Spleen and Kidney deficiency. – LI HUO TANG22 – Drain Fire Decoction – QING GAN ZHI LIN TANG23 – Clearing the Liver and Stopping ‘Lin’ Decoction This formula is for red vaginal discharge from Damp-Heat and LiverFire.
Prognosis and prevention Both acupuncture and herbal medicine are effective for excessive vaginal discharge but the results will definitely be slow because this condition can be very stubborn. Herbal medicine is more effective than acupuncture especially for the Full patterns because herbs are better at resolving Dampness and Toxic-Heat. The pattern from Toxic-Heat is the most difficult to treat and the one from Spleen deficiency and Dampness the easiest (or rather, least difficult). A woman suffering from excessive vaginal discharge should definitely refrain from eating excessive amounts of dairy and greasy foods and sugar: in severe conditions, complete abstention from eating these foods would be recommended.
Western view A slight vaginal discharge is physiological: this is clear in colour and consists of cervical mucus, vaginal transudate, bacteria and squamous epithelial cells. The physiological discharge varies in amount according to individual variations, pregnancy, sexual response and menstrual cycle (being thicker during mid-cycle). A physiological discharge will have no odour and will not be accompanied by itching or burning, and the vaginal pH will be normal (i.e. less than 5). The possible causes of an excessive vaginal discharge are: • infection/inflammation • foreign body • neoplasm (including cervical, endometrial or vaginal carcinoma) • cervical erosion • fistulae • non-genital causes. Infection can take place in the lower genital tract giving rise to vaginitis, or in the upper genital tract. The two main infections, from Candida albicans and Trichomonas vaginalis, are discussed in Chapter 62 on vaginal itching. Candidiasis is characterized by a thick, white discharge with itching but without odour. The presence of an odour suggests bacterial vaginosis, a fistula or a foreign body such as a tampon. A dark discharge may indicate a neoplasm, a foreign body or a fistula. An intra-uterine device may cause infection of the upper genital tract, but it may also cause a non-infectious, mucus, clear discharge. Cervical erosion may be characterized by a mucoid discharge. Cervical carcinoma may manifest with a watery, dark, offensive discharge and
endometrial carcinoma with a brown, watery, offensive discharge. Non-genital causes of excessive vaginal discharge include urinary incontinence and urinary tract fistulae. The sudden onset of a discharge suggests infection which can be associated with the end of a pregnancy, the contraceptive pill, a course of antibiotics or a new sexual relationship. In 90% of cases, excessive vaginal discharge is caused by infection from one of three agents: Candida albicans, Trichomonas vaginalis and Gardnerella vaginalis. The first two are discussed in Chapter 62. Gardnerella vaginalis is a bacterial infection of the vagina which causes a foul-smelling, thin, greyish discharge, sometimes with tiny bubbles. Another possible cause of vaginal discharge is infection with Chlamydia trachomatis which is classified as a bacterium but is actually an obligate intracellular parasite. Infection with Chlamydia is often symptomless but the long-term consequences of its untreated infection are potentially serious, including pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy, infertility and perinatal transmission to infants. In the USA, 30– 50% of cases of pelvic inflammatory disease are due to infection with Chlamydia. When symptoms do occur they may include a vaginal discharge, dysuria and lower abdominal pain. The incidence of infection from Chlamydia in women with genitourinary symptoms in the UK varies between 6% and 9%. End notes 1. Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke
), Shanghai People’s Publishing House, Shanghai, p. 1. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..
2. Cited in Chinese Medicine Research Institute and Guangzhou College of Traditional Chinese Medicine 1980 Concise Dictionary of Chinese Medicine (Jian Ming Zhong Yi Ci Dian
), People’s Health Publishing House, Beijing, p. 983..
3. Ibid., p. 414..
4. Fu Qing Zhu’s Gynaecology, p. 2..
5. Ibid., p. 4..
6. Long Jiajun, Zhang Qi, Shen Kang, Lin Hongyang 1996 Dr Zhang Jian Zhai’s Experience in Treating Gynaecological Diseases (Zhang Jian Zhai Zhi Liao Fu Ke Bing Jing Yan), Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi
), China Academy of Traditional Chinese Medicine, Beijing, No. 1, p. 17..
7. Ibid., p. 17..
8. Cong Chun Yu 1994 Selection of Clinical Experiences in Chinese Medicine Gynaecology (Zhong Yi Fu Ke Lin Chuang Jing Yan Xuan
), Chinese Pharmacology Publishing House, Beijing, p. 146..
9. Ibid., p. 144..
10. Ibid., p. 144..
11. Ibid., p. 145..
12. Hu Xi Ming 1990 Great Treatise of Secret Formulae in Chinese Medicine (Zhong Guo Zhong Yi Mi Fang Da Quan
), Culture Publishing House, Shanghai, Vol. 2, p. 117..
13. Ibid., p. 145..
14. Ibid., p. 145..
15. Shandong College of Traditional Chinese Medicine 1980 An Explanation of the ABC of Acupuncture (Zhen Jiu Jia Yi Jing Jiao Shi
), People’s Health Publishing House, Beijing, p. 1471. The ABC of Acupuncture was written by Huang Fu Mi c. AD 259..
16. Ibid., p. 1471..
17. Ibid., p. 1471..
18. Ibid., pp 1471–1472..
19. Heilongjiang Province National Medical Research Group 1984 An Explanation of the Great Compendium of Acupuncture (Zhen Jiu Da Cheng Jiao Shi
), People’s Health Publishing House, Beijing, p. 1107. The Great Compendium of Acupuncture itself was published in 1601..
20. Fu Qing Zhu’s Gynaecology, p. 2..
21. Ibid., p. 3..
22. Ibid., p. 5..
23. Ibid., pp 6–7..
CHAPTER 62 Vaginal Itching (and Trichomonas and Candida Infections and Genital Eczema)
AETIOLOGY 827 PATHOLOGY 828 IDENTIFICATION OF PATTERNS AND TREATMENT 828 Damp-Heat in the Liver channel 828 Dampness and Spleen-Qi deficiency 829 Liver- and Kidney-Yin deficiency 830 Ancient acupuncture prescriptions for vaginal itching 831 PROGNOSIS AND PREVENTION 831 WESTERN VIEW 831 APPENDIX I: TRICHOMONAS AND CANDIDA INFECTIONS 832 Trichomonas vaginalis infection 832 Candida infection 832 APPENDIX II: GENITAL ECZEMA 832 IDENTIFICATION OF PATTERNS AND TREATMENT 833 Damp-Heat in the Liver channel 833 Blood deficient and dry 833
This chapter discusses persistent itching of the vulva and/or vagina, which may be accompanied by an excessive vaginal discharge, but may also occur on its own. For the Chinese disease category of ‘Excessive Vaginal Discharge’, see Chapter 61.
Aetiology
Emotional problems Emotional problems that affect the Liver cause stagnation of Liver-Qi; after some time, this may turn into Heat and affect the Liver main and Connecting channels both of which flow to the external genitalia. Heat in the Liver channel may cause itching of the vulva. Irregular diet Excessive consumption of dairy and greasy foods may lead to the formation of Dampness which often settles in the Lower Burner. Dampness is also a major cause of itching, and frequently occurs in the vulva. When irregular diet is combined with emotional problems, Heat in the Liver channel combines with Dampness and forms Damp-Heat in the Lower Burner which causes even more intense vulvar itching. Excessive physical work Excessive physical work or sports may weaken the Spleen: after some time, the deficient Spleen-Qi fails to transform and transport fluids which accumulate in the form of Dampness. Overwork Working long hours without adequate rest for many years may cause a deficiency of Liver- and Kidney-Yin. The Yin and Blood deficiency cause dryness and itching of the vulva.
Pathology The pathology of vulvar itching is overwhelmingly characterized by Dampness which may occur with or without Heat and which may be related to the Liver or Spleen channels. Of the deficiency types, there is only that due to Liver- and Kidney-Yin deficiency, which occurs mostly in older women. In this case, the deficiency of Yin leads to dryness and also to the development of a kind of internal Wind that causes the itching. In the deficiency type of vulvar itching, the organs involved are the Liver (whose channel curves around the genitalia) and the Kidneys (whose channel controls the two lower orifices). Thus, Heat, Dampness and Wind are the three main causes of vulvar itching and, indeed, the main causes of itching in general. The patterns discussed are: • Damp-Heat in the Liver channel • Dampness and Spleen-Qi deficiency • Liver- and Kidney-Yin deficiency.
Identification of patterns and treatment
Damp-Heat in the Liver channel
Clinical manifestations Intense vulvar or vaginal itching, yellow vaginal discharge, occasionally pain on intercourse, mental restlessness, irritability, insomnia, dark urine. Tongue: Red, with redder sides and a yellow, sticky coating on the root with Red spots. Pulse: Slippery or Wiry. Treatment principle Clear the Liver, drain Dampness, clear Heat, kill parasites, stop itching. The modern equivalent of killing parasites is combating fungal infection, a function that many of the herbs that kill parasites also have. Acupuncture Ren-3 Zhongji, Ren-2 Qugu, LIV-5 Ligou, LIV-4 Zhongfeng, SP-9 Yinlingquan, SP-6 Sanyinjiao, BL-33 Zhongliao. All with reducing or even method, no moxa. Explanation
– Ren-3 and Ren-2 drain Damp-Heat from the genital area and regulate the Directing Vessel. – LIV-5, Connecting point, drains Dampness from the Liver channel in the genital area. The Connecting channel circles around the genitalia.
– LIV-4 stops pain and itching in the genitalia. – SP-9 and SP-6 drain Dampness from the Lower Burner and genitalia. – BL-33 drains Dampness from the genital region. Herbal treatment
a Prescription
– BI XIE SHEN SHI TANG Variation – Dioscorea Draining Dampness Decoction Variation Explanation
– Bi Xie, Yi Yi Ren, Ze Xie, Fu Ling, Tong Cao, Hua Shi and Huang Bo drain Damp-Heat from the Lower Burner and the genito-urinary system. – Mu Dan Pi clears Heat from the Liver channel. – Ku Shen drains Dampness and kills parasites. See also below. b Prescription
– LONG DAN XIE GAN TANG – Gentiana Draining the Liver Decoction
Explanation This formula, already explained, drains Liver-Fire and Liver-related DampHeat from the Upper and Lower Burner: in this case, it can drain Liver-Fire and Damp-Heat from the genital system. Compared with the previous formula, the present one is for Damp-Heat deriving from Liver-Fire and is therefore suitable when the symptoms of Liver-Fire are pronounced (bitter taste, thirst, scanty, dark urine, red face, constipation) and the tongue is Red with redder and swollen sides and a yellow coating. The previous formula concentrates more on draining Dampness and is therefore suitable for Dampness without pronounced Heat. The tongue presentation appropriate to the previous formula is a Red body with a yellow, sticky coating on the root. Modifications These modifications apply to both formulae. • If there are pronounced symptoms of Fire with constipation, add Da Huang Radix et Rhizoma Rhei. • If there is a fungal infection, add Bai Xian Pi Cortex Dictami and Ku Shen Radix Sophorae flavescentis (unless already in the prescription). • If there is redness of the vagina and vulva, add Zi Hua Di Ding Herba Violae, Pu Gong Ying Herba Taraxaci and Jin Yin Hua Flos Lonicerae. External washes
– Huang Bo Cortex Phellodendri – Ku Shen Radix Sophorae flavescentis
– She Chuang Zi Fructus Cnidii – Ming Fan Alumen – Bai Zhi Radix Angelicae dahuricae Boil 10 g of each herb in about 2 pints of water for about half an hour, strain, dilute with some cold water and pour into a shallow, lukewarm bath where the patient should sit for about 15 minutes. Another external wash is composed of: – Mang Xiao Sulfas Natrii – Ku Shen Radix Sophorae flavescentis – She Chuang Zi Fructus Cnidii – Huang Bo Cortex Phellodendri – Chuan Jiao Pericarpium Zanthoxyli (one-fifth of the dose of the other herbs)1 And another2 is composed of: – She Chuang Zi Fructus Cnidii 50 g – Bai Xian Pi Cortex Dictami 50 g – Huang Bo Cortex Phellodendri 50 g – Jing Jie Herba Schizonepetae 15 g – Fang Feng Radix Saposhnikoviae 15 g – Ku Shen Radix Sophorae flavescentis 15 g – Long Dan Cao Radix Gentianae 15 g
– Bo He Herba Menthae haplocalycis 1 g This external wash is suitable particularly for acute cases with intense itching. Three Treasures remedies
– DRAIN FIRE This remedy is a variation of the formula Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction which drains Liver-Fire and resolves Damp-Heat from the Lower Burner. The tongue presentation appropriate to this remedy is a Red body, with redder sides and with a dry, yellow coating. – SEPARATE CLEAR AND TURBID This remedy promotes the transformation of fluids in the Lower Burner (and therefore resolves Dampness) and tonifies Qi. The tongue presentation appropriate to this remedy is a sticky coating. Summary Damp-Heat in the Liver channel
Clinical manifestations
Intense vulvar or vaginal itching, yellow vaginal discharge, occasionally pain on intercourse, mental restlessness, irritability, insomnia, dark urine. Tongue: Red, with redder sides and a yellow, sticky coating on the root with Red spots. Pulse: Slippery or Wiry. Treatment principle
Clear the Liver, drain Dampness, clear Heat, kill parasites, stop itching. Acupuncture
Ren-3 Zhongji, Ren-2 Qugu, LIV-5 Ligou, LIV-4 Zhongfeng, SP-9 Yinlingquan, SP-6 Sanyinjiao, BL-33 Zhongliao. All with reducing or even method, no moxa. Herbal treatment
Pre scriptions
• BI XIE SHEN SHI TANG Variation Dioscorea Draining Dampness Decoction Variation • LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction Three Treasures remedies
• DRAIN FIRE • SEPARATE CLEAR AND TURBID
Dampness and Spleen-Qi deficiency
Clinical manifestations Vulvar and vaginal itching, a slight white, vaginal discharge, tiredness, loose stools. Tongue: Pale with a sticky, white coating. Pulse: Weak and slightly Slippery. Treatment principle Resolve Dampness, kill parasites, tonify the Spleen. Acupuncture SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-12 Zhongwan, Ren-9 Shuifen, ST36 Zusanli, BL-20 Pishu, BL-22 Sanjiaoshu, BL-32 Ciliao, BL-33 Zhongliao, Ren-3 Zhongji, Ren-2 Qugu. All with reducing or even method except for Ren-12, ST-36 and BL-20 which should be needled with reinforcing method. Moxa can be used. Explanation
– SP-9 and SP-6 drain Dampness from the genital system. – Ren-12, ST-36 and BL-20 tonify the Spleen. – Ren-9 and BL-22 promote the transformation of fluids and therefore help to drain Dampness. – BL-32 and BL-33 drain Dampness from the genito-urinary system. BL-
32 also has a slight tonic action. – Ren-3 and Ren-2 drain Dampness from the genital system and regulate the Directing Vessel. Herbal treatment
Prescription
– BI XIE FEN QING YIN and LIU JUN ZI TANG Variation – Dioscorea Separating the Clear Decoction and Six Gentlemen Decoction Variation Explanation The first four herbs constitute the formula Bi Xie Fen Qing Yin which drains Dampness from the genito-urinary system. – Bi Xie drains Dampness and separates clear from turbid in the genitourinary system. – Yi Zhi Ren and Wu Yao warm the Bladder and Kidneys to help to separate turbid from clear fluids. – Shi Chang Pu opens the orifices and the Water passages and thus helps to drain Dampness in the genito-urinary system. – Ren Shen and Bai Zhu tonify Qi. – Fu Ling drains Dampness.
– Zhi Gan Cao harmonizes. – Chen Pi and Ban Xia help to resolve Dampness. – Ku Shen kills parasites, has an anti-fungal effect and stops itching. Three Treasures remedies
– SEPARATE CLEAR FROM TURBID and SOOTHE THE CENTRE The first remedy, Separate Clear from Turbid, is a variation of the formula Bi Xie Fen Qing Yin mentioned above which drains Dampness, and the second remedy is a variation of the formula Xiang Sha Liu Jun Zi Tang Aucklandiae-Amomum Six Gentlemen Decoction which tonifies the Spleen, moves Qi and resolves Dampness. When two remedies are used together, their dosages should be reduced; I would suggest taking two tablets for each of the remedies per day. Summary Dampness and Spleen-Qi deficiency
Clinical manifestations
Vulvar and vaginal itching, a slight white, vaginal discharge, tiredness, loose stools. Tongue: Pale with a sticky, white coating. Pulse: Weak and slightly Slippery. Treatment principle
Resolve Dampness, kill parasites, tonify the Spleen.
Acupuncture
SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-12 Zhongwan, Ren-9 Shuifen, ST36 Zusanli, BL-20 Pishu, BL-22 Sanjiaoshu, BL-32 Ciliao, BL-33 Zhongliao, Ren-3 Zhongji, Ren-2 Qugu. All with reducing or even method except for Ren-12, ST-36 and BL-20 which should be needled with reinforcing method. Moxa can be used. Herbal treatment
Pre scription
• BI XIE FEN QING YIN and LIU JUN ZI TANG Variation Dioscorea Separating the Clear Decoction and Six Gentlemen Decoction Variation Three Treasures remedies
• SEPARATE CLEAR FROM TURBID • SOOTHE THE CENTRE
Liver- and Kidney-Yin deficiency
Clinical manifestations Slight itching of the vulva and vagina with a burning sensation, dryness of the vagina, five-palm heat, dizziness, tinnitus, a feeling of heat in the afternoon. Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty. Treatment principle Nourish Liver- and Kidney-Yin, clear Empty-Heat. Acupuncture Ren-4 Guanyuan, LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), LIV-5 Ligou, Ren-3 Zhongji. All with reinforcing method; no moxa. Explanation
– Ren-4 nourishes Liver and Kidneys. – LIV-8, SP-6 and KI-3 nourish Liver and Kidneys. – LU-7 and KI-6 regulate the Directing Vessel and nourish Liver and Kidney-Yin. – LIV-5 regulates the Liver Connecting channel which flows to the genitalia.
– Ren-3 drains Dampness from the genito-urinary system. Herbal treatment
Prescription
– ZHI BO DI HUANG WAN Variation – Anemarrhena-Phellodendron-Rehmannia Pill Variation Explanation The first eight herbs constitute the formula Ba Wei Di Huang Wan, already explained, which nourishes Liver- and Kidney-Yin and clears Empty-Heat. – Bai Xian Pi and Ku Shen drain Dampness and stop itching. Summary Liver- and Kidney-Yin deficiency
Clinical manife stations
Slight itching of the vulva and vagina with a burning sensation, dryness of the vagina, five-palm heat, dizziness, tinnitus, a feeling of heat in the afternoon. Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty. Tre atme nt principle
Nourish Liver- and Kidney-Yin, clear Empty-Heat.
Acupuncture
Ren-4 Guanyuan, LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), LIV-5 Ligou, Ren-3 Zhongji. All with reinforcing method; no moxa. He rbal tre atme nt
Prescription
• ZHI BO DI HUANG WAN Variation Anemarrhena-PhellodendronRehmannia Pill Variation Exte rnal tre atme nts
The following prescriptions for external washes apply to all the above patterns. • TA YANG FANG Calming Itching Formula • SHE CHUANG ZI SAN Cnidium Powder
Ancient acupuncture prescriptions for vaginal itching3
1. Ren-3 Zhongji for coldness on the sides of the abdomen, itching and pain of the vagina and amenorrhoea (ABC of Acupuncture, Zhen Jiu Jia Yi Jing, 259 AD). 2. Ren-1 Huiyin, Ren-3 Zhongji and SP-6 Sanyinjiao for sudden redness, swelling and pain of the external genitalia (Great Compendium of Acupuncture, Zhen Jiu Da Cheng, 1601).
Prognosis and prevention Both acupuncture and herbal medicine give good results for vulvar and vaginal itching but it may take a long time (i.e. weeks or even months) to eradicate the problem completely, especially if it is caused by Candida or Trichomonas infection. External treatment with herbal washes is essential to the success of the treatment. It is very important for a woman suffering from vaginal itching not to consume too many dairy foods or greasy foods which create Dampness. She should also avoid eating sugar.
Western view The two most common conditions that may cause vulvar and vaginal itching are Candida and Trichomonas infection. Candidiasis Candida albicans is the most common of the fungi causing vulvovaginitis. Factors which predispose women to Candida infection are antibiotics, pregnancy, stress, diabetes, immunodeficiency and immunosuppressive agents such as cytotoxic drugs and corticosteroids. Oral contraceptives also contribute to an increased risk of yeast infection. The main clinical manifestations of Candida infection are a vaginal discharge, itching, dyspareunia (pain on intercourse) and dysuria. There may be no vaginal discharge or one which may range from little to profuse. Its consistency may also vary but most commonly it is a white discharge that resembles cottage cheese. Trichomonas vaginalis This is a protozoan that causes vulvovaginitis. It is usually sexually transmitted but it is sometimes transmitted via infested reservoirs such as hot tubs. The organism infects the vulva and vagina but also the Bartholin’s glands, the periurethral glands, urethra and bladder. The main clinical manifestations are a vaginal discharge often associated with odour, itching and, occasionally, burning. The discharge may be frothy green or yellow. There is also vulvar oedema and erythema (redness).
Appendix i: trichomonas and candida infections Modern Chinese books report the treatment of Western-defined diseases such as infection with Trichomonas vaginalis or Candida albicans (see above).
Trichomonas vaginalis infection From the Chinese point of view, infection with Trichomonas vaginalis falls under the category of ‘Excessive Vaginal Discharge’ (Ch. 61) or ‘Vaginal Itching’. The pathology of Trichomonas vaginalis infection is usually due to a Spleen-Qi deficiency with Damp-Heat. Seen from a Chinese perspective, it is the presence of Damp-Heat in the genital system that favours the infection from the Trichomonas vaginalis organism. The treatment principle is therefore to tonify the Spleen, resolve Dampness, clear Heat, kill parasites and stop itching. The modern equivalent of ‘killing parasites’ consists in the use of herbs that have an anti-fungal and anti-parasite effect. Prescription
– BI XIE SHEN SHI TANG – Dioscorea Draining Dampness Decoction Explanation This formula has already been explained above. External treatments
The following prescriptions may be used as a wash. – TA YANG FANG – Calming Itching Formula
– YIN DAO 1 HAO PIAN – Vaginal No. 1 Suppository This is a prepared vaginal suppository but the two herbs can also be used as a wash. – SHE HUA TANG – Cnidium-Zanthoxylum Decoction As for acupuncture, the treatment is the same as the ones listed above for the Liver Damp-Heat or Spleen deficiency with Dampness types.
Candida infection From a Chinese perspective, this is also due to a Spleen deficiency leading to Dampness in the genital system. As for Trichomonas vaginalis, it is the Dampness that creates a favourable environment for the multiplication of the Candida fungus. The following are prescriptions for external treatments as a wash. The internal treatment must be based on one of the above-mentioned formulae that resolve Dampness in cases of Excessive Vaginal Discharge or Vaginal Itching. External treatments
a. EMPIRICAL PRESCRIPTION b. ZHI MEI XI JI – Treating Fungus [infection] Wash Formula
Appendix ii: genital eczema Genital eczema in women manifests with a red rash, vesicles or papules around the external genitalia. The vesicles or papules exude a fluid. This problem is due to the downward infusion of Damp-Heat in the genital area or to deficiency and dryness of the Blood. In the old times, it would have been classified under ‘Vaginal Itching’.
Identification of patterns and treatment
Damp-Heat in the Liver channel
Clinical manifestations Genital eczema with papules which ooze a fluid, genital area red and moist, itching. Tongue: yellow, sticky coating. Pulse: Slippery on the whole and Wiry on the left Middle position. Treatment principle Clear the Liver, clear Heat, drain Dampness, expel Wind, stop itching. Acupuncture LU-7 Lieque on the right and KI-6 Zhaohai on the left, Ren-1 Huiyin, SP-9 Yinlingquan, SP-6 Sanyinjiao, LIV-5 Ligou, BL-22 Sanjiaoshu, L.I.-11 Quchi, SP-10 Xuehai, Baichongwo (extra point). All with even method. Explanation
– LU-7 and KI-6 regulate the Directing Vessel and affect the external genitalia. – Ren-1 resolves Dampness and affects the external genitalia. – SP-9 and SP-6 resolve Damp-Heat. – LIV-5 resolves Dampness from the Liver channel in the external genitalia area.
– BL-22 resolves Dampness from the Lower Burner. – L.I.-11 clears Heat and resolves Dampness. – SP-10, particularly in combination with L.I.-11, cools Blood and stops itching. – Baichongwo, an extra point situated one cun above SP-10 on the Spleen channel, stops itching. Its name means ‘100 insects’ nest’, a metaphor for intense itching as if insects were crawling under the skin. Herbal treatment
Prescription
– QING GAN HUA SHI TANG – Clearing the Liver and Resolving Dampness Decoction Explanation
– Long Dan Cao drains Damp-Heat from the Liver channel in the Lower Burner. – Bi Xie, Yi Yi Ren, Huang Bo, Fu Ling, Ze Xie and Cang Zhu drain Damp-Heat from the Lower Burner. – Mu Dan Pi clears Heat from the Liver channel. – Tong Cao removes obstructions from the Connecting channels.
– Cang Er Zi and Bai Ji Li expel Wind and stop itching. Women’s Treasure remedy
– DRAIN THE JADE VALLEY This remedy drains Damp-Heat from the genital system. The tongue presentation appropriate to this remedy is a sticky, yellow coating on the root with Red spots. Summary Damp-Heat in the Liver channel
Clinical manifestations
Genital eczema with papules which ooze a fluid, genital area red and moist, itching. Tongue: yellow, sticky coating. Pulse: Slippery on the whole and Wiry on the left Middle position. Treatment principle
Clear the Liver, clear Heat, drain Dampness, expel Wind, stop itching. Acupuncture
LU-7 Lieque on the right and KI-6 Zhaohai on the left, Ren-1 Huiyin, SP-9 Yinlingquan, SP-6 Sanyinjiao, LIV-5 Ligou, BL-22 Sanjiaoshu, L.I.-11 Quchi, SP-10 Xuehai, Baichongwo (extra point). All with even method. Herbal treatment
Pre scription
• QING GAN HUA SHI TANG Clearing the Liver and Resolving Dampness Decoction Women’s Treasure remedy
• DRAIN THE JADE VALLEY
Blood deficient and dry
Clinical manifestations Genital eczema with thickening of the skin, dryness of the vagina, dry, red rash, itching. Tongue: Pale, Thin and dry. Pulse: Choppy. Treatment principle Nourish and moisten Blood, stop itching. Acupuncture LU-7 Lieque on the right and KI-6 Zhaohai on the left, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, SP-10 Xuehai, Baichongwo, LIV-5 Ligou. All with reinforcing method except for SP-10, Baichongwo and LIV-5 which should be needled with even method. Explanation
– LU-7 and KI-6 regulate the Directing Vessel and affect the external genitalia. – Ren-4, ST-36 and SP-6 nourish Blood. – SP-10 and Baichongwo stop itching. – LIV-5 affects the Liver channel in the external genitalia area. Herbal treatment
Prescription
– HE XUE ZHI YANG TANG – Harmonizing Blood and Stopping Itching Decoction Modifications
• If itching is intense, add Zhen Zhu Mu Concha margaritiferae usta, Di Long Pheretima and Chan Tui Periostracum Cicadae. • If there is constipation, increase the dosage of Shou Wu Radix Polygoni multiflori preparata and add Huo Ma Ren Semen Cannabis. External treatment
– QING DAI SAN – Indigo Powder Explanation
– Qing Dai resolves Toxic-Heat. – Huang Bo and Hua Shi drain Damp-Heat from the Lower Burner. – Shi Gao clears Heat and stops itching.
This formula is applicable to both patterns of genital eczema. The above dosages are for a 5-day wash. The herbs are boiled for an hour in 7–8 pints of water, strained and then divided into five doses. Each dose is then diluted with water and applied to the genital area; alternatively, the mixture can be poured into the bath with the woman sitting in it for about 20 minutes. The doses should be kept in the fridge. Summary Blood deficient and dry
Clinical manife stations
Genital eczema with thickening of the skin, dryness of the vagina, dry, red rash, itching. Tongue: Pale, Thin and dry. Pulse: Choppy. Tre atme nt principle
Nourish and moisten Blood, stop itching. Acupuncture
LU-7 Lieque on the right and KI-6 Zhaohai on the left, Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, SP-10 Xuehai, Baichongwo, LIV-5 Ligou. All with reinforcing method except for SP-10, Baichongwo and LIV-5 which should be needled with even method. He rbal tre atme nt
Prescription
• HE XUE ZHI YANG TANG Harmonizing Blood and Stopping Itching Decoction Exte rnal tre atme nt
• QING DAI SAN Indigo Powder
End notes 1. Hu Xi Ming 1990 Great Treatise of Secret Formulae in Chinese Medicine (Zhong Guo Zhong Yi Mi Fang Da Quan
), Culture Publishing House, Shanghai, Vol. 2, p. 95..
2. Ibid., p. 97..
3. Wang Xue Tai 1995 Great Treatise of Chinese Acupuncture (Zhong Guo Zhen Jiu Da Quan
), Henan Science and Technology Publishing House, p. 470..
CHAPTER 63 Prolapse of the Uterus
AETIOLOGY AND PATHOLOGY 835 IDENTIFICATION OF PATTERNS AND TREATMENT 835 Spleen-Qi sinking 836 Kidney-Qi deficient and sinking 836 Ancient acupuncture prescriptions for prolapse of the uterus 837 PROGNOSIS AND PREVENTION 838 WESTERN VIEW 838 Prolapse of the uterus is always due to Spleen-Qi or Kidney-Qi sinking and it therefore always occurs against a background of Spleen or Kidney deficiency.
Aetiology and pathology
Excessive physical exercise Excessive physical exercise or sports over a long period of time injures the muscles and leads to Spleen-Qi deficiency. Excessive lifting over a long period of time injures the Kidneys. In both these cases, Spleen- or KidneyQi deficiency easily progresses to Qi sinking which causes the prolapse. Chronic illness A prolonged illness inevitably leads to a deficiency of the Spleen and/or Kidneys: if this turns into Qi sinking, it causes a prolapse. Childbirth A long labour with excessive strain often leads to prolapse of the uterus. From a Chinese perspective, this is due to the great muscle strain occurring during labour which injures the Spleen, as this organ governs the muscles. Prolonged coughing Prolonged, chronic coughing induces an excessive descent of Qi and may cause a uterine prolapse.
Identification of patterns and treatment The pathology of prolapse of the uterus is always due to Qi deficient and sinking: this may be Spleen-Qi, Kidney-Qi or both. It should be noted that a prolapse of the uterus can cause clinical manifestations even when it is very slight. Symptoms include a feeling of bearing down in the lower abdomen and frequent urination. From an acupuncture perspective, apart from the Spleen and Kidneys, three Extraordinary Vessels are involved in the pathology of prolapse of the uterus: the Governing, Directing and Girdle Vessels. The Governing and Directing Vessels run along the midline of the body, one Yang, one Yin in nature. As the uterus is centrally located, a weakness of these two vessels may cause a prolapse. For this reason, a combination of Governing and Directing Vessel points is particularly effective to treat prolapse of the uterus, e.g. Du-20 Baihui and Ren-6 Qihai. The Girdle Vessel is also involved in prolapses because it is the belt that ‘binds’ the lower abdominal organs: when the belt is too slack, the organs sag and prolapses may occur (see Ch. 7). For this reason, points from the Girdle Vessel, such as G.B.-28 Weidao, are also used for uterine prolapse. The patterns discussed are: • Spleen-Qi sinking • Kidney-Qi deficient and sinking.
Spleen-Qi sinking
Clinical manifestations Prolapse of the uterus, a feeling of bearing down in the lower abdomen, tiredness, loose stools, poor appetite, depression. Tongue: Pale. Pulse: Weak. Treatment principle Tonify and raise Spleen-Qi. Acupuncture Du-20 Baihui, Ren-12 Zhongwan, Ren-6 Qihai, ST-36 Zusanli, SP-3 Taibai, BL-20 Pishu, G.B.-28 Weidao, Zigong (extra point). All with reinforcing method, moxa is applicable. Explanation
– Du-20 raises Qi to treat prolapses. It is particularly effective if stimulated with direct moxa cones. – Ren-12, ST-36, SP-3 and BL-20 tonify Spleen-Qi. – Ren-6 tonifies and raises Qi. This needle can be also be inserted horizontally downward for about 1.5 or 2 inches and rotated until the patient experiences the propagation of the needling sensation to the hypogastrium. – G.B.-28, a point of the Girdle Vessel, raises Qi by ‘tightening the belt’ of
this vessel. This needle may also be inserted horizontally towards the midline for about 1.5–2 inches and rotated until the patient experiences the propagation of the needling sensation to the hypogastrium. – Zigong strengthens the Uterus. It is situated four cun below the navel (level with Ren-3 Zhongji) and three cun lateral to the midline. Herbal treatment
Prescription
– BU ZHONG YI QI TANG – Tonifying the Centre and Benefiting Qi Decoction Explanation This formula, already explained, tonifies and raises Qi and is specific to treat prolapses. Three Treasures remedy
– TONIFY QI AND EASE THE MUSCLES This remedy is a variation of the formula Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction which tonifies and raises Qi. The tongue presentation appropriate to this remedy is a Pale body. Summary
Spleen-Qi sinking
Clinical manifestations
Prolapse of the uterus, a feeling of bearing down in the lower abdomen, tiredness, loose stools, poor appetite, depression. Tongue: Pale. Pulse: Weak. Treatment principle
Tonify and raise Spleen-Qi. Acupuncture
Du-20 Baihui, Ren-12 Zhongwan, Ren-6 Qihai, ST-36 Zusanli, SP-3 Taibai, BL-20 Pishu, G.B.-28 Weidao, Zigong (extra point). All with reinforcing method, moxa is applicable. Herbal treatment
Pre scription
• BU ZHONG YI QI TANG Tonifying the Centre and Benefiting Qi Decoction Three Treasures remedy
• TONIFY QI AND EASE THE MUSCLES
Kidney-Qi deficient and sinking
Clinical manifestations Prolapse of the uterus, frequent urination, a bearing-down feeling in the lower abdomen, backache, depression. Tongue: Pale. Pulse: Deep, Weak. Treatment principle Tonify and raise Kidney-Qi. Acupuncture Du-20 Baihui, Ren-6 Qihai, ST-36 Zusanli, KI-3 Taixi, BL-23 Shenshu, G.B.-28 Weidao, Du-1 Changqiang, Ren-5 Shimen. All with reinforcing method, moxa is applicable. Explanation
– Du-20 raises Qi. It is particularly effective if stimulated with direct moxa cones. – Ren-6 and ST-36 tonify and raise Qi. The needle in Ren-6 can be also be inserted horizontally downward for about 1.5 or 2 inches and rotated until the patient experiences the propagation of the needling sensation to the hypogastrium. – KI-3 and BL-23 tonify the Kidneys. – G.B.-28, a point of the Girdle Vessel, raises Qi by ‘tightening the belt’ of
this vessel. This needle may also be inserted horizontally towards the midline for about 1.5–2 inches and rotated until the patient experiences the propagation of the needling sensation to the hypogastrium. – Du-1, with moxa cones only, tonifies the Governing Vessel to lift the uterus. – Ren-5, with moxa cones only, and especially in combination with Du-1, strengthens the Uterus and the Kidneys. Herbal treatment
a Prescription
– SHENG TI GU TUO JIAN – Lifting and Raising and Consolidating Collapse Decoction Explanation
– Dang Shen, Bai Zhu and Huang Qi tonify and raise Spleen-Qi. – Huang Jing and Gui Ban tonify the Kidneys and consolidate the Directing Vessel. – Ba Ji Tian tonifies Kidney-Yang. – Dang Gui nourishes Blood and strengthens the Uterus. – Zhi Ke and Yi Mu Cao move Qi and invigorate Blood and are added to
counteract the cloying action of the tonic herbs. – Sheng Ma, in combination with Huang Qi, raises Qi. – Da Zao harmonizes. b Prescription
– DA BU YUAN JIAN Variation – Great Tonifying the Original Qi Pill Variation Explanation
– Ren Shen tonifies the Original Qi. – Shu Di Huang, Shan Yao and Shan Zhu Yu tonify the Kidneys. – Bai Shao nourishes Blood and consolidates collapse. – Bai Zhi resolves Dampness from the genital tract. – Wu Wei Zi, Mu Li and Wu Zei Gu are absorbent and consolidate collapse. – Bai Zhu, Chai Hu and Sheng Ma tonify and raise Qi. – Chuan Lian Zi moves Qi. – Da Zao harmonizes. Summary
Kidney-Qi deficient and sinking
Clinical manife stations
Prolapse of the uterus, frequent urination, a bearing-down feeling in the lower abdomen, backache, depression. Tongue: Pale. Pulse: Deep, Weak. Tre atme nt principle
Tonify and raise Kidney-Qi. Acupuncture
Du-20 Baihui, Ren-6 Qihai, ST-36 Zusanli, KI-3 Taixi, BL-23 Shenshu, G.B.-28 Weidao, Du-1 Changqiang, Ren-5 Shimen. All with reinforcing method, moxa is applicable. He rbal tre atme nt
Prescriptions
• SHENG TI GU TUO JIAN Lifting and Raising and Consolidating Collapse Decoction • DA BU YUAN JIAN Variation Great Tonifying the Original Qi Pill Variation
Ancient acupuncture prescriptions for prolapse of the uterus 1
1. BL-31 for infertility, prolapse uteri and dribbling white vaginal discharge (ABC of Acupuncture, Zhen Jiu Jia Yi Jing, 1601). 2. HE-8 Shaofu and LIV-8 Ququan (The Classic of Miraculous Moxibustion, Shen Jiu Jing Lun, 1851). 3. LIV-3 Taichong, HE-8 Shaofu, KI-6 Zhaohai and LIV-8 Ququan (Great Compendium of Acupuncture and Moxibustion, Zhen Jiu Da Cheng, 1601).
Prognosis and prevention Both acupuncture and herbal medicine give good results in uterine prolapse. Often, acupuncture alone is enough. However, the prognosis depends on the degree of prolapse (see below). First-degree prolapse can be helped, second-degree prolapse is difficult to treat and third-degree prolapse will not respond to treatment. Women who have a very slight prolapse or who have been cured of a prolapse should pay great attention to not exercising too much and, in particular, to not running (jogging) or lifting. They should also make sure that they do not overwork and alternate work with periods of rest lying down.
Western view Prolapse of the uterus develops as a result of weight-bearing during pregnancy and the trauma of delivery. The decrease in oestrogen associated with the menopause is also a factor as this decrease causes a weakening of pelvic tissues. Prolapse of the uterus is classified in three degrees: • First degree: the cervix descends to the introitus. • Second degree: the cervix protrudes through the introitus. • Third degree: the entire uterus protrudes through the vaginal outlet (Fig. 63.1).
Figure 63.1 Three degrees of uterine prolapse. In the early stages, prolapse consists only in an elongated cervix which may reach up to 10 cm in length (instead of a normal 3 cm). When the striated muscular support of the vaginal canal is weakened by childbirth, coughing, lifting, straining, etc., there may be a marked descent of the anterior vaginal wall and of the base of the bladder, creating a cystocele; if the rectum bulges forward it gives rise to a rectocele. A cystocele will
cause a characteristic bearing-down sensation and frequency or incontinence of urine. A rectocele will cause an uncomfortable sensation in the rectum and constipation (see Fig. 63.2)
Figure 63.2 Cystocele and rectocele.
End note 1. Wang Xue Tai 1995 Great Treatise of Chinese Acupuncture (Zhong Guo Zhen Jiu Da Quan
), Henan Science and Technology Publishing House, p. 458..
CHAPTER 64 Vulvar Sores
AETIOLOGY 841 PATHOLOGY 841 IDENTIFICATION OF PATTERNS AND TREATMENT 842 Toxic-Heat with Liver-Fire and Damp-Heat 842 Retention of Cold 844 PROGNOSIS AND PREVENTION 846 WESTERN VIEW 846 ‘Vulvar
Sores’,
called
Yin
Chuang
(
) in Chinese medicine, may manifest with vulvar swelling, pain, itching, erosion, lumps, discharge of pus and excessive vaginal discharge. These local manifestations may be accompanied by systemic symptoms and signs such as shivers, fever, lassitude, abdominal distension, dark urine, thirst, constipation, a Slippery or Wiry and Rapid pulse and a Red tongue with a thick, sticky yellow coating. This Chinese disease category may correspond to various diseases of the genitalia such as vulvitis, vaginitis, boils or ulcers of the external genitalia,
inflammation of the Bartholin’s glands, cancer of the external genitalia or genital herpes.
Aetiology
Invasion of external Dampness External Dampness easily invades the leg channels to settle in the genital system: this is more common in women and it is more likely to happen when women are exposed to Dampness during or immediately after the period. Dampness often mixes with Heat and gives rise to Damp-Heat. Irregular diet Excessive consumption of hot, spicy and greasy foods leads to the formation of internal Damp-Heat: this often infuses downwards and settles in the genital system in women. Emotional strain Emotional problems such as anger, repressed anger, resentment and frustration often lead to stagnation of Liver-Qi; after some time, stagnant Qi may turn into Fire and give rise to Liver-Fire. Liver-Fire may affect the genitals especially when it is combined with Damp-Heat. Excessive use of Yang tonics In the old times, the excessive or improper use of Yang tonics to stimulate libido was a possible cause of disease in the Chinese medicine category of Vulvar Sores. This is not a common cause of disease nowadays, especially in women. However, it may occur, when people self-prescribe Red Ginseng which is hot in energy.
Pathology The Chinese pathology of Vulvar Sores includes Fire, Damp-Heat and Cold: the first two are by far the most common pathological conditions found in this disease. In addition, the pathology is characterized often by invasion of ‘parasites’. As discussed in Chapter 61 on excessive vaginal discharge, Toxic-Heat or Damp-Heat are often accompanied by infestation of what the
ancient Chinese called ‘parasites’ (chong ); certain types of vaginal discharges and vulvar sores are caused by ‘parasites’. The ancient Chinese doctors were very perceptive because we know from modern medicine that fungal or bacterial infections, spread through sexual contact, may cause vaginal discharges or vulvar sores. In such cases, the treatment principle is to ‘kill parasites’ (sha chong
), i.e. eliminate bacteria or fungi with herbs that have an anti-bacterial or anti-fungal effect and the majority of which also kill parasites.
Identification of patterns and treatment When treating vulvar sores, one must differentiate clearly deficiency from excess. Excess conditions include Damp-Heat, Toxic-Heat, Fire and parasites; thus, common treatment principles adopted are to resolve Dampness, clear Heat, resolve Toxic-Heat, drain Fire and kill parasites. The relationship between the external genitalia and internal organs and channels should be studied and the main channels involved are the Directing Vessel and the Liver channel. As for deficiency, the main organs involved are Liver and Kidneys; normally, Damp-Heat and Toxic-Heat occur against a background of Yin deficiency, but they may also occur against one of Yang deficiency. In the acute phase, one needs to treat the Manifestation by expelling pathogenic factors; in the chronic phase (in between attacks) one needs to treat the Root by tonifying the Liver and Kidneys. The patterns discussed are: • Toxic-Heat with Liver-Fire and Damp-Heat • retention of Cold.
Toxic-Heat with Liver-Fire and Damp-Heat
Clinical manifestations Sores of external genitalia, redness, swelling, heat and pain of the external genitalia, oozing of yellow fluid or pus. Tongue: Red, redder sides, thick, sticky, dry, yellow coating with Red spots on the root. Pulse: Slippery, Wiry, Rapid. Treatment principle Clear Heat, resolve Dampness, resolve Toxic-Heat, drain Liver-Fire. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-3 Zhongji, SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-1 Huiyin, BL-34 Xialiao, BL-22 Sanjiaoshu. All with reducing or even method. Explanation
– LU-7 and KI-6 regulate the Directing Vessel and treat the external genitalia area. – Ren-3 and Ren-1 resolve Dampness from the genital region. – SP-9, SP-6, BL-34 and BL-22 resolve Damp-Heat and affect the genital region. Herbal treatment
a. Prescription
– LONG DAN XIE GAN TANG – Gentiana Draining the Liver Decoction Explanation This formula, already explained, drains Damp-Heat from the genital region and drains Liver-Fire. Modifications
• If there is Toxic-Heat, add Pu Gong Ying Herba Taraxaci and Zi Hua Di Ding Herba Violae. • If there is an underlying deficiency of Qi, add Huang Qi Radix Astragali. b. Prescription
– WU WEI XIAO DU YIN – Five-Ingredient Dissolving Toxin Decoction Explanation All the ingredients of this formula resolve Toxic-Heat. Thus, it is indicated
when Toxic-Heat is predominant, while the former prescription is used when Damp-Heat and Liver-Fire predominate. Three Treasures remedy
– DRAIN FIRE This remedy is a variation of the formula Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction and it drains Liver-Fire and Heart-Fire. It is therefore especially suitable when there is also Heart-Fire deriving from emotional problems. The tongue presentation appropriate to this remedy is a Red body with redder sides and tip and with a dry, yellow coating; it may also have a Heart crack. Summary Toxic Heat with Liver-Fire and Damp-Heat
Clinical manifestations
Sores of the external genitalia, redness, swelling, heat and pain of the external genitalia, oozing of yellow fluid or pus. Tongue: Red, redder sides, thick, sticky, dry, yellow coating with Red spots on the root. Pulse: Slippery, Wiry, Rapid. Treatment principle
Clear Heat, resolve Dampness, resolve Toxic-Heat, drain Liver-Fire. Acupuncture
LU-7 Lieque on the right and KI-6 Zhaohai on the left, Ren-3 Zhongji, SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-1 Huiyin, BL-34 Xialiao, BL-22 Sanjiaoshu. All with reducing or even method. Herbal treatment
Pre scriptions
• LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction • WU WEI XIAO DU YIN Five-Ingredient Dissolving Toxin Decoction Three Treasures remedy
• DRAIN FIRE
Case history A 48-year-old woman had been suffering from genital herpes for 10 years. She had attacks every 3 weeks which were characterized by painful vesicles, with the pain extending to the thighs. In addition to this, she also suffered from recurrent bladder infections characterized by burning on urination, a dark urine and hypogastric pain: this problem dated back nearly 30 years and she had received many courses of antibiotics over that time. On interrogation, it transpired that she also suffered with tiredness, dizziness, loose stools, frequent, pale urination, chilliness, night sweating, backache and nocturia. Her tongue was Red, partially peeled and with a Heart crack; in places where there was a coating, it was yellow (Plate 13). Her pulse was Weak in general but especially on the right Front position and slightly Floating-Empty on the left. Diagnosis
This was a complicated and contradictory case. As far as the herpes was concerned, this was due to Damp-Heat in the genital system, which also caused the recurrent urinary infections. This Damp-Heat occurred against a background of Kidney-Yin deficiency as evidenced by the Red and partially peeled tongue and the night sweating. However, there was a glaring contradiction in that she had many symptoms of Spleen- and Kidney-Yang deficiency: tiredness, dizziness, loose stools, frequent, pale urination (except when she had an infection), chilliness, backache and nocturia. I concluded that this contradiction could only be explained as a transformation of KidneyYang into Kidney-Yin deficiency: although the Kidney-Yin deficiency manifested on the tongue, there was still enough Kidney-Yang deficiency to cause the above symptoms. Treatment principle The above contradiction made the treatment particularly difficult: if I tonified Kidney-Yang, it would make the Damp-Heat worse; if I used bitter and cold herbs to resolve Damp-Heat, it would injure Spleen- and Kidney-Yang. I decided to rely most of all on acupuncture as this treatment modality does not present the problems encountered with herbal medicine: with acupuncture, one can tonify Kidney-Yin or Kidney-Yang without injuring the other. I did use herbal medicine but only with very simple decoctions which deviated from the ones listed above under the pattern of Toxic-Heat with Damp-Heat. The treatment principle adopted was to tonify the Kidneys (both Yin and Yang), strengthen the Spleen and resolve Damp-Heat. Acupuncture
The points I used were selected from the following: • LU-9 Taiyuan to tonify Qi in general.
• ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu and BL-23 Shenshu to tonify the Spleen and Kidneys. • Ren-3 Zhongji, SP-9 Yinlingquan and BL-34 Xialiao to resolve Damp-Heat from the genito-urinary region. • LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), to regulate the Directing Vessel, nourish Yin and affect the genito-urinary region. Herbal treatment
I initially used a modification of the formula Zhi Zi Chi Tang Gardenia-Soya Decoction: the original formula, composed of only Shan Zhi Zi Fructus Gardeniae and Dan Dou Chi Semen Sojae preparatum, clears residual Heat. I considered her longstanding condition of Damp-Heat to be a form of residual Heat. The modification used was as follows: • Shan Zhi Zi Fructus Gardeniae 6 g • Dan Dou Chi Semen Sojae preparatum 6 g • Ban Lan Gen Radix Isatidis 6 g • Da Qing Ye Folium Isatidis 4.5 g • Ze Xie Rhizoma Alismatis 6 g • Rou Gui Cortex Cinnamomi 0.5 g • Gan Cao Radix Glycyrrhizae 3 g
Explanation
• Shan Zhi Zi and Dan Dou Chi form the original prescription which clears residual Heat. • Ban Lan Gen and Da Qing Ye were used for their anti-viral effect.
• Ze Xie drains Damp-Heat. • Rou Gui, in a minute dose, was added to tonify Kidney-Yang and the Minister Fire. The small amount of Rou Gui acts as a ‘spark’ to activate the Minister Fire which promotes the transformation of fluids in the Lower Burner and therefore helps to resolve Dampness. • Gan Cao resolves Toxic-Heat.
I used variations of this formula for several months with additions such as Huang Bo Cortex Phellodendri to resolve Damp-Heat and Huang Qi Radix Astragali to tonify Qi and strengthen the immune resistance. After 9 months of treatment, the herpes attacks became much less frequent and less intense and I was able to change to a Kidney-tonic formula such as Zhi Bo Di Huang Wan Anemarrhena-Phellodendron-Rehmannia Pill (variation): • Shu Di Huang Radix Rehmanniae preparata 9 g • Shan Zhu Yu Fructus Corni 4.5 g • Shan Yao Rhizoma Dioscoreae 6 g • Ze Xie Rhizoma Alismatis 6 g • Fu Ling Poria 6 g • Mu Dan Pi Cortex Moutan 9 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Huang Bo Cortex Phellodendri 6 g • Rou Gui Cortex Cinnamomi 3 g
Rou Gui was added for the reasons explained above. After this formula had been taken for a further 6 months, her herpes attacks did not return.
Retention of Cold
Clinical manifestations Erosion and pain of the vulva, pale lesions in the genital area, chronic condition with repeated attacks, lassitude. Tongue: Pale. Pulse: Weak. Treatment principle Tonify Qi and Blood, resolve Toxin. Acupuncture Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-13 Feishu, Ren-6 Qihai, SP-9 Yinlingquan, Ren-1 Huiyin, Ren-3 Zhongji. All with reinforcing method except for the last three which should be needled with even method. Explanation
– Ren-12, ST-36, SP-6, BL-20, Ren-6 and BL-13 tonify Qi. – SP-9, Ren-1 and Ren-3 resolve Dampness from the genital region. Herbal treatment
Prescription
– TUO LI XIAO DU SAN – Supporting the Interior and Dissolving Toxin Powder Explanation
– Huang Qi, Dang Shen, Bai Zhu and Zhi Gan Cao tonify Qi. Huang Qi also helps to resolve Toxin in chronic cases occurring against a background of deficiency: in such cases, the body’s Qi is so deficient that it cannot expel Toxin and bring an attack to an end. – Fu Ling drains Dampness. – Bai Zhi opens the orifices and helps to resolve Toxin from the genital region. – Dang Gui, Bai Shao and Chuan Xiong nourish and invigorate Blood. – Zao Jiao Ci, Jin Yin Hua and Jie Geng resolve Toxin and expel pus. Summary Retention of Cold
Clinical manife stations
Erosion and pain of the vulva, pale lesions in the genital area, chronic condition with repeated attacks, lassitude. Tongue: Pale. Pulse: Weak. Tre atme nt principle
Tonify Qi and Blood, resolve Toxin. Acupuncture
Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-13 Feishu, Ren-6 Qihai, SP-9 Yinlingquan, Ren-1 Huiyin, Ren-3 Zhongji. All with reinforcing method except for the last three which should be needled with even method. He rbal tre atme nt
Prescription
• TUO LI XIAO DU SAN Supporting the Interior and Dissolving Toxin Powder
Case history A 41-year-old woman had been suffering from recurrent genital herpes for 6 years: the attacks usually came either before or after the period and were characterized by vesicular lesions which then erupted to form ulcers. The lesions were pale and not very painful. Her tongue was Bluish-Purple with large blue areas on the sides (Plate 14); her pulse was extremely Weak and Deep on the right side and Slippery on the left. Diagnosis
This is an example of vulvar sores occurring against a background of Cold and Yang deficiency. Her pulse showed a severe Kidney-Yang deficiency, while her tongue showed Cold and stasis of Blood. Treatment principle
I treated her with both acupuncture and herbs. The treatment principle
adopted was to tonify Kidney-Yang and invigorate Blood. Acupuncture
The points used were selected from the following: • LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left) to regulate the Directing Vessel and affect the genital area. • P-6 and SP-10 to invigorate Blood and eliminate stasis. • ST-36, KI-3 and BL-23, with warm needle, to tonify Kidney-Yang. He rbal tre atme nt
I used a modification of the formula Tuo Li Xiao Du San Supporting the Interior and Dissolving Toxin Powder: • Huang Qi Radix Astragali 9 g • Dang Shen Radix Codonopsis 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Bai Zhi Radix Angelicae dahuricae 3 g • Bai Shao Radix Paeoniae alba 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Zao Jiao Ci Spina Gleditsiae 4 g • Jin Yin Hua Flos Lonicerae 4 g • Jie Geng Radix Platycodi 3 g
• Gui Zhi Ramulus Cinnamomi 3 g • Yi Mu Cao Herba Leonuri 6 g Explanation
• Gui Zhi was added to the original formula to tonify Yang. • Yi Mu Cao was added to invigorate Blood and eliminate stasis.
After 9 months of treatment, her herpes attacks were very infrequent and no longer occurred every month. The patient is still under treatment.
Prognosis and prevention The prognosis in the treatment of vulvar sores depends, to a certain extent, on the Western diagnosis (see below). The most difficult condition to treat is that of genital herpes. This will necessarily take many months if not years and requires patience on the part of the practitioner and the patient. The treatment should alternate between treating the Manifestation during an attack and the Root (i.e. tonify the body’s Qi) in between attacks. Although herbal medicine is generally better than acupuncture at treating Toxic-Heat or Damp-Heat, the power of acupuncture in the treatment of genital herpes should not be underestimated. I often find that an acupuncture treatment in the acute stage gives almost immediate relief and, in some cases, it may even stop the attack in its tracks.
Western view Vulvar and peri-vulvar lesions are often associated with pruritus. Vulvar lesions are often classified into red, white, dark and ulcerative. The main types are as follows: Red lesions Red lesions can be inflammatory or neoplastic. Inflammatory
Infections The most common infections causing vulvitis are those from Candida albicans: this has been discussed in Chapters 61 and 62 on excessive vaginal discharge and vaginal itching respectively. Vulvitis Vulvitis is an inflammatory condition caused by irritants such as detergent, dyes, perfume, spermicide creams, lubricants, saliva or semen. It is characterized by erythema, swelling and pruritus. Vestibular adenitis The vestibular glands are located between the hymen and the labia minora: when they become inflamed they cause vulvar pain, erythema and pruritus.
Psoriasis Psoriasis can occur in the vulva area with lesions which are scaly, red and with a sharp edge. Dermatitis Dermatitis is characterized by a symmetrical erythema and greasy eruptions. Neoplastic
The vulva is the fourth commonest site of gynecological neoplasia. Its peak incidence is in the 60s and 70s although 15% of all vulvar neoplasms occur in women under 40. Vulvar neoplasia has been associated aetiologically with the human papilloma virus. The clinical manifestations of vulvar neoplasm include pruritus, erythema and swelling. The lesions may be grey, white, red or dark. White lesions
Vulvar neoplasia
Vulvar neoplasm of the white variety is difficult to distinguish from vulvar dystrophy. It is characterized by erythema, swelling and pruritus. Vitiligo
Vitiligo is a depigmentation disorder. In the vulva, it is characterized by well-
defined areas of depigmentation. Leukoderma
Leukoderma is a depigmentation of the skin that is secondary to trauma or ulceration. For example, herpes and syphilis may cause this condition. Dark lesions
Nevi
Nevi or ‘moles’ are collections of crest cells which are present from birth. Nevi do not cause any symptoms but 30% of all malignant melanomas develop from nevi. Neoplasm
This has already been discussed above. Ulcerative lesions
Inflammatory: infectious
Viral Herpes simplex is by far the most common viral infection of the vulva. The
infection is acquired through sexual contact. The lesion are vesicular, red, raised, painful and itchy. After some time, the vesicles or papules rupture and often coalesce forming painful ulcers. The lesions usually last 10–14 days, form a crust and then disappear. Common sites of infection are the cervix, vulva, vagina, perineum and urethra. Bacterial Bacterial infections of the vulva include infections from Treponema pallidum (of syphilis) or Calymmatobacterium granulomatis. The vulvar lesions of syphilis are papular and soft. Pyoderma is an opportunistic infection of the vulvar skin deriving from poor hygiene. It manifests with erythema and pruritus. Inflammatory: non-infectious
Behçet’s disease This condition is characterized by relapsing oral and genital ulcers; it is often associated with ulcerative colitis, arthritis and iritis. The genital ulcers are deep and painful. Crohn’s disease Crohn’s disease may also present with oral and genital ulcers which are difficult to distinguish from those of Behçet’s disease. Neoplastic
Basal cell and squamous cell carcinoma may present with vulvar ulcers. The
lesion is usually single.
CHAPTER 65 Endometriosis
WESTERN MEDICAL PERSPECTIVE 849 CHINESE MEDICAL PERSPECTIVE 858 IDENTIFICATION OF PATTERNS AND TREATMENT 862 Liver-Blood stasis 862 Stagnation of Cold 865 Dampness 866 Damp-Phlegm in the Uterus 868 Kidney-Yang deficiency 869 Kidney-Yin deficiency 871 Blood deficiency 872 COMBINED PATTERNS 873 Blood stasis, Kidney-Yang deficiency and Dampness 873 Blood stasis, Kidney-Yin deficiency and Dampness 874 Cold in the Uterus, Blood stasis, Kidney-Yang deficiency and Dampness 877 Blood stasis, Kidney-Yang deficiency with Damp-Phlegm in the Uterus 878 MODERN CHINESE LITERATURE 877 CLINICAL TRIALS 882 Acupuncture 882 Herbal treatment 884
Western medical perspective
Definition Endometriosis is a condition resulting from the presence of actively growing and functioning endometrial tissue in locations outside the uterus. The areas where endometriosis may occur are widespread and usually multiple. They include: • ovaries • uterine wall • fallopian tubes • abdominal scars • umbilicus • sigmoid colon • rectum • ureters • bladder • vagina. Endometriosis should be differentiated from adenomyosis (historically thought to be similar) which describes an ingrowing of the endometrium into the myometrium. Occurrence
The incidence of endometriosis is currently on the increase. The following groups may be affected by it: • Nulliparous women between the ages of 25 and 40. • Teenagers (previously not thought to be commonly affected). • Women who have undergone elective tubal sterilization. • Familial incidence (7% relative risk of developing it if a first-degree female relative has it). Endometriosis is mostly a disease of young women. The age distribution given by the US Endometriosis Association is as follows: • Under 15: 14.9%. • 15–19: 25.7%. • 20–24: 19.6%. • 25–29: 23.3%. • 30–34: 12.5%. • 35–39: 4%. Aetiology Although many theories exist, the pathogenesis of endometriosis is still not fully understood in the Western medical world. The following are some of the most common theories Retrograde menstruation and tubal reflux
This was proposed by Samson who believed that menstrual blood is forced out along the fallopian tubes into the peritoneal cavity. He suggested that menstrual blood contains fragments of endometrium which may implant on pelvic structures and grow. Excessive uterine contractions characteristic of primary dysmenorrhoea (often present in women with endometriosis) may contribute to a bidirectional menstrual flow from the uterus. Coelomic metaplasia
This was proposed by Meyer and Ivanoff who suggested that all tissues in which endometriosis arises are embryologically derived from coelomic epithelium, i.e. epithelium of the peritoneal cavity. In this hypothesis, peritoneal cells would change into endometrial tissue. Chronic irritation of the peritoneum by menstrual blood may cause coelomic metaplasia, which can subsequently result in endometriosis. Direct implantation
According to this theory, endometrial tissue is displaced into an implant in the new sites. This explains why endometriosis may be found in surgical scars. Genetic factors
There is a 5.8% familial incidence among immediate female siblings, an 8.1% risk if the mother had endometriosis and a 7% risk if a female sibling has endometriosis. These figures suggest a polygenic and multifactorial inheritance for endometriosis. Lymphatic dissemination
Halban suggested that normal endometrium might ‘metastasize’ via lymphatic channels and thus spread to extra-uterine sites where implantation and growth would produce the characteristic lesions of endometriosis. Vascular theory
This theory was proposed by Navratil who suggested that normal endometrium was deported via the veins to remote areas of the body. Immunologic factors
Recent research has suggested involvement of the immune system in the pathogenesis of endometriosis. Women with this disorder appear to exhibit increased humoral immune responsiveness and macrophage activation while showing diminished cell-mediated immunity with decreased T-cell and natural killer cell responsiveness. There seems to be a correlation between endometriosis and the use of tampons and intra-uterine contraceptive devices (the coil), and with intercourse during menstruation. It has been suggested that intercourse during menses might increase tubal activity and increase the backflow of the menstrual cycle through the tubes and thus increase the risk of endometriosis. However, there are no statistics to bear this out and indeed some even hold the opposite view, i.e. that sexual intercourse during the period may help to prevent endometriosis. As we shall see below when we discuss the aetiology of endometriosis from the Chinese perspective, sexual intercourse during the period may indeed be a factor in the development of endometriosis. The following are the risk factors in endometriosis: • Family history of endometriosis. • Early age of menarche.
• Short menstrual cycles (<27 days). • Long duration of menstrual flow (>7 days). • Heavy bleeding during menses. • Inverse relationship to parity. • Delayed childbearing. • Defects in the uterus or fallopian tubes. • Hypoxia and iron deficiency may contribute to the early onset of endometriosis. Some of the risk factors above are interesting from the Chinese perspective. In fact, early age of menarche, the inverse relationship to parity and the delayed childbearing are all risk factors that are related to having more menstrual cycles. In other words, having an early menarche, few children and delayed childbearing mean that the woman will have more periods than one who starts her periods later, has more children and has children earlier in life. As we discussed in Chapter 4 on aetiology, some doctors have advanced the hypothesis that the increasing incidence of endometriosis may be correlated with the increased number of menstrual cycles between the time of menarche and that of the first pregnancy. Summary Aetiology
• Retrograde menstruation and tubal reflux: menstrual blood forced out along the Fallopian tubes into the peritoneal cavity.
• Coelomic metaplasia: tissues in which endometriosis arises are embryologically derived from coelomic epithelium, i.e. epithelium of the peritoneal cavity. In this hypothesis, peritoneal cells would change into endometrial tissue. • Direct implantation: endometrial tissue is displaced into an implant in the new sites. • Genetic factors: there is a 5.8% familial incidence among immediate female siblings, an 8.1% risk if the mother had endometriosis and a 7% risk if a female sibling has endometriosis. • Lymphatic dissemination: normal endometrium might ‘metastasize’ via lymphatic channels and thus spread to extra-uterine sites. • Vascular theory: normal endometrium deported via the veins to remote areas of the body. • Immunologic factors: involvement of the immune system in the pathogenesis of endometriosis.
Pathology There are three diagnostic histologic features of endometriosis. They are: 1. endometrial glands 2. endometrial stroma 3. evidence of haemorrhage. The typical lesion will show an abundance of inflammatory cells and fibrous connective tissue. Ovarian endometriosis occurs in the form of small superficial deposits on the surface of the ovary or as larger cysts which may be up to 10 cm in size (known as endometriomas or ‘chocolate cysts’) and which may rupture (Plate 65.1). In the ovary, the process is almost always bilateral. There is usually considerable fibrosis and puckering of the ovarian surface in the
region of the cyst as well as adherence to neighbouring structures. In the other most frequently involved areas, i.e. throughout the pelvic peritoneum, the lesions are normally smaller and more numerous and are surrounded by dense, fibrous scar tissue (Plate 65.2). Endometriosis is frequently accompanied by mesothelial hyperplasia of the pelvic peritoneum. Mesothelial hyperplasia most commonly involves the surface of the ovaries, the Fallopian tubes, the pelvic peritoneum and the omentum.1 Clinical Note From the Chinese perspective, mesothelial hyperplasia indicates Dampness. Dampness is a frequent secondary pathological factor in endometriosis (after Blood stasis). Endometriosis develops mostly in women of reproductive age and regresses after menopause or ovariectomy, suggesting that the growth is oestrogen dependent. Indeed, the lesions contain oestrogen receptors as well as aromatase, an enzyme that catalyses the conversion of androgens to oestrogens, suggesting that local oestrogen production may stimulate the growth of lesions. Clinical manifestations The most commonly seen symptoms and signs of endometriosis are: • dysmenorrhoea (97%) • pelvic pain (62%) • lower backache radiating to the anterior thigh • heavy periods • irregular bleeding
• infertility (47%) • dyspareunia (59%) • pain sometimes accompanied by nausea and vomiting or diarrhoea • pain on defaecation (68%) • rectal pressure • tender and enlarged ovaries • pelvic nodularities and thickenings • fatigue (64%). The clinical manifestations of endometriosis given by the USA Endometriosis Association differ slightly from the above and they are: • dysmenorrhoea (96.2%) • dyspareunia (59.6%) • heavy periods or irregular bleeding (65.3%) • infertility (44%) • pain sometimes accompanied by nausea and vomiting (57.7%) • diarrhoea (79%) • dizziness, headaches with period (59%) • fatigue (82.1%) • low-grade fever (29.4%)
• low resistance to infection (39.1%) • no symptoms (2.6%).2 Interestingly, there is no direct correlation between the severity of the pain and the extent of endometriosis: thus, a woman with advanced endometriosis may suffer less pain than a woman with the beginning stages of the disease. ! There is no direct correlation between the severity of the pain and the extent of endometriosis: the Chinese explanation of this phenomenon is that the amount of pain depends on the severity of Blood stasis. Diagnosis Diagnosis of endometriosis is made principally by taking a clinical history. If it is suspected, confirmation is usually obtained by laparoscopy which shows endometriotic cysts and deposits. Definitive diagnosis can be made by microscopic examination of excised tissue that demonstrates both glands and stroma. A diagnostic laparoscopy is the ‘gold standard’ for diagnosing endometriosis. A diagnosis of endometriosis should not be considered unless the endometriosis has been seen during a laparoscopy. Most gynecologists also insist that a biopsy of the endometrial tissue be examined by a pathologist before confirming the diagnosis (Plate 65.3). Usually, if minimal to moderate endometriosis is found, a diagnostic laparoscopy will be combined with an operative laparoscopy to remove any endometriotic lesions and adhesions. This means that the endometriosis can be diagnosed and treated at the same time, and only one operation is needed. Diagnosis is, however, fraught with difficulties and is affected by subjectivity. Laparoscopy relies entirely on the visual and subjective
assessment of the pelvis by the operator and consequently is prone to misinterpretation and subjectivity. Another difficulty is that the symptoms of endometriosis are very similar to those of other diseases, e.g. pelvic inflammatory disease, ovarian tumours and irritable bowel syndrome, making differential diagnosis problematic. Summary Diagnosis
• Diagnosis of endometriosis is made principally by taking a clinical history. • Confirmation is usually obtained by laparoscopy which shows endometriotic cysts and deposits. • Definitive diagnosis can be made by microscopic examination of excised tissue that demonstrates both glands and stroma. • Diagnosis is affected by subjectivity. • The symptoms of endometriosis are very similar to those of other diseases, e.g. pelvic inflammatory disease, ovarian tumours and irritable bowel syndrome, making differential diagnosis problematic.
Treatment The main aim of Western medical treatment of endometriosis is to halt menstruation so that cyclical endometrial bleeding is prevented and any areas of endometrium outside the uterus may have an opportunity to recede. To this aim, many drugs are used: • Combined contraceptive pill.
• Progestins. • Mirena® intra-uterine device (IUD). • Gonadotropin-releasing hormone (GnRH) agonists. • Danazol. • Aromatase inhibitors. • Painkillers. Combined contraceptive pill
There are many different types, each of which contains a specific low-dose combination of synthetic oestrogen and progestagen (progesterone). It alleviates the pain of endometriosis by suppressing menstruation and inhibiting the growth of the endometrial implants. Very few studies have looked at the effectiveness of the combined oral contraceptive pill in treating the pain-related symptoms of endometriosis. Nevertheless, the existing evidence suggests that its effectiveness in alleviating pain is similar to that of the other hormonal drugs during treatment, and there is no difference 6 months after stopping taking the pill. Side effects of the combined contraceptive pill Side effects of the combined contraceptive pill may include nausea, weight gain, sore or swollen breasts, small amount of blood, spotting between periods, lighter periods, mood changes. The following side effects are less common but more serious. They include: • abdominal pain
• chest pain • headaches (severe) • eye problems (blurred vision) • swelling and/or aching in the legs and thighs. These symptoms may indicate a serious disorder, such as liver disease, gall bladder disease, stroke, blood clots, high blood pressure, or heart disease. Progestins
Progestins are a group of drugs that behave like progesterone. They have been used since the mid-1950s to treat the symptoms of endometriosis. They are also sometimes referred to as gestogens, progestogens or progestagens. Progestins on the market include Alesse®, Brevicon®, Cyclessa®, Demulen®, Genora®, Levlen® and many others. The progestins are effective treatments for the symptoms of endometriosis. However, like all the hormonal drugs used for endometriosis, they have side effects, which some women find intolerable. They are safer and cheaper than the GnRH agonists and danazol, which some gynecologists believe makes them appropriate for women who need prolonged or repeated treatments. It is not known precisely how progestins relieve the symptoms of endometriosis, but they probably work by suppressing the growth of endometrial implants in some way, causing them to gradually waste away. They may also reduce endometriosis-induced inflammation in the pelvic cavity. At the dosages usually used for endometriosis, most women will stop ovulating and menstruating during treatment. The levonorgestrel intra-uterine system does not always stop ovulation. In the first 3–6 months, many women will experience spotting, but some may experience heavy or prolonged bleeding. Later, most women will have lighter periods than previously, and
some will have no periods. Most women will resume ovulating and menstruating within 4–6 weeks of stopping treatment. Women who have had long-acting injections may experience prolonged delays in the return of menstruation, and a few women may not menstruate for more than a year after their last injection. Side effects of progestins The side effects of progestins vary from progestin to progestin depending on their chemical nature and the dosage used. Nevertheless, women usually experience fewer side effects with progestin treatment than with GnRHagonist or danazol treatment. Most women will experience at least one or two mild to moderate side effects, and some may experience several. The main side effects are acne, bloating, breakthrough bleeding, breast discomfort, depression, dizziness, fluid retention, headaches, irregular bleeding, lethargy, moodiness, nausea, prolonged bleeding, spotting, vomiting and weight gain. The levonorgestrel intra-uterine system is sometimes expelled by the uterus, particularly in the first year. Infrequently, it may perforate the uterus (particularly if inserted within 6 weeks of a vaginal birth, or 12 weeks of a Caesarian birth), or lead to a pelvic infection (especially in the first 3 weeks after insertion). The side effects of progestins are reversible and they usually disappear soon after completing treatment. Little research has been conducted into the effectiveness of the progestins for the treatment of endometriosis. Nevertheless, the results of clinical trials conducted to date suggest that the different progestins are equally effective, and that when taken continuously (every day) they relieve endometriosis-associated pain as effectively as the other hormonal drugs. They are not usually effective when taken only during the luteal phase (second half) of the menstrual cycle. The progestins control pain symptoms in approximately three of four women and they may not relieve symptoms completely. Symptoms often recur following treatment months or years after treatment ceases.
Mirena® IUD
The Mirena® IUD is a small, plastic, T-shaped intra-uterine device that is increasingly being used to treat women with endometriosis. It contains a progestogen that is released into the uterus over a period of 5 years. It is sometimes also known by its generic name, levonorgestrel intra-uterine system or LNG-IUS. Studies indicate that the Mirena® IUD is an effective treatment for endometriosis, and may have the potential to be a long-term treatment for women who want to postpone pregnancy. As indicated above, progestins relieve the symptoms of endometriosis by suppressing the growth of endometrial implants, causing them to gradually waste away. They may also reduce endometriosis-induced inflammation in the pelvic cavity. At the dosages usually used for endometriosis, most women will stop ovulating and menstruating during treatment. The levonorgestrel intra-uterine system does not always stop ovulation. In the first 3–6 months, many women will experience spotting, but some may experience heavy or prolonged bleeding. Later, most women will have lighter periods than previously, and some will have no periods. Most women will resume ovulating and menstruating within 4–6 weeks of stopping treatment. Side effects of Mirena® IUD Side effects of the Mirena® IUD include irregular bleeding, pelvic pain or weight gain. The most common side effect of Mirena® is irregular vaginal bleeding, which includes erratic bleeding, frequent spotting or light bleeding between periods, heavy bleeding, and longer or shorter periods. However, these problems usually settle after 3–6 months. Although the levonorgestrel in the IUD is released into the uterus, a small amount is absorbed into the bloodstream. The amount of levonorgestrel in the blood is about one-seventh of that found in the oral contraceptive pill, so there are fewer side effects than with the oral progestogen treatments for endometriosis. Side effects often disappear after 4–6 weeks.
The progestogen-related side effects include acne, decreased libido, headache, lower abdominal pain, low back pain, nausea, period pain, sweating, tender breasts, water retention and weight gain. Women using the Mirena® IUD are more likely to develop benign ‘simple’ ovarian cysts. The most common symptom of a simple cyst is abdominal pain that does not resolve with simple painkillers. Such cysts usually disappear without treatment in 2–3 months. The Mirena® IUD system is designed to minimize the risk of infection, but there is still a slight risk of developing a pelvic infection while using the IUD, particularly in the first 3 weeks after insertion. Such infections are usually related to sexually transmitted diseases. Overall, about 1.5% of women will develop an infection with 5 years of use of the IUD. Table 65.1 lists the various types of progestins for endometriosis. Table 65.1 Types of progestins used for endometriosis
GnRH agonists
The GnRH agonists are a group of drugs that have been used to treat women with endometriosis for over 20 years. They are modified versions of gonadotropin-releasing hormone, which ‘orchestrates’ the menstrual cycle. All the GnRH agonists are very similar chemically, but they come in different forms: 3-monthly injection, monthly injection, daily injection and nasal spray. When used in combination with add-back medication, the GnRH agonists are effective and generally well tolerated by most women. GnRH agonists stop the production of oestrogen by a series of
mechanisms. This deprives the endometrial implants of oestrogen, causing them to become inactive and degenerate. Through downregulation, agonists are able to exert a prolonged suppression effect. Most women will stop bleeding within 2 months of starting treatment. However, some will experience 3–5 days of vaginal bleeding or spotting about 10–14 days after beginning treatment. There is usually an improvement in symptoms within 4–8 weeks of beginning treatment. The return of ovulation and menstruation after stopping the medication is very variable. Most women will menstruate within 4–6 weeks of their last spray of buserelin or nafarelin, or within 6–10 weeks of their last injection of goserelin, leuprorelin or triptorelin. Table 65.2 lists the various types of GnRH agonists for endometriosis. Table 65.2 Types of GnRH agonists
Side effects of GnRH agonists The side effects of the GnRH agonists are largely the result of the low levels of oestrogen in the body and they therefore may cause menopausal-like symptoms. Side effects are common, and most women will experience at least one or two. The severity of the side effects varies from mild to severe, and some women will find them intolerable. Most women will experience hot flushes (flashes) or night sweats or both. The other common side effects are insomnia, decreased libido, headaches, mood swings, vaginal dryness, decreased breast size, acne, muscle pains, dizziness and depression. The menopausal-type symptoms usually disappear soon after treatment ceases. The most serious side effect of treatment with a GnRH agonist is thinning of the bones, particularly the bones of the spine. When the levels of oestrogen in the body are low, the rate of breakdown of the bones’ matrix becomes greater than the rate of regeneration, so the bone matrix becomes less dense. The decrease in bone density is typically about 4–6% at the end of a 6-month course of treatment. It is thought that most of the bone lost during treatment regenerates within 6 months of completing treatment, and that 18–24 months after completing treatment probably most, if not all, the lost bone has been replaced. Therefore, a single 6-month course of treatment will not usually be detrimental for women with normal bone density. However, in women at risk of developing the condition, treatment with a GnRH agonist could predispose them to developing osteoporosis. Danazol (Danocrine®)
Danazol has been used to treat women with endometriosis since the 1970s. It was the most commonly used drug in the early 1980s, but its use declined markedly after the introduction of the GnRH agonists in the late 1980s and early 1990s. Danazol is a synthetic androgen. Androgens are responsible for the
functioning of the male reproductive system and the development of the male characteristics, such as facial hair and a deep voice. The ovaries also produce small amounts of androgens. Danazol is an effective treatment for endometriosis, and has the same effectiveness as the other hormonal treatments. However, it has many androgenic side effects, including weight gain, increased body hair and acne. Its unpleasant side effects and its tendency to adversely affect blood lipid (cholesterol) levels mean it is not usually the first choice of treatment for endometriosis. Like all the other hormonal treatments, danazol does not cure endometriosis permanently. Rather, it suppresses its growth and development temporarily, so the disease may recur following treatment. Danazol has a multitude of effects on the body. Some of these effects combine to produce high levels of androgen and low levels of oestrogen in the body. This hormonal environment stops menstruation and suppresses the growth of endometrial implants, causing them to degenerate. Most women will stop ovulating and menstruating by the second month of treatment, though this may depend on the dosage used. The symptoms of endometriosis usually begin to diminish by the end of the second month. Most women will resume ovulating and menstruating within 4–6 weeks of stopping treatment. Side effects of Danazol Danazol can cause many side effects the number and severity of which is sometimes related to the dosage being used. Reducing the dosage to the minimum needed to stop the periods may reduce the side effects experienced. Many of the side effects are due to its androgenic effects. These include weight gain, acne, oily skin and hair, bloating, fluid retention, voice changes, increase in body hair, decreased breast size, decreased libido and enlargement of the clitoris (rare). Weight gain is a common side effect. Most women experience weight
gain, usually 1–5 kg (2.2–11 lb) but occasionally more. When treatment finishes, most women lose much of the weight gain within 1–2 months. Some women experience a change in their voice. The change may involve a deepening of the voice, or it may become husky, or it may peter out at times. Some of the side effects are due to the low levels of oestrogen in the body. These include hot flushes, night sweats and vaginal dryness. Danazol can also cause other side effects, including irregular vaginal bleeding or spotting, skin rash, nausea, headaches, muscle cramps, tingling of the limbs, emotional instability, fatigue, adverse effects on blood lipid (cholesterol) levels and decreased glucose tolerance. Most of the side effects disappear soon after completing treatment. However, some of the androgenic side effects, such as deepening of the voice, increased body hair (especially if profuse) and enlargement of the clitoris, are sometimes irreversible. Long-term use is associated with a small risk of developing liver tumors and a theoretical risk of developing heart disease. If treatment lasts longer than 6 months, liver function should be monitored. Aromatase inhibitors
Aromatase inhibitors are usually prescribed for women with endometriosis who have not had success with other treatments or who cannot use other treatments because of their side effects. Although the use of aromatase inhibitors is new in endometriosis, they have been used to treat postmenopausal women with some forms of breast cancer for nearly 10 years. In fact, aromatase inhibitors are currently the most effective non-toxic drugs for the treatment of post-menopausal breast cancer. At the moment, the treatment of endometriosis with aromatase inhibitors is still experimental, because the research is still in its early days. Aromatase is a protein that is responsible for producing oestrogen. Normally, it is found in the ovaries, and to a much lesser extent in the skin and fat. Research has shown that aromatase is also found in high levels in the ectopic endometrial
tissue of women with endometriosis, which contributes to the growth of their endometriosis. Inhibiting the aromatase suppresses the growth of the endometriosis and reduces the associated inflammation. This, in turn, significantly reduces pelvic pain. Side effects of aromatase inhibitors The most common side effects of aromatase inhibitors are mild hot flushes and decreased libido. The following is my own assessment of the biomedical treatment of endometriosis and its possible effect in terms of Chinese medicine: • Combined contraceptive pill: it merely masks the symptoms of endometriosis. Induces Blood deficiency. • Progestins: same as above, they merely mask the problem. Progestins cause Dampness and Liver-Qi stagnation. • Mirena® IUD: same as above. In addition, obstruction of the Uterus causes Blood stasis (which is the cause of endometriosis in the first place). • GnRH agonists: again, they just mask the problem. They deplete Kidneys and Essence. • Danazol: same as above. Causes Dampness and Phlegm. • Aromatase inhibitors: they mask the problem by inducing menopause. They cause Kidney deficiency. In conclusion, I do not combine Chinese herbal treatment with Western hormonal treatment because Chinese herbs cannot regulate the hormones naturally when the woman’s hormonal system is being manipulated artificially and ovulation suppressed. Laser and diathermy
Endometriosis is also treated surgically with laser or diathermy. Usually, if minimal to moderate endometriosis is found, a diagnostic laparoscopy will be combined with an operative laparoscopy to remove any endometriotic lesions and adhesions. This means that the endometriosis can be diagnosed and treated at the same time, and only one operation is needed. For the surgical treatment of endometriosis, the surgeon will aim to remove endometrial implants, separate any adhesions, and drain and treat any large cysts with the use of a laser beam. The advantage of laser surgery is that the effect of the laser is very precise and reduces tissue damage. Diathermy, which uses an electric current, may be used to divide tissue as well as coagulate tissue, particularly blood vessels to control any bleeding. Endometrial implants can be treated using two techniques: excision and coagulation. Excision removes endometrial implants by cutting them away from the surrounding tissue with scissors, a very fine heat gun or a laser beam. The technique does not damage the implants, so the gynecologist is able to send a biopsy of the excised tissue to the pathologist to confirm that it is endometriosis and not cancer or another condition. Excision allows the gynecologist to separate the implants from the surrounding tissue, thus ensuring that the entire implant is removed and no endometrial tissue is left. Coagulation destroys implants by burning them with a fine heat gun or vaporizing them with a laser beam. When coagulating implants, care must be taken to ensure that the entire implant is destroyed, so it cannot regrow. Care must also be taken to ensure that only the implant is destroyed, and no underlying tissue such as the bowel, bladder or ureter. The possibility of accidentally damaging the underlying tissue means that most gynecologists are wary of using coagulation on implants that lie over vital organs, such as the bowel and large blood vessels. It should be noted that pregnancy usually induces a marked regression of the lesions. However, as infertility is commonly associated with endometriosis, this is rarely a practical solution to the problem.
Chinese medical perspective
Aetiology
Intercourse during menstruation
When a woman becomes sexually aroused, the Minister Fire goes upwards. If this happens when menstrual blood is flowing downwards, the two will ‘meet’, blocking each other and therefore leading to stagnation of Qi and Blood in the Uterus (Fig. 65.1).
Figure 65.1 Effect of sexual activity during the period.
Intercourse at too early an age
Intercourse at an early age damages the Directing and Penetrating Vessels (Ren and Chong Mai) because the Uterus is in a vulnerable condition at an early age. This may cause either a deficiency of the Directing and Penetrating Vessels or Blood stasis in the Uterus, in which case it may contribute to the development of endometriosis By ‘early age’ I mean during puberty and certainly before puberty. I would consider sexual intercourse too early if it occurs within 2 years of puberty. Excessive physical work or exercise
Excessive physical work or exercise can weaken the Spleen, Liver and Kidneys and adversely affect the Penetrating and Directing Vessels. This is especially the case during puberty when the Penetrating and Directing Vessels are in a state of change and not yet fully developed. Depending on the constitution of the girl, excessive physical work or exercise will either weaken these two vessels or cause stagnation in the Uterus. Excessive physical exercise includes girls working on a farm, excessive sports, excessive running and also intensive ballet practice at puberty. External Cold
Women are particularly prone to invasion of Cold just before, during and just after the period, as well as just after childbirth. When Cold invades the Uterus, it contracts tissues causing Blood to stagnate. The Uterus is also particularly prone to invasion of Cold during puberty: this occurs when young girls play sports in shorts in winter, sit on damp grass or keep wet swimming suits on after swimming. These situations are aggravated also by the consumption of ice-cold liquids.
Please note that invasion of the Uterus by Cold occurs also in warm countries. Tampons
Tampons block the normal downward flow of menstrual blood thereby leading to stasis of Blood. Emotional stress
Emotional stress that leads to Liver-Qi stagnation (such as that from anger, frustration, resentment, worry, guilt, etc.) often leads to Blood stasis in women. Irregular diet
Dampness is a pathological feature of endometriosis and it may be caused either by the excessive consumption of sweets, sugar and dairy foods or by irregular eating habits. Summary Aetiology
• Intercourse during menstruation • Intercourse at too early an age • Excessive physical work or exercise • External Cold
• Tampons • Emotional stress • Irregular diet
Pathology In the pathology of endometriosis, there is always a Kidney deficiency and disharmony of Liver and Spleen. Retention of menses
Retention of menses is an important factor, often occurring after childbirth. Dr Xia Gui Cheng attaches great importance to what he calls ‘retention of menses’ in the pathology of endometriosis. He says that the menses represent a way of getting rid of ‘old’ blood: if this discharge is insufficient, after some years endometriosis may develop. It is interesting that we, as practitioners, tend to pay great attention to heavy menstrual flow but not enough to scanty menstrual flow. ‘Retention of menses’ can be judged only in relation to a woman’s menstrual constitution. For example, if a woman’s periods have always lasted 7 days and they then start to last 5 days, she has ‘retention of menses’: this would not be the case in a woman whose periods have always lasted 5 days. If a woman’s periods always lasted 5 days and then she starts having periods that last only 3 days, she has ‘retention of menses’. Blood stasis
We can assume that in endometriosis there is always Blood stasis. The very appearance of the endometriosis lesions confirms this: they always look
purple, sometimes reddish-purple and sometimes bluish-purple (see Plate 65.2). The Blood stasis accounts for the menstrual pain experienced with endometriosis. Blood stasis is also a factor in the infertility that derives from endometriosis: from a Chinese perspective, the stagnant Blood in the Uterus may prevent implantation of the ovum. Kidney deficiency
We can also assume that in endometriosis there is always an underlying Kidney deficiency: this may be of Kidney-Yang or Kidney-Yin but more often the former. The Kidney deficiency is also a contributing factor to the infertility that derives from endometriosis. From a modern perspective, a deficiency of Kidney-Yang is often the cause of a luteal insufficiency. As there is both Blood stasis (the Biao) and Kidney deficiency (the Ben), in treatment we should place the emphasis on the Manifestation (Biao), i.e. Blood stasis, only if the period is very painful. Cold, Dampness, Damp-Phlegm
Endometriosis is characterized by an insufficient growth of Yang during phase 4 so that Yin pathogenic factors are not expelled. Example of Yin pathogenic factors in endometriosis are Blood stasis, Dampness, Cold or Phlegm. Thus, besides Blood stasis, other pathogenic factors include Cold, Dampness and Damp-Phlegm. These pathogenic factors form more easily when there is an insufficient growth of Yang in phase 4 due to Kidney-Yang deficiency. Cold, Dampness and Damp-Phlegm may all obstruct the Uterus in the same way as stagnant Blood does and therefore prevent fertilization. Cold in the Uterus is a frequent pathogenic factor pertaining to the Manifestation: this is particularly frequent in young women. When it is retained for a long time, Cold in the Uterus injures Yang and leads to Kidney-Yang deficiency.
As for Dampness, in my practice, 50% of women with endometriosis present with Dampness. Temperature chart The temperature chart is flat in endometriosis for two reasons, one due to the Manifestation (Biao), the other to the Root (Ben). The temperature does not decrease enough during the period because of Blood stasis (Biao) and it does not increase enough after ovulation due to Kidney-Yang deficiency (Ben). The result is a temperature chart line that is somewhat flat (Fig. 65.2).
Figure 65.2 Basal temperature chart in endometriosis. To summarize, the main Full patterns (Manifestation) in endometriosis are: Blood stasis, Cold in the Uterus, Dampness and Damp-Phlegm. The main Empty patterns (Root) are: Kidney deficiency (Yin or Yang) and Blood deficiency (Table 65.3). Table 65.3 Summary of the main patterns in endometriosis
Manifestation
Root
Blood stasis Kidney deficiency Cold Dampness Blood deficiency Damp-Phlegm In my practice, here is the distribution of patterns I find in endometriosis. Please note that the total does not add up to 100% because every patient has more than one pattern (e.g. Blood stasis, Kidney-Yang deficiency and Dampness): • Blood stasis: 80%. • Dampness: 50%. • Cold in the Uterus: 36%. • Kidney-Yang deficiency: 36%. • Kidney deficiency (Yang and Yin): 20%. • Kidney-Yin deficiency: 10%. Summary Pathology
• There is always a Kidney deficiency and disharmony of Liver and Spleen. • There is also always Blood stasis but also often Dampness. • Retention of menses is an important factor. • The temperature chart is flat in endometriosis for two reasons, one due to the Manifestation (Biao), i.e. Blood stasis, the other to the Root (Ben), i.e. KidneyYang deficiency. • Endometriosis is also characterized by an insufficient growth of Yang during phase 4 so that Yin pathogenic factors (Blood stasis, Dampness or Phlegm) are not expelled. • In endometriosis there is always Blood stasis, but in infertility due to endometriosis there are other factors at play and especially Kidney-Yang deficiency causing a luteal insufficiency. • In treatment, we should place the emphasis on the Manifestation (Biao), i.e. Blood stasis, only if the period is very painful.
Treatment principles Before discussing treatment principles, we should discuss the relationship between the biomedical entity of ‘endometriosis’ and Chinese medicine gynecological diseases. As discussed in previous chapters, Painful Periods, Heavy Periods or Bleeding between Periods are ‘diseases’ (bing) in Chinese medicine (hence the use of initial caps) but not in Western medicine. In Western medicine, painful periods, heavy periods and bleeding in between periods are symptoms, not diseases (Fig. 65.3).
Figure 65.3 Western versus Chinese diseases. Old Chinese gynecology books would not have a chapter called ‘Endometriosis’ but they would have one entitled ‘Painful Periods’ (Tong Jing). The question arises, therefore, to what Chinese gynecological disease does endometriosis correspond? We can say with certainty that it definitely corresponds to ‘Painful Periods’ because this is a prominent symptom of endometriosis in 97% of cases. This means that if we refer to the treatment of the Chinese disease of ‘Painful Periods’, we can get some idea as to how to treat endometriosis. However, endometriosis may also correspond to ‘Heavy Periods’ (Yue Jing Guo Duo) or to ‘Flooding and Trickling’ (Beng Lou). Moreover, most modern Chinese gynecologists also say that endometriosis must be treated not only as ‘Painful Periods’ but also as ‘Abdominal Masses’ (Zheng Jia). This is because the endometriotic lesions in the abdominal cavity can be considered as a form of ‘Abdominal Masses’ (from Blood stasis) even though they are not palpable. What difference does it make whether we treat endometriosis as ‘Painful Periods’ or as ‘Abdominal Masses’? There is an important difference in the herbal treatment. Abdominal masses from Blood stasis are treated not only by invigorating Blood but also by ‘breaking Blood’ and softening masses. Herbs that ‘break Blood’ strongly invigorate Blood and have a special function of dissolving masses. Examples of such herbs are E Zhu Rhizoma Curcumae and San Leng Rhizoma Sparganii. Herbs that soften masses include Yi Yi Ren Semen Coicis, Zhe Bei Mu Bulbus Fritillariae thunbergii, Hai Zao Sargassum, etc.
When using herbal medicine, apart from treating the presenting patterns, it is necessary to use the method of ‘penetrating downwards’ (Tong Xia) to stimulate the downward flow of blood and to stop pain. Obviously this treatment method needs to be tempered if the periods are heavy. The ‘penetrating downwards’ method consists in stimulating the downward flow of Qi and Blood through the bowel movement with herbs such as Da Huang Radix et Rhizoma Rhei. When used in its prepared form, this herb also invigorates Blood. In order to stop pain, besides the obvious treatment of invigorating Blood by treating the Liver, calming the Heart is also important. While the Liver stores Blood, the Heart governs Blood and its stasis also affects the Uterus (through the Uterus Vessel – Bao Mai – connecting Heart and Uterus). Herbs that stop pain by calming the Heart include Dan Shen Radix Salviae miltiorrhizae, Bai Zi Ren Semen Platycladi and Suan Zao Ren Semen Ziziphi spinosae. It is necessary to treat both the Root and the Manifestation: this means tonifying the Kidneys and invigorating Blood (and if necessary expelling Cold or resolving Dampness). Many modern Chinese articles place the emphasis exclusively on invigorating Blood: in my opinion, this is not good practice. It is important to treat both the Root and the Manifestations and especially to do so by giving treatment according to the four phases. He Xian Lin and Frosolone say: Although there are many ways to achieve the same goal, one thing is agreed upon by all sources with regard to endometriosis. The major pathology is that of Qi and Blood stagnation. Both patterns need to be addressed but at the root of it all there is Kidney-Qi deficiency. Attention should also be paid to treatment according to the four phases and predominance of the most severe symptom (dysmenorrhoea or menorrhagia/metrorrhagia).3 Generally, I treat the Manifestation (e.g. Blood stasis) in phases 4 and 1 and the Root (e.g. Kidney deficiency) in phases 2 and 3. This is not a rigid rule as it is sometimes necessary to treat the Manifestation also in phase 3.
It is important to warm the Uterus even if there are no specific signs of Cold in order to ensure the growth of Yang in phases 3 and 4. This is an interesting concept and I follow it also if there is Kidney-Yin deficiency. Even in the presence of Kidney-Yin deficiency, during phase 4 I would use one or two herbs that warm the Uterus to ensure the growth of Yang during the luteal phase and to eliminate Yin pathogenic factors (such as Blood stasis, Dampness or Phlegm). Examples of herbs that I would use to warm the Uterus are Xu Duan Radix Dipsaci, Gui Zhi Ramulus Cinnamomi and Ai Ye Folium Artemisiae argyi. Obviously we cannot warm the Uterus if there is Liver-Fire or Damp-Heat. Summary Treatment principles
• Treat endometriosis as ‘Painful Periods’ and as ‘Abdominal Masses. • Use Tong Xia (Penetrating downwards) method to stop pain. • To stop pain, calming the Heart is also important. • Treat Biao and Ben, i.e. invigorate Blood and tonify the Kidneys. • Invigorating Blood only is not enough. Far better to regulate the menses according to the four phases. • Must warm the Uterus even if there are no specific signs of Cold in order to ensure the growth of Yang in phases 3 and 4. Obviously not if there is Liver-Fire or Damp-Heat.
Acupuncture and herbal medicine in the treatment of endometriosis In my opinion, herbal treatment is essential in the therapy of endometriosis. I
use herbal medicine to treat the patterns (e.g. Blood stasis, Kidney deficiency, Dampness, etc.) and acupuncture to regulate the Governing, Directing and Penetrating Vessels (Du, Ren and Chong Mai). I give the herbal treatment always according to the phases as follows: – Phase 1: invigorate Blood (or invigorate Blood and stop bleeding). – Phase 2: tonify the Kidneys (and nourish Blood if necessary). – Phase 3: tonify the Kidneys and Spleen; if necessary, resolve Dampness. – Phase 4: invigorate Blood, expel Cold from the Uterus, resolve Dampness or Phlegm. With acupuncture, I treat primarily the Penetrating Vessel (Chong Mai) because it is the Sea of Blood and because Blood stasis is one of its chief pathologies. However, I also treat the Directing and Governing Vessels (Ren and Du Mai). I treat the former especially if there is Kidney-Yin deficiency and the latter especially if there is Kidney-Yang deficiency. Penetrating Vessel (Chong Mai)
The Penetrating Vessel is the Sea of Blood, and any Blood pathology, and especially Blood stasis, in gynecology should be treated with this vessel. To activate this vessel involves two steps: first, I use its opening points, i.e. SP-4 Gongsun and P-6 Neiguan; second, I use points on the vessel to move Blood and particularly KI-14 Siman and LIV-3 Taichong (the descending branch of the Penetrating Vessel goes to LIV-3). In women, I use the main point SP-4 (on the right) and P-6 (on the left). Thus, a typical treatment of the Penetrating Vessel for Blood stasis in endometriosis might involve these points: SP-4 Gongsun (on the right), P-6 Neiguan (on the left), L.I.-4 Hegu (on the right), LIV-3 Taichong (on the left) and KI-14 Siman (bilaterally) (Fig. 65.4).
Figure 65.4 Penetrating Vessel treatment for Blood stasis in endometriosis. The Penetrating Vessel can be used in any phase, but I often use the Penetrating Vessel in phases 4 and 1 and the Directing Vessel in phases 2 and 3.
Directing Vessel (Ren Mai)
The Directing Vessel governs Yin and it tonifies Kidney-Yin. It also regulates the Uterus. Although it is the Sea of Yin, I do use the Ren Mai also to tonify Kidney-Yang. The Directing Vessel has a very wide application in gynecology. When I use the Directing Vessel in women, I use LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left). I then combine these opening points with points on the vessel according to symptoms. In endometriosis, I would usually combine LU-7 and KI-6 with Ren-4 Guanyuan. If there is KidneyYang deficiency, I use direct moxa cones on Ren-4 (Fig. 65.5).
Figure 65.5 Directing Vessel treatment in endometriosis.
Governing Vessel (Du Mai)
The Governing Vessel governs the Yang and it controls Kidney-Yang. I use it in gynecology only when there is a pronounced deficiency of Kidney-Yang. I usually use it in phases 2 and 3. When I use the Governing Vessel in gynecology, I use S.I.-3 Houxi (on the right) and BL-62 Shenmai (on the left). I usually combine these two points with Ren-4 Guanyuan with moxa cones (Fig. 65.6).
Figure 65.6 Governing Vessel treatment in endometriosis. In case of infertility from Kidney deficiency, I use anacupuncture treatment to promote ovulation. This is based on two point formulae that are alternated. They are:
1. Ren-3 Zhongji, SP-6 Sanyinjiao, KI-12 Dahe. 2. Ren-4 Guanyuan, Ren-3 Zhongji, SP-6 Sanyinjiao, Zigong. Start when cervical secretion appears.
Identification of patterns and treatment
Liver-Blood stasis
Clinical manifestations Intense, stabbing pain before or during the period, pain relieved after passing clots, dark menstrual blood with large clots, ovaries may be palpable if there are endometrial cysts, irritability, mental restlessness (Fig. 65.7). Tongue: Purple. Pulse: Wiry, Firm or Choppy.
Figure 65.7 Liver-Blood stasis in endometriosis.
Treatment principle Invigorate Blood, eliminate stasis, pacify the Liver, stop pain. Acupuncture SP-4 Gongsun and P-6 Neiguan, LIV-3 Taichong, Ren-6 Qihai, ST-29 Guilai, SP-10 Xuehai, SP-6 Sanyinjiao, BL-17 Geshu, KI-14 Siman. All with reducing or even method. Explanation
– SP-4 and P-6 activate the Penetrating Vessel and invigorate Blood. – LIV-3 invigorates Blood, activates the Penetrating Vessel and stops pain. – Ren-6 moves Qi in the lower abdomen and it is used to invigorate Blood by moving Qi. – ST-29 invigorates Blood and stops pain. – SP-10 invigorates Blood – SP-6 invigorates Blood and stops pain – BL-17 invigorates Blood – KI-14 invigorates Blood of the Penetrating Vessel.
Example of combination
– SP-4 (on the right) with P-6 (on the left), KI-14 bilateral, LIV-3 (bilateral) (Fig. 65.8).
Figure 65.8 Example of point combination for Liver-Blood stasis.
Herbal treatment
a. Prescription
– DA QI QI TANG – Big Seven Qi Decoction Explanation
– Qing Pi, Chen Pi and Xiang Fu move Qi in order to invigorate Blood. – San Leng and E Zhu invigorate and ‘break’ Blood. – Jie Geng and Huo Xiang stimulate the diffusing of Lung-Qi to help tp move Qi. – Rou Gui and Yi Zhi Ren warm the Uterus which helps to invigorate Blood. – Gan Cao, Sheng Jiang and Da Zao harmonize. b. Prescription
– NEI YI FANG – Endometriosis Formula Explanation
– Xiang Fu moves Qi to help to invigorate Blood.
– Dang Gui, Dan Shen, Xue Jie, Chuan Niu Xi and Chi Shao invigorate Blood. – E Zhu ‘breaks’ Blood. – Gui Zhi warms the Uterus to help to invigorate Blood. – Zao Jiao Ci resolves Toxic-Heat. – Hai Zao softens masses (as endometriosis is considered a form of ‘Abdominal Masses’). c Prescription
– HUA YU DING TONG TANG – Eliminating Stasis and Stopping Pain Decoction Explanation
– Dang Gui, Dan Shen, Chuan Xiong, Chuan Niu Xi, Chi Shao, Xue Jie, Mo Yao, Su Mu, Yan Hu Suo, Wu Ling Zhi and Pu Huang invigorate Blood. Pu Huang also stops bleeding. This last formula should be modified with the addition of E Zhu Rhizoma Curcumae and San Leng Rhizoma Sparganii. Women’s Treasure remedies
– STIR FIELD OF ELIXIR This remedy is a variation of Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction which invigorates Blood in the Lower
Burner. – HARMONIZING THE MOON This remedy is a variation of Gui Zhi Fu Ling Wan Ramulus Cinnamomi-Poria Pill which invigorates Blood, eliminates stasis and dissolves masses. Summary Liver-Blood stasis
Clinical manifestations
Intense, stabbing pain before or during the period, pain relieved after passing clots, dark menstrual blood with large clots, ovaries may be palpable if there are endometrial cysts, irritability, mental restlessness. Tongue: Purple. Pulse: Wiry, Firm or Choppy. Treatment principle
Invigorate Blood, eliminate stasis, pacify the Liver, stop pain. Acupuncture
LIV-3 Taichong, Ren-6 Qihai, ST-29 Guilai, SP-10 Xuehai, SP-6 Sanyinjiao, SP-4 Gongsun and P-6 Neiguan, BL-17 Geshu, KI-14 Siman. All with reducing or even method. Herbal treatment
Pre scriptions
• DA QI QI TANG Big Seven Qi Decoction • NEI YI FANG Endometriosis Formula • HUA YU DING TONG TANG Eliminating Stasis and Stopping Pain Decoction Women’s Treasure remedies
• STIR FIELD OF ELIXIR • HARMONIZING THE MOON
Stagnation of Cold
Clinical manifestations Painful period, pain central, pain relieved by the application of heat, menstrual blood rather scanty and bright red with small, dark clots, feeling cold, feeling colder during the period, sore back. Tongue: Pale-Bluish or Bluish-Purple (Fig. 65.9). Pulse: Deep and Tight or Deep and Wiry.
Figure 65.9 Stagnation of Cold in endometriosis.
Treatment principle Warm the Uterus, expel Cold, invigorate Blood. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-6 Qihai, ST-29 Guilai, SP-6 Sanyinjiao, ST-36 Zusanli, ST-28 Shuidao. Reducing method except on ST-36 which should be reinforced. Moxa must be used. Explanation
– LU-7 and KI-6 activate the Directing Vessel. – Ren-4 warms the Uterus (with direct moxa cones). – Ren-6 (with moxa) tonifies Qi and expels Cold. – ST-29 and SP-6 invigorate Blood. – ST-36 (with moxa) expels Cold. – ST-28 (with moxa) expels Cold. Example of combination
– LU-7 (on the right) with KI-6 (on the left), Ren-4, ST-29 bilateral, SP-6 (bilateral) (Fig. 65.10).
Figure 65.10 Example of point combination for stagnation of Cold.
Herbal treatment
Prescription
– WEN JING TANG – Warming the Menses Decoction Explanation
– Wu Zhu Yu, Gui Zhi and Sheng Jiang warm the Uterus and expel Cold. – Dang Gui, E Jiao and Bai Shao nourish Blood. This is necessary because Cold in the Uterus may interfer with the making of menstrual Blood. – Dang Shen tonifies Qi in order to help to make Blood. – Chuan Xiong and Mu Dan Pi invigorate Blood. Mu Dan Pi is in the formula also to clear any Empty-Heat that may derive from Blood or Yin deficiency (see next line). – Mai Men Dong nourishes Yin and is added in case the Blood deficiency progresses to Yin deficiency. – Ban Xia is in the formula not to resolve Phlegm but to harmonize the Uterus via the Stomach channel. This connection between Uterus and Stomach channels takes place through the Penetrating Vessel (Chong Mai). Women’s Treasure remedy
– WARM THE MENSES This remedy is a variation of Wen Jing Tang Warming the Menses Decoction which expels Cold from the Uterus. Summary Stagnation of Cold
Clinical manifestations
Painful period, pain central, pain relieved by the application of heat, menstrual blood rather scanty and bright red with small, dark clots, feeling cold, feeling colder during the period, sore back. Tongue: Pale-Bluish or Bluish-Purple. Pulse: Deep and Tight or Deep and Wiry. Treatment principle
Warm the Uterus, expel Cold, invigorate Blood. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-6 Qihai, ST-29 Guilai, SP-6 Sanyinjiao, ST-36 Zusanli, ST-28 Shuidao. Reducing method except on ST-36 which should be reinforced. Moxa must be used. Herbal treatment
Pre scription
• WEN JING TANG Warming the Menses Decoction Women’s Treasure remedy
• WARM THE MENSES
Dampness
Clinical manifestations Hypogastric pain before the period and sometimes on mid-cycle, menstrual blood red with small clots, vaginal discharge, scanty, dark urine, a feeling of fullness in the abdomen, a feeling of heaviness (Fig. 65.11). Tongue: sticky coating, possibly Swollen. Pulse: Slippery.
Figure 65.11 Dampness in endometriosis.
In case of Damp-Heat
Burning sensation extending to the sacrum, feeling of heat, thirst, mental restlessness. Tongue: Red, sticky, yellow coating. Pulse: Slippery-Rapid. Treatment principle Resolve Dampness, eliminate stasis, clear Heat if there is Heat. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-3 Zhongji, ST-28 Shuidao, BL-32 Ciliao, BL-22 Sanjiaoshu, Ren-9 Shuifen, SP-10 Xuehai, LIV-3 Taichong. Reducing or even method. Explanation
– LU-7 and KI-6 activate the Directing Vessel. – SP-9, SP-6, Ren-3, ST-28, BL-32, BL-22, Ren-9 resolve Dampness. ST-28 is an important local point to resolve Dampness from the Lower Burner. – SP-10 and LIV-3 invigorate Blood. Example of combination
LU-7 (on the right) with KI-6 (on the left), ST-28 bilateral, Ren-3, SP-9 and SP-6 (both bilateral) (Fig. 65.12).
Figure 65.12 Example of point combination for Dampness in the Uterus.
Herbal treatment
a. Prescription
– QING RE TIAO XUE TANG – Clearing Heat and Regulating Blood Decoction Explanation
– Xiang Fu moves Qi. – Chuan Xiong, Hong Hua, Tao Ren, E Zhu and Yan Hu Suo invigorate and ‘break’ Blood. – Dang Gui and Bai Shao nourish Blood. – Mu Dan Pi invigorate Blood and clears Liver-Heat. – Sheng Di Huang cools Blood. – Huang Lian clears Heat and resolves Dampness. b. Prescription
– ER MIAO SAN Variation
– Two Wonderful Powder Variation Explanation
– Cang Zhu and Huang Bo form the original prescription and they resolve Dampness and clear Heat in the Lower Burner. – Bai Jiang Cao resolves Toxic-Heat from the Uterus. – Yan Hu Suo invigorates Blood. Women’s Treasure remedy
– DRAIN REDNESS This remedy is a variation of Qing Re Tiao Xue Tang Clearing Heat and Regulating Blood Decoction which clears Heat and resolves Dampness from the Uterus. Summary Dampness
Clinical manifestations
Hypogastric pain before the period and sometimes in mid-cycle, menstrual blood red with small clots, vaginal discharge, scanty, dark urine, a feeling of fullness in the abdomen, a feeling of heaviness. Tongue: sticky coating, possibly Swollen. Pulse: Slippery. In case of Damp-Heat
Burning sensation extending to the sacrum, feeling of heat, thirst, mental restlessness. Tongue: Red, sticky, yellow coating. Pulse: Slippery-Rapid. Treatment principle
Resolve Dampness, eliminate stasis, clear Heat if there is Heat. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-3 Zhongji, ST-28 Shuidao, BL-32 Ciliao, BL-22 Sanjiaoshu, Ren-9 Shuifen, SP-10 Xuehai, LIV-3 Taichong. Reducing or even method. Herbal treatment
Pre scriptions
• QING RE TIAO XUE TANG Clearing Heat and Regulating Blood Decoction • ER MIAO SAN Variation Two Wonderful Powder Variation Women’s Treasure remedy
• DRAIN REDNESS
Damp-Phlegm in the Uterus
Clinical manifestations Painful periods, abdominal fullness, a feeling of heaviness, excessive vaginal discharge, obesity, possibly soft abdominal masses (Fig. 65.13). Tongue: Swollen, with a sticky coating which is thicker on the root. Pulse: Slippery.
Figure 65.13 Damp-Phlegm in the Uterus in endometriosis.
Treatment principle Resolve Damp and Phlegm, move Qi, invigorate Blood. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-12 Zhongwan, BL-20 Pishu, Ren-6 Qihai, ST-40 Fenglong, SP-6 Sanyinjiao, ST-28 Shuidao, SP-9 Yinlingquan, BL-22 Sanjiaoshu. Reducing or even method, except on Ren-12 and BL-20 which should be reinforced. Explanation
– LU-7 and KI-6 activate the Directing Vessel. – Ren-12 and BL-20 tonify the Spleen to resolve Phlegm. – Ren-6, ST-40, SP-6, ST-28, SP-9 and BL-22 resolve Phlegm. ST-28 is an important local point to resolve Phlegm in the Lower Burner and the Uterus specifically. Example of combination LU-7 (on the right) with KI-6 (on the left), Ren-6, ST-28 bilateral, SP-6 bilateral, ST-40 (bilateral) (Fig. 65.14). Leave 20 minutes, then ask patient to turn over and do BL-20 and BL-22 (both bilateral).
Figure 65.14 Example of point combination for Damp-Phlegm in the Uterus.
Herbal treatment
Prescription
– CANG FU DAO TAN WAN Variation – Atractylodes-Cyperus Conducting Phlegm Pill Variation Explanation
– Cang Zhu, Fu Ling and Chen Pi resolve Dampness. – Xiang Fu and Zhi Ke move Qi. – Dan Nan Xing resolves Phlegm. – Gan Cao and Sheng Jiang harmonize. – Shen Qu dissolves food accumulation: this helps to resolve Phlegm. Women’s Treasure remedy
– CLEAR THE PALACE This is a variation of Qi Gong Wan which resolves Damp-Phlegm from the Uterus. Summary Damp-Phlegm in the Uterus
Clinical manifestations
Painful periods, abdominal fullness, a feeling of heaviness, excessive vaginal discharge, obesity, possibly soft abdominal masses. Tongue: Swollen, with a sticky coating which is thicker on the root. Pulse: Slippery. Treatment principle
Resolve Damp and Phlegm, move Qi, invigorate Blood. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-12 Zhongwan, BL-20 Pishu, Ren-6 Qihai, ST-40 Fenglong, SP-6 Sanyinjiao, ST-28 Shuidao, SP-9 Yinlingquan, BL-22 Sanjiaoshu. Reducing or even method, except on Ren-12 and BL-20 which should be reinforced. Herbal treatment
Pre scription
• CANG FU DAO TAN WAN Variation Atractylodes-Cyperus Conducting Phlegm Pill Variation Women’s Treasure remedy
• CLEAR THE PALACE
Kidney-Yang deficiency
Clinical manifestations Painful periods, abdominal pain relieved by pressure and the application of heat, water retention and bloating before the period, pale red menstrual blood, feeling cold, backache, dizziness, tinnitus, depression (Fig. 65.15). Tongue: Pale and wet. Pulse: Deep-Weak.
Figure 65.15 Kidney-Yang deficiency in endometriosis.
Treatment principle Tonify and warm Yang, invigorate Blood. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Du-4 Mingmen, KI-13 Qixue, KI-3 Taixi, BL-23 Shenshu, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-3 Taichong. All with reinforcing method, except for SP-6 and LIV-3 which should be needled with even method; moxa should be used. Explanation
– LU-7 and KI-6 activate the Directing Vessel. – Ren-4, Du-4, KI-13, BL-23 tonify the Kidneys. I use Du-4 with moxa only in cases of severe Yang deficiency. – ST-36 tonifies the Spleen. – SP and LIV-3 invigorate Blood. Example of combination LU-7 (on the right) with KI-6 (on the left), Ren-4, KI-13 bilateral, ST-36 and KI-3 (both bilateral). Retain for 20 minutes, then turn over and use BL23 bilateral.
Herbal treatment
a. Prescription
– GU YIN JIAN – Consolidating the Yin Decoction Note: in spite of its name, this formula can be used to tonify KidneyYang. Explanation
– Ren Shen tonifies Qi and Blood. – Shu Di Huang, Shan Yao, Shan Zhu Yu and Tu Si Zi tonify the Kidneys. – Yuan Zhi calms the Mind and opens the Mind’s orifices. – Wu Wei Zi nourishes Lung-Yin and Kidney-Essence. – Zhi Gan Cao harmonizes. b. Prescription
– YOU GUI WAN – Restoring the Right [Kidney] Pill Explanation
This formula is a well-known Kidney-Yang tonic which has already been explained. Women’s Treasure remedies
– STRENGTHEN THE ROOT This remedy is a variation of You Gui Wan and it tonifies Kidney-Yang. – UNICORN PEARL This remedy also tonifies Kidney-Yang and is a variation of Yu Lin Zhu. It is specific for infertility. Summary Kidney-Yang deficiency
Clinical manifestations
Painful periods, abdominal pain relieved by pressure and the application of heat, water retention and bloating before the period, pale red menstrual blood, feeling cold, backache, dizziness, tinnitus, depression. Tongue: Pale and wet. Pulse: Deep-Weak. Treatment principle
Tonify and warm Yang, invigorate Blood. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Du-4 Mingmen, KI-13 Qixue, KI-3 Taixi, BL-23 Shenshu, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-3 Taichong. All with reinforcing method, except for SP-6 and LIV-3 which should be needled with even method; moxa should be used. Herbal treatment
Pre scriptions
• GU YIN JIAN Consolidating the Yin Decoction • YOU GUI WAN Restoring the Right [Kidney] Pill Women’s Treasure remedies
• STRENGTHEN THE ROOT • UNICORN PEARL
Kidney-Yin deficiency
Clinical manifestations Dull hypogastric pain towards the end of or after the period, pain relieved by pressure, scanty bleeding, sore back, dizziness, tinnitus, exhaustion, night sweating (Fig. 65.16). Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty.
Figure 65.16 Kidney-Yin deficiency in endometriosis.
Treatment principle Nourish Yin, tonify the Kidneys. Acupuncture LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-3 Taixi, ST-36 Zusanli. Reinforcing method. Explanation
– LU-7 and KI-6 activate the Directing Vessel and nourish Yin. – Ren-4, SP-6, KI-3 and ST-36 nourish Kidney-Yin. Example of combination
– LU-7 (on the right) with KI-6 on the left, Ren-4, SP-6 and KI-3 (both bilateral). Herbal treatment
a. Prescription
– BU SHEN DI HUANG TANG – Tonifying the Kidneys Rehmannia Decoction Explanation
– Shu Di Huang, Xuan Shen, Gui Ban Jiao, Shan Zhu Yu, Mai Men Dong and Shan Yao nourish Kidney-Yin. – Zhi Mu and Huang Bo clear Empty-Heat deriving from Kidney-Yin deficiency. – Yuan Zhi, Suan Zao Ren, Ze Xie and Fu Shen calm the Mind and opens the Mind’s orifices. – Mu Dan Pi clears Heat and invigorates Blood. – Sang Piao Xiao nourishes Yin and astringes. – Zhu Ye clears Lung-Heat. b Prescription
– ZUO GUI WAN – Restoring the Left [Kidney] Pill Explanation
– This formula is a well-known Kidney-Yin tonic and it has already been explained.
Women’s Treasure remedies
– NOURISH THE ROOT or GROWING JADE Nourish the Root is a variation of Zuo Gui Wan while Growing Jade is a variation of Yang Jing Zhong Yu Tang Nourishing the Essence and Planting Jade Decoction: they both nourish Kidney-Yin and the latter is specific for infertility. Summary Kidney-Yin deficiency
Clinical manifestations
Dull hypogastric pain towards the end of or after the period, pain relieved by pressure, scanty bleeding, sore back, dizziness, tinnitus, exhaustion, night sweating. Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty. Treatment principle
Nourish Yin, tonify the Kidneys. Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-3 Taixi, ST-36 Zusanli. Reinforcing method. Herbal treatment
Pre scriptions
• BU SHEN DI HUANG TANG Tonifying the Kidneys Rehmannia Decoction • ZUO GUI WAN Restoring the Left [Kidney] Pill Three Treasures remedies
• NOURISH THE ROOT • GROWING JADE
Blood deficiency
Clinical manifestations Dull pain towards the end or after the period, scanty periods, tiredness after the period, blurred vision, dizziness, tingling limbs (Fig. 65.17). Tongue: Pale. Pulse: Choppy or Thin.
Figure 65.17 Liver-Blood deficiency in endometriosis.
Treatment principle Nourish Blood, strengthen the Liver.
Acupuncture LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, BL-17 Geshu, BL-18 Ganshu. All points with reinforcing method; direct moxa on BL-17 and BL-18. Explanation
– LU-7 and KI-6 open the Directing Vessel. – LIV-8, ST-36 and SP-6 nourish Liver-Blood. – KI-3 and Ren-4 nourish Kidney-Yin. It is necessary to strengthen the Kidneys because menstrual blood is Tian Gui deriving from the Kidneys. – BL-17 and BL-18 in combination nourish Liver-Blood. Example of combination LIV-8, ST-36, SP-6, KI-3 (all bilateral), Ren-4. Herbal treatment
Prescription
– REN SHEN YANG RONG TANG – Ginseng Nourishing and Flourishing Decoction
Explanation This formula is a Qi and Blood tonic that has already been explained. Women’s Treasure remedy
– PRECIOUS SEA This is a variation of Ba Zhen Tang Eight Precious Decoction which nourishes Blood. Summary Blood deficiency
Clinical manifestations
Dull pain towards the end or after the period, scanty periods, tiredness after the period, blurred vision, dizziness, tingling limbs. Tongue: Pale. Pulse: Choppy or Thin. Treatment principle
Nourish Blood, strengthen the Liver. Acupuncture
LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, BL-17 Geshu, BL-18 Ganshu. All points with reinforcing method; direct moxa on BL-17 and BL-18.
He rbal tre atme nt
Prescription
• REN SHEN YANG RONG TANG Ginseng Nourishing and Flourishing Decoction Women’s Treasure remedy
• PRECIOUS SEA
Combined patterns The patterns indicated above never occur individually but are always combined. The following are only examples of combinations and there may be more combinations besides the ones indicated below.
Blood stasis, Kidney-Yang deficiency and Dampness
Clinical manifestations Painful periods, scanty or heavy periods, dark blood with dark clots, vaginal discharge, mid-cycle hypogastric pain, possibly abdominal masses, lower backache, frequent, pale urination, feeling cold. Tongue: Pale with Purple sides. Pulse: Deep, Firm and possibly Slippery. This combination of patterns is one of the most commonly seen in practice. The patterns are listed in order of importance, i.e. Blood stasis, Kidney-Yang deficiency and Dampness. Blood stasis and Dampness are the Manifestation (Biao) and Kidney-Yang deficiency is the Root (Ben) which may cause a luteal insufficiency. Treatment principle
1. Menstrual phase: invigorate Blood, eliminate stasis. 2. Post-menstrual phase (about 7 days): warm and tonify Kidney-Yang, tonify Spleen-Qi. 3. Mid-cycle phase (about 7 days): warm and tonify Kidney-Yang, tonify Spleen-Qi, resolve Dampness. 4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis, resolve Dampness. Acupuncture
1. Menstrual phase: SP-4 Gongsun with P-6 Neiguan, KI-14 Siman, LIV3 Taichong, SP-10 Xuehai. 2. Post-menstrual phase (about 7 days): LU-7 Lieque and KI-6 Zhaohai. ST-36 Zusanli, LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi. 3. Mid-cycle phase (about 7 days): LU-7 Lieque with KI-6 Zhaohai, ST36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan. 4. Pre-menstrual phase (about 7 days): SP-4 Gongsun with P-6 Neiguan, KI-14 Siman, LIV-3 Taichong, SP-10 Xuehai, SP-9 Yinlingquan. Herbal treatment
1. Menstrual phase: Da Qi Qi Tang Big Seven Qi Decoction, Nei Yi Fang Endometriosis Formula or Hua Yu Ding Tong Tang Eliminating Stasis and Stopping Pain Decoction. 2. Post-menstrual phase (about 7 days): Gu Yin Jian Consolidating the Yin Decoction, You Gui Wan Restoring the Right [Kidney] Pill. 3. Mid-cycle phase (about 7 days): Gu Yin Jian Consolidating the Yin Decoction, You Gui Wan Restoring the Right [Kidney] Pill modified with some herbs to resolve Dampness. 4. Pre-menstrual phase (about 7 days): Da Qi Qi Tang Big Seven Qi Decoction, Nei Yi Fang Endometriosis Formula or Hua Yu Ding Tong Tang Eliminating Stasis and Stopping Pain Decoction. Summary Blood stasis, Kidney-Yang deficiency and Dampness
Treatment principle
1. Menstrual phase: invigorate Blood, eliminate stasis. 2. Post-menstrual phase (about 7 days): Warm and tonify Kidney-Yang, tonify Spleen-Qi. 3. Mid-cycle phase (about 7 days): Warm and tonify Kidney-Yang, tonify Spleen-Qi, resolve Dampness. 4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis, resolve Dampness.
Acupuncture
1. Menstrual phase: SP-4 Gongsun with P-6 Neiguan, KI-14 Siman, LIV-3 Taichong, SP-10 Xuehai. 2. Post-menstrual phase (about 7 days): LU-7 Lieque and KI-6 Zhaohai. ST-36 Zusanli, LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi. 3. Mid-cycle phase (about 7 days): LU-7 Lieque with KI-6 Zhaohai, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan. 4. Pre-menstrual phase (about 7 days): SP-4 Gongsun with P-6 Neiguan, KI14 Siman, LIV-3 Taichong, SP-10 Xuehai, SP-9 Yinlingquan.
Herbal treatment
1. Menstrual phase: Da Qi Qi Tang Big Seven Qi Decoction, Nei Yi Fang Endometriosis Formula, or Hua Yu Ding Tong Tang Eliminating Stasis and Stopping Pain Decoction. 2. Post-menstrual phase (about 7 days): Gu Yin Jian Consolidating the Yin
Decoction, You Gui Wan Restoring the Right [Kidney] Pill. 3. Mid-cycle phase (about 7 days): Gu Yin Jian Consolidating the Yin Decoction, You Gui Wan Restoring the Right [Kidney] Pill modified with some herbs to resolve Dampness. 4. Pre-menstrual phase (about 7 days): Da Qi Qi Tang Big Seven Qi Decoction, Nei Yi Fang Endometriosis Formula, or Hua Yu Ding Tong Tang Eliminating Stasis and Stopping Pain Decoction.
Blood stasis, Kidney-Yin deficiency and Dampness
Clinical manifestations Painful periods, stabbing or heavy abdominal pain, mid-cycle hypogastric pain, possibly abdominal masses, sore back, scanty or heavy periods, vaginal discharge, dizziness, tinnitus. Tongue: without coating. Pulse: Floating-Empty and Slippery-Wiry. Treatment principle
1. Menstrual phase (about 5 days): invigorate Blood, eliminate stasis. 2. Post-menstrual phase (about 7 days): nourish Kidney-Yin, tonify Spleen-Qi. 3. Mid-cycle phase (about 7 days): nourish Kidney-Yin, tonify Spleen-Qi, resolve Dampness. 4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis, resolve Dampness. Acupuncture
1. Menstrual phase (about 5 days): SP-4 Gongusn with P-6 Neiguan, KI14 Siman, LIV-3 Taichong, SP-10 Xuehai. 2. Post-menstrual phase (about 7 days): LU-7 Lieque with KI-6 Zhaohai, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan.
3. Mid-cycle phase (about 7 days): LU-7 Lieque with KI-6 Zhaohai, SP6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, Ren-12 Zhongwan, Ren-9 Shuifen, SP-9 Yinlingquan. 4. Pre-menstrual phase (about 7 days): SP-4 Gongusn with P-6 Neiguan, KI-14 Siman, LIV-3 Taichong, SP-10 Xuehai, Ren-12 Zhongwan, Ren-9 Shuifen, SP-9 Yinlingquan. Herbal treatment
1. Menstrual phase (about 5 days): Da Qi Qi Tang Big Seven Qi Decoction, Nei Yi Fang Endometriosis Formula, or Hua Yu Ding Tong Tang Eliminating Stasis and Stopping Pain Decoction. 2. Post-menstrual phase (about 7 days): Bu Shen Di Huang Tang Tonifying the Kidneys Rehmannia Decoction, Zuo Gui Wan Restoring the Left [Kidney] Pill. Modify with the addition of a Spleen tonic. 3. Mid-cycle phase (about 7 days): same as in phase 2 above. 4. Pre-menstrual phase (about 7 days): same as in phase 1 above with the addition of a Spleen tonic (such as Bai Zhu Rhizoma Atractylodis macrocephalae) and one herb to resolve Dampness (such as Fu Ling Poria). Summary Blood stasis, Kidney-Yin deficiency and Dampness
Treatment principle
1. Menstrual phase (about 5 days): invigorate Blood, eliminate stasis. 2. Post-menstrual phase (about 7 days): nourish Kidney-Yin, tonify Spleen-Qi. 3. Mid-cycle phase (about 7 days): nourish Kidney-Yin, tonify Spleen-Qi, resolve Dampness. 4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis, resolve Dampness.
Acupuncture
1. Menstrual phase (about 5 days): SP-4 Gongusn with P-6 Neiguan, KI-14 Siman, LIV-3 Taichong, SP-10 Xuehai. 2. Post-menstrual phase (about 7 days): LU-7 Lieque with KI-6 Zhaohai, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan. 3. Mid-cycle phase (about 7 days): LU-7 Lieque with KI-6 Zhaohai, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, Ren-12 Zhongwan, Ren-9 Shuifen, SP-9 Yinlingquan. 4. Pre-menstrual phase (about 7 days): SP-4 Gongusn with P-6 Neiguan, KI14 Siman, LIV-3 Taichong, SP-10 Xuehai, Ren-12 Zhongwan, Ren-9 Shuifen, SP-9 Yinllingquan.
Herbal treatment
1. Menstrual phase (about 5 days): Da Qi Qi Tang Big Seven Qi Decoction, Nei Yi Fang Endometriosis Formula, or Hua Yu Ding Tong Tang Eliminating Stasis and Stopping Pain Decoction. 2. Post-menstrual phase (about 7 days): Bu Shen Di Huang Tang Tonifying the Kidneys Rehmannia Decoction, Zuo Gui Wan Restoring the Left [Kidney] Pill. Modify with the addition of a Spleen tonic.
3. Mid-cycle phase (about 7 days): same as in phase 2 above. 4. Pre-menstrual phase (about 7 days): same as in phase 1 above with the addition of a Spleen tonic and one herb to resolve Dampness.
Cold in the Uterus, Blood stasis, Kidney-Yang deficiency and Dampness
Clinical manifestations Severe, cramp-like abdominal period pain, pain central, pain relieved by the application of heat, menstrual blood scanty with small, dark clots, feeling cold, feeling colder during the period, white vaginal discharge, feeling of heaviness and fullness, lower backache, frequent, pale urination, cold feet. Tongue: Pale-Bluish or Bluish-Purple with sticky, white coating. Pulse: DeepWeak-Tight. Treatment principle
1. Menstrual phase (about 5 days): invigorate Blood, eliminate stasis, expel Cold, warm Yang. 2. Post-menstrual phase (about 7 days): tonify and warm Kidney-Yang, tonify Spleen-Qi. 3. Mid-cycle phase (about 7 days): tonify and warm Kidney-Yang, tonify Spleen-Qi, resolve Dampness. 4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis, expel Cold, resolve Dampness. Acupuncture
1. Menstrual phase (about 5 days): SP-4 Gongsun (on the right) with P-6
Neiguan (on the left), KI-14 Siman, LIV-3 Taichong, SP-10 Xuehai, Ren-4 with moxa box. 2. Post-menstrual phase (about 7 days): LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 with direct moxa cones, ST-36 Zusanli, KI-3 Taixi, BL-23 Shenshu, BL-20 Pishu. 3. Mid-cycle phase (about 7 days): LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 with direct moxa cones, ST-36 Zusanli, KI-3 Taixi, BL-23 Shenshu, BL-20 Pishu, SP-6 Sanyinjiao, SP-9 Yinlingquan, ST-28 Shuidao. 4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis, scatter Cold, resolve Dampness. Herbal treatment
1. Menstrual phase (about 5 days): Da Qi Qi Tang Big Seven Qi Decoction, Nei Yi Fang Endometriosis Formula or Hua Yu Ding Tong Tang Eliminating Stasis and Stopping Pain Decoction. Add Gui Zhi Ramulus Cinnamomi. 2. Post-menstrual phase (about 7 days): Gu Yin Jian Consolidating the Yin Decoction, You Gui Wan Restoring the Right [Kidney] Pill. Add a Spleen tonic such as Bai Zhu Rhizoma Atractylodis macrocephalae. 3. Mid-cycle phase (about 7 days): same as in phase 2 but with the addition of herbs to tonify the Spleen and resolve Dampness such as Bai Zhu Rhizoma Atractylodis macrocephalae and Fu Ling Poria. 4. Pre-menstrual phase (about 7 days): Wen Jing Tang Warming the Menses Decoction.
Summary Cold In The Uterus, Blood stasis, Kidney-Yang Deficiency and Dampness
Treatment principle
1. Menstrual phase (about 5 days): invigorate Blood, eliminate stasis, expel Cold, warm Yang. 2. Post-menstrual phase (about 7 days): tonify and warm Kidney-Yang, tonify Spleen-Qi. 3. Mid-cycle phase (about 7 days): tonify and warm Kidney-Yang, tonify Spleen-Qi, resolve Dampness. 4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis, expel Cold, resolve Dampness.
Acupuncture
1. Menstrual phase (about 5 days): SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), KI-14 Siman, LIV-3 Taichong, SP-10 Xuehai, Ren-4 with moxa box. 2. Post-menstrual phase (about 7 days): LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 with direct moxa cones, ST-36 Zusanli, KI-3 Taixi, BL-23 Shenshu, BL-20 Pishu. 3. Mid-cycle phase (about 7 days): LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 with direct moxa cones, ST-36 Zusanli, KI-3 Taixi, BL-23 Shenshu, BL-20 Pishu, SP-6 Sanyinjiao, SP-9 Yinlingquan, ST-28 Shuidao. 4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis,
scatter Cold, resolve Dampness.
Herbal treatment
1. Menstrual phase (about 5 days): Da Qi Qi Tang Big Seven Qi Decoction, Nei Yi Fang Endometriosis Formula or Hua Yu Ding Tong Tang Eliminating Stasis and Stopping Pain Decoction. 2. Post-menstrual phase (about 7 days): Gu Yin Jian Consolidating the Yin Decoction, You Gui Wan Restoring the Right [Kidney] Pill. Add a Spleen tonic such as Bai Zhu Rhizoma Atractylodis macrocephalae. 3. Mid-cycle phase (about 7 days): same as in phase 2 but with the addition of herbs to tonify the Spleen and resolve Dampness such as Bai Zhu Rhizoma Atractylodis macrocephalae and Fu Ling Poria. 4. Pre-menstrual phase (about 7 days): Wen Jing Tang Warming the Menses Decoction.
Case history A 32-year-old woman had been diagnosed with endometriosis 18 months previously. The first symptoms of it had appeared 8 years previously. She suffered from severe abdominal pain 1 week prior to the period, during and after it, and also experienced a milder pain mid-cycle. The pain was in the central midline, was alleviated by warmth and aggravated by pressure. She also had a dull pain in her lower back during the period. Her periods were regular, lasted 5–6 days, the blood was a normal colour with small, stringy clots. She experienced abdominal fullness and heaviness at mid-cycle. The pulse was Wiry in the left Middle position and Weak in the two Rear positions. The tongue was a Pale-Purple colour with a sticky coating. In this case, the endometriosis is caused by Cold in the Uterus and Liver-Blood stasis with an underlying Kidney deficiency and Dampness. I prescribed a variation of Wen Jing Tang Warming the Menses Decoction and added Yan Hu Suo Rhizoma Corydalis, Yi Mu Cao Herba Leonuri
and Pu Huang Pollen Typhae. I later changed the prescription to a variation of Si Miao San Four Wonderful Powder. After months, the patient had a laparoscopy which showed ‘minimal’ endometriosis. Her periods were totally free of pain and there were no clots in the menstrual blood. Case history A 36-year-old woman had been suffering from endometriosis for the previous 3 years. She had a dull ache the week before the period and a stabbing pain in the central and lateral abdomen during the period. This pain was relieved by a hot water bottle. After the period, the pain was worse in the epigastrium. She also suffered from pre-menstrual breast distension. She had diarrhoea on the first day of the period and then constipation. The pulse was Wiry and the tongue had a dirty, sticky coating, with Red spots in the front and Pale sides. I diagnosed Cold in the Uterus, with stasis of Blood and an underlying Blood deficiency. I prescribed Shao Fu Zhu Yu Tang Lesser Abdomen Eliminating Stasis Decoction and later changed to Wen Jing Tang Warming the Menses Decoction, to which I added Yan Hu Suo Rhizoma Corydalis. I then changed the prescription to a variation of You Gui Wan Restoring the Right [Kidney] Pill and added Hong Hua Flos Carthami, Tao Ren Semen Persicae, Yi Mu Cao Herba Leonuri and Yan Hu Suo Rhizoma Corydalis.
Blood stasis, Kidney-Yang deficiency with Damp-Phlegm in the Uterus
Clinical manifestations Painful periods, abdominal pain which is relieved by warmth, scanty or heavy periods, dark blood with clots, mid-cycle hypogastric pain, possibly soft and moveable abdominal masses, tingling limbs, dizziness, lower backache, frequent, pale urination, excessive vaginal discharge, feeling cold. Tongue: Swollen, Pale with Purple sides. Pulse: Deep-Weak-Slippery-Wiry. Treatment principle
1. Menstrual phase: invigorate Blood, eliminate stasis. 2. Post-menstrual phase (about 7 days): warm and tonify Kidney-Yang, tonify Spleen-Qi. 3. Mid-cycle phase (about 7 days): warm and tonify Kidney-Yang, tonify Spleen-Qi, resolve Dampness and Phlegm. 4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis, resolve Dampness and Phlegm. Acupuncture
1. Menstrual phase: SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), KI-14 Siman, LIV-3 Taichong, SP-10 Xuehai.
2. Post-menstrual phase (about 7 days): LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 with direct moxa cones, ST-36 Zusanli, KI-3 Taixi, BL-23 Shenshu, BL-20 Pishu. 3. Mid-cycle phase (about 7 days): LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 with direct moxa cones, ST-36 Zusanli, KI-3 Taixi, BL-23 Shenshu, BL-20 Pishu, ST-28 Shuidao, SP-6 Sanyinjiao, BL22 Sanyinjiao, ST-40 Fenglong. 4. Pre-menstrual phase (about 7 days): SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), KI-14 Siman, LIV-3 Taichong, SP-10 Xuehai, ST-28 Shuidao, SP-6 Sanyinjiao, BL-22 Sanyinjiao, ST-40 Fenglong. Herbal treatment
1. Menstrual phase: Da Qi Qi Tang Big Seven Qi Decoction, Nei Yi Fang Endometriosis Formula or Hua Yu Ding Tong Tang Eliminating Stasis and Stopping Pain Decoction. 2. Post-menstrual phase (about 7 days): Gu Yin Jian Consolidating the Yin Decoction, You Gui Wan Restoring the Right [Kidney] Pill. Add a Spleen tonic such as Bai Zhu Rhizoma Atractylodis macrocephalae. 3. Mid-cycle phase (about 7 days): Gu Yin Jian Consolidating the Yin Decoction, You Gui Wan Restoring the Right [Kidney] Pill. Add a Spleen tonic such as Bai Zhu Rhizoma Atractylodis macrocephalae and one to resolve Phlegm such as Ban Xia Rhizoma Pinelliae preparatum. 4. Pre-menstrual phase (about 7 days): Qi Gong Wan Arousing the Uterus Pill. Summary
Blood stasis, Kidney-Yang deficiency with Damp-Phlegm in the Uterus
Treatment principle
1. Menstrual phase: invigorate Blood, eliminate stasis. 2. Post-menstrual phase (about 7 days): warm and tonify Kidney-Yang, tonify Spleen-Qi. 3. Mid-cycle phase (about 7 days): warm and tonify Kidney-Yang, tonify Spleen-Qi, resolve Dampness and Phlegm. 4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis, resolve Dampness and Phlegm.
Acupuncture
1. Menstrual phase: SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), KI-14 Siman, LIV-3 Taichong, SP-10 Xuehai. 2. Post-menstrual phase (about 7 days): LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 with direct moxa cones, ST-36 Zusanli, KI-3 Taixi, BL-23 Shenshu, BL-20 Pishu. 3. Mid-cycle phase (about 7 days): LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 with direct moxa cones, ST-36 Zusanli, KI-3 Taixi, BL-23 Shenshu, BL-20 Pishu, ST-28 Shuidao, SP-6 Sanyinjiao, BL-22 Sanyinjiao, ST-40 Fenglong. 4. Pre-menstrual phase (about 7 days): SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), KI-14 Siman, LIV-3 Taichong, SP-10 Xuehai, ST-28 Shuidao, SP-6 Sanyinjiao, BL-22 Sanyinjiao, ST-40 Fenglong.
Herbal treatment
1. Menstrual phase: Da Qi Qi Tang Big Seven Qi Decoction, Nei Yi Fang Endometriosis Formula or Hua Yu Ding Tong Tang Eliminating Stasis and Stopping Pain Decoction. 2. Post-menstrual phase (about 7 days): Gu Yin Jian Consolidating the Yin Decoction, You Gui Wan Restoring the Right [Kidney] Pill. Add a Spleen tonic such as Bai Zhu Rhizoma Atractylodis macrocephalae. 3. Mid-cycle phase (about 7 days): Gu Yin Jian Consolidating the Yin Decoction, You Gui Wan Restoring the Right [Kidney] Pill. Add a Spleen tonic such as Bai Zhu Rhizoma Atractylodis macrocephalae and one to resolve Phlegm such as Ban Xia Rhizoma Pinelliae preparatum. 4. Pre-menstrual phase (about 7 days): Qi Gong Wan Arousing the Uterus Pill.
Case history A 36-year-old woman was diagnosed with endometriosis in the uterosacral ligaments, left ovary and bladder. She suffered from a continuous pain in the back and abdomen which was worse on intercourse and before the period. Her periods were extremely painful with scanty dark red blood and small clots. She generally felt very cold. She also experienced abdominal fullness and heaviness. The pulse was generally Deep and Weak and the tongue had a rootless but sticky coating and with peeled patches. In this case, the endometriosis was caused by Liver-Blood stasis from Cold with an underlying Kidney-Yang deficiency. I prescribed a variation of Wen Jing Tang Warming the Menses Decoction and added Yan Hu Suo Rhizoma Corydalis, Shu Di Huang Radix Rehmanniae preparata and Tu Si Zi Semen Cuscutae. I later changed the prescription to a variation of Si Miao San Four Wonderful Powder and then to a variation of You Gui Wan Restoring the Right [Kidney] Pill. A laparoscopy showed that the endometriosis had receded.
Modern chinese literature
Wang Da Zeng 1992 The treatment of endometriosis with the method of resolving stasis and penetrating the Fu, Journal of Chinese Medicine (Zhong Yi Za Zhi
) 33(11): 33
According to Dr Wang, endometriosis is always due to Blood stasis. The formula he uses is very simple and it contains only three herbs: Da Huang Radix et Rhizoma Rhei, Chuan Shan Jia Squama Manitis, Tao Ren Semen Persicae. As it contains Da Huang, we can see that Dr Wang applies the principle of ‘conducting downwards’ (tong xia) mentioned above. Comment Obviously this formula by itself would not be enough to treat endometriosis as it would (at best) treat only the Manifestation (Biao) of Blood stasis and not the Root (Ben) of Kidney deficiency. Li Yang Yun 1989 Clinical experience in the treatment of endometriosis by invigorating Blood and eliminating stasis, Journal of Chinese Medicine (Zhong Yi Za Zhi) 30(11): 35
Dr Li advocates the use of enemas for endometriosis. He uses the following herbs for the enema: San Leng Rhizoma Sparganii, E Zhu Rhizoma Curcumae, Su Mu Lignum Sappan, Hong Hua Flos Carthami, Zao Jiao Ci Spina Gleditsiae and Pu Gong Ying Herba Taraxaci. Comment Dr Li’s formula for enema obviously treats only one pattern, i.e. Blood stasis. It is an interesting adjuvant to the treatment according to pattern differentiation but it certainly is not meant to replace it. Indeed, the same Di Li differentiates five patterns in endometriosis in the same article. 1 Invigorate Blood, eliminate stasis, warm the menses, penetrate the Connecting channels (Tong Luo) Dr Li uses this method of treatment for Blood stasis from Cold. For this, he uses the following formula: Fu Zi Radix Aconiti lateralis preparata, Gui Zhi Ramulus Cinnamomi, Tao Ren Semen Persicae, Hong Hua Flos Carthami, Dang Gui Radix Angelicae sinensis, Shu Di Huang Radix Rehmanniae preparata, Chi Shao Radix Paeoniae rubra, Xue Jie Resina Demonoropis, Dan Shen Radix Salviae miltiorrhizae, Chuan Xiong Rhizoma Chuanxiong, Shan Yao Rhizoma Dioscocerae, Ze Xie Rhizoma Alismatis, Mu Dan Pi Cortex Moutan, Fu Ling Poria. 2 Invigorate Blood, eliminate stasis, clear Heat, resolve knottedness Dr Li uses this method for Blood stasis with Heat. He uses the following formula: Dang Gui Radix Angelicae sinensis, Chuan Xiong Rhizoma Chuanxiong, Bai Shao Radix Paeoniae alba, Sheng Di Huang Radix Rehmanniae, Huang Lian Rhizoma Coptidis, Hong Teng Caulis Sargentodoxae, Xiang Fu Rhizoma Cyperi, Tao Ren Semen Persicae,
Hong Hua Flos Carthami, E Zhu Rhizoma Curcumae, Xue Jie Resina Demonoropis, Yan Hu Suo Rhizoma Corydalis, Mu Dan Pi Cortex Moutan, Xia Ku Cao Spica Prunellae. 3 Invigorate Blood, move Qi, break stasis, resolve knottedness Dr Li uses this method for advanced and widespread endometriosis with endometriomas. He uses the following formula: San Leng Rhizoma Sparganii, E Zhu Rhizoma Curcumae, Chuan Shan Jia Squama Manitis, Lu Lu Tong Fructus Liquidambaris, Di Bie Chong Eupolyphaga, Xia Ku Cao Spica Prunellae, Xiang Fu Rhizoma Cyperi, Wei Ling Xian Radix Clematidis, Ru Xiang Olibanum, Mo Yao Myrrha, Dan Shen Radix Salviae miltiorrhizae, Chi Shao Radix Paeoniae rubra, Gui Zhi Ramulus Cinnamomi. 4 Invigorate Blood, eliminate stasis, warm Yang, tonify the Kidneys Dr Li uses this method for Blood stasis from Cold with Kidney-Yang deficiency. He uses the following formula: Dang Gui Radix Angelicae sinensis, Chuan Xiong Rhizoma Chuanxiong, Xiang Fu Rhizoma Cyperi, Xiao Hui Xiang Fructus Foeniculi, Gui Ban Plastrum Testudinis, Lu Jiao Cornu Cervi, Dang Shen Radix Codonopsis, Huang Qi Radix Astragali, Shu Di Huang Radix Rehmanniae preparata, Tu Si Zi Semen Cuscutae, Xian Ling Pi Herba Epimedii, Dan Shen Radix Salviae miltiorrhizae, Chi Shao Radix Paeoniae rubra, Yan Hu Suo Rhizoma Corydalis. 5 Invigorate Blood, eliminate stasis, resolve Phlegm, soften hardness Dr Li uses this method for Blood stasis with Phlegm in the Uterus. He uses the following formula: Dang Gui Radix Angelicae sinensis, Shu Di Huang Radix Rehmanniae preparata, Shan Yao Rhizoma Dioscoerae, Xian Ling
Pi Herba Epimedii, Rou Cong Rong Herba Cistanches, Zao Jiao Ci Spina Gleditsiae, Huang Yao Zi Rhizoma Dioscoerae bulbiferae, Dan Nan Xing Rhizoma Arisaematis preparatum, Xia Ku Cao Spica Prunellae, Zhe Bei Mu Bulbus Fritillariae thunbergii, Shan Zhu Yu Fructus Corni, Yan Hu Suo Rhizoma Corydalis. Comment Dr Li’s approach to the treatment of endometriosis in my opinion is much more elegant than the article reported above. Dr Li’s differentiation of five patterns does not only treat according to pattern but he also makes an interesting discrimination based on the severity of the endometriosis. Zhai Xiao Zhu 1991 Cai Xiao Sun’s experience on the treatment of endometriosis, Journal of Chinese Medicine (Zhong Yi Za Zhi) 32(11): 15
Dr Cai differentiates the treatment principle for endometriosis into four types according to the main presenting symptom, i.e. dysmenorrhoea, heavy periods, fever and infertility. 1 Dysmenorrhoea Eliminate stasis and stop pain with Dang Gui Radix Angelicae sinensis 9 g, Dan Shen Radix Salviae miltiorrhizae 9 g, Chuan Niu Xi 12 Radix Cyathulae 6 g, Chi Shao Radix Paeoniae rubra 12 g, Xiang Fu 9 Rhizoma Cyperi 6 g, Chuan Xiong Rhizoma Chuanxiong 6 g, Gui Zhi Ramulus Cinnamomi 4.5 g, Mo Yao Myrrha 6g, Shi Xiao San (Break into a Smile Powder, i.e. Pu Huang Pollen Typhae and Wu Ling Zhi Faeces Trogopterori) 12 g, Xue Jie Resina Daemonoropis 3 g. 2 Heavy periods
Simultaneously ‘penetrate’ (tong) and consolidate (gu) with Dang Gui Radix Angelicae sinensis 9 g, Chuan Niu Xi Radix Cyathulae 12 g, Chi Shao Radix Paeoniae rubra 12 g, Xiang Fu Rhizoma Cyperi 9 g, Pu Huang Pollen Typhae 6 g, Dan Shen Radix Salviae miltiorrhizae 9 g, Xue Jie Resina Daemonoropis 3 g. 3 Fever Eliminate stasis with Fu Ling Poria 12 g, Gui Zui Ramulus Cinnamomi 4.5 g, Tao Ren Semen Persicae 10 g, Chi Shao Radix Paeoniae rubra 10 g, Mu Dan Pi Cortex Moutan 10 g, Zao Jiao Ci Spina Gleditsiae 20 g, Gui Jian Yu Herba Euonymi alati 9 g, Shi Jian Chuan Herba Salviae chinensis 15 g. 4 Infertility Simultaneously ‘attack’ (i.e. expel pathogenic factors such as Blood stasis) and tonify (the Kidneys) with Fu Ling Poria 12 g, Shu Di Huang Radix Rehmanniae preparata 15 g, Gui Zhi Ramulus Cinnamomi 2.4 g, Xian Mao Rhizoma Curculiginis 10 g, Xian Ling Pi Herba Epimedii 12 g, Lu Lu Tong Fructus Liquidambaris 10 g, Ding Xiang Flos Caryophylli 2.4 g. This formula is taken from the end of the period until ovulation. After ovulation until the next period, take: Sheng Di Huang Radix Rehmanniae 15 g, Shu Di Huang Radix Rehmanniae preparata 15 g, Fu Ling Poria 12 g, Lu Jiao Cornu Cervi 10 g, Xian Ling Pi Herba Epimedii 12 g, Ba Ji Tian Radix Morindae officinalis 10 g, Rou Cong Rong Herba Cistanches 10 g, Han Lian Cao Herba Ecliptae 12 g, Nu Zhen Zi Fructus Ligustri lucidi 10 g, Huai Niu Xi Radix Achyranthis bidentatae 12 g. Comment Of interest in this article is the emphasis placed on treating the Root, i.e.
tonifying the Kidneys, when the main presenting symptom is infertility. Essentially Dr Cai tonifies the Kidneys in phase 2 and part of phase 3 until ovulation and then invigorates Blood the rest of the time. It is also useful as it draws our attention to treating not only according to pattern but also according to presenting symptom, e.g. dysmenorrhoea, heavy period, etc. Yi Si Tu 1995 Observation on the treatment of 58 cases of endometriosis with E Leng mixture, Journal of Chinese Medicine (Zhong Yi Za Zhi) 36(5): 296
In this article, Dr Yi reports the results of a clinical trial of 58 women. The age distribution was as follows: • Under 25: 4. • 26–30: 14. • 31–35: 16. • 41–45: 6. • Over 45: 1. Fifteen of the patients presented primarily with infertility (11 primary). The distribution according to stage was as follows: • Stage I: 8. • Early stage II: 10 • Late stage II: 11. • Early stage III: 15.
• Late stage III: 11. • Stage IV: 3. Dr Yi used the following formula: E Zhu Rhizoma Curcumae 6 g, San Leng Rhizoma Sparganii 6 g, Dan Shen Radix Salviae miltiorrhizae 15 g, Yu Jin Radix Curcumae 12 g, Chi Shao Radix Paeoniae rubra 15 g, Ji Nei Jin Endothelium Corneum gigeriae galli 10 g, Zhe Bei Mu Bulbus Fritillariae thunbergii 15 g, Dang Gui Radix Angelicae sinensis 10 g, Zhi Ke Fructus Aurantii 12 g, Bie Jia Carapax Tryonicis 15 g, Shui Zhi Hirudo 4.5 g. The trial produced results for infertility and it also showed marked improvement in blood tests (viscosity, erythrocyte coagulation, sedimentation rate) and nailbed microcirculation. Comment As I explain in the Preface, many of the clinical trials reported in Chinese journals do not meet the criteria of reliable trials. Nevertheless, I include them to show the treatment principles followed and formulae used by modern Chinese doctors. I would personally consider this approach rather ‘crude’ as it merely invigorates (and ‘breaks’) Blood without treating the Root. It is interesting to note the use of herbs to soften masses such as Zhe Bei Mu Bulbus Fritillariae thunbergii and Bie Jia Carapax Tryonicis. This confirms that modern Chinese doctors see endometriosis as a form of ‘Abdominal Masses’ (Zheng Jia). Chang Nuan 1997 Clinical study on the treatment of endometriosis with the formula Fu Tong Ning, Journal of Chinese Medicine (Zhong Yi Za Zhi) 38(8): 488
The formula used by Dr Chang is: Xue Jie Resina Daemonoropis, E Zhu
Rhizoma Curcumae, San Leng Rhizoma Sparganii, Chuan Shan Jia Squama Manitis, Dan Shen Radix Salviae miltiorrhizae, Bie Jia Carapax Tryonicis, Zao Jiao Ci Spina Gleditsiae, Hai Zao Sargassum, Yi Yi Ren Semen Coicis. Comment Again, in my opinion, there is too much emphasis on Blood stasis and not enough on the treatment of the Root. Zhou Cui Zhen 1996 Titbits from the experience of Dr Cai Xiao Sun in the treatment of difficult gynaecological diseases, Journal of Chinese Medicine (Zhong Yi Za Zhi) 37(2): 79
Dr Zhou confirms that Blood stasis is the main pathological factor in endometriosis. He uses the following formula: Dang Gui Radix Angelicae sinensis 10 g, Dan Shen Radix Salviae miltiorrhizae 10 g, Chuan Xiong Rhizoma Chuanxiong 4.5 g, Chuan Niu Xi Radix Cyathulae 10 g, Chi Shao Radix Paeoniae rubra 10 g, Xue Jie Resina Daemonoropis 3 g, Mo Yao Myrrha 6 g, Su Mu Lignum Sappan 10 g, Yan Hu Suo Rhizoma Corydalis 10 g, Shi Xiao San Break into a Smile Power 15 g. Comment Again, in my opinion, there is too much emphasis on Blood stasis and not enough on the treatment of the Root. Wang Zu Qian, Wang Da Zhen et al 1992 Clinical and experimental studies on the use of the Blood-invigorating and Fu-penetrating methods in the treatment of endometriosis, Shanghai Journal of Traditional Chinese Medicine (Shang Hai Zhong Yi Za Zhi
) 9: 8–12
The authors of this article used the following formula for a clinical trial: Nei Yi Wan No. 1 Endometriosis Formula No. 1: Da Huang Radix et Rhizoma Rhei, Bie Jia Carapax Tryonicis, Hu Po Succinum (proportions 2:2:1). Both Da Huang and Bie Jia were treated with vinegar. Ground into powder, prepared as pills, 5 g twice a day for 3 months cycles. Other decoctions were given according to symptoms, e.g. for menorrhagia or pain. Modifications
• Qi deficiency: Huang Qi Radix Astragali, Dang Shen Radix Codonopsis. • Stomach and Spleen deficiency: Xiang Sha Liu Jun Zi Wan AucklandiaAmomum Six Gentlemen Pill. • Qi-Blood deficiency: Shi Quan Da Bu Wan Ten Complete Great Tonification Pill. • KI-Yang deficiency: You Gui Wan Restoring the Right [Kidney] Pill. • KI-Yin deficiency: Liu Wei Di Huang Wan Six Ingredients Rehmannia Pill
• Heat: Mu Dan Pi Cortex Moutan, Shan Zhi Zi Fructus Gardeniae, Huang Qin Radix Scutellariae. • Qi stagnation: Xiao Yao San Free and Easy Wanderer Powder. In the study, there were 95 women, ranging from 24 to 48 years old, median age 35.9. The average duration of the disease was 3.34 years. Twenty-five came for infertility, 24 for dysmenorrhoea. Twenty-three had had laser excision, 28 hormone therapy and 17 herbal medicine. The main presenting symptoms were: dysmenorrhoea (91%); pelvic pain (71%); dyspareunia (36%); menstrual irregularity (37%); bearing-down pain of anus (68%); infertility 28%. The main patterns were: Heat, Qi-Blood stagnation, Blood stasis with Kidney deficiency, Blood stasis with Qi deficiency. The treatment induced improvement in symptoms and blood values (viscosity, agglutination index, etc.). Yu Chao Qin, Wang Da Zhen, Wang Zu Qian 1993 Influence of Endometriosis Formula No. 2 on levels of beta-EP and DynA1-13 in endometriosis, Chinese Journal of Integrated Chinese and Western Medicine (Zhong Guo Zhong Xi Yi Jie He Za Zhi
) 13: 7–9
The authors of this clinical trial used the formula Nei Yi Wan No. 2 Endometriosis Formula No. 2: Da Huang Radix et Rhizoma Rhei, Bie Jia Carapax Tryonicis, Tao Ren Semen Persicae, Hu Po Succinum
(proportions 2:2:2:1). All soaked in vinegar, baked dry, ground into pills, 7 g twice a day for three menstrual cycles as a course. There were 37 women in the trial, age range 26–44, median age 35.7; the duration of the disease ranged from 3 months to 14 years, median 4.9 years. Requirement: no Western hormonal treatment for at least 6 months before the trial. There was a control group of 14 women, age range 24–33. NOTE: beta-EP is an endorphin secreted by the hypothalamus influencing pituitary release of follicle-stimulating hormone and luteinizing hormone. Li Xiang Yun 1997 Clinical investigation on the treatment of endometriosis by tonifying the Kidneys and eliminating stasis, Journal of Chinese Medicine (Zhong Yi Za Zhi) 38(5): 292
Dr Li conducted a clinical trial on 258 women, youngest 22, oldest 54. Thirty-four women presented with primary infertility, 75 with secondary infertility. The article specifically recommends the strategy of tonifying the Kidneys and invigorating Blood as opposed to doing the latter only. It claims a success rate of 62% for infertility from endometriosis. The formula used was: San Leng Rhizoma Sparganii, E Zhu Rhizoma Curcumae, Shui Zhi Hirudo, Di Bie Chong Eupolyphaga, Chuan Shan Jia Squama Manitis, Tu Si Zi Semen Cuscutae, Xian Ling Pi Herba Epimedii. Wang Da Zhen, Wang Zu Qian, Zhang Zhi Feng 1991 Study on the treatment of endometriosis by the Invigorating Blood and Moving Downward Method, Chinese Journal of Integrated Western and Traditional Medicine (Zhong Guo Zhong Xi Yi Jie He Za Zhi
) 11: 524–526
The authors of this article conducted a clinical trial on endometriosis using the formula Nei Yi Wan No. 1 Endometriosis Formula No. 1: Da Huang Radix et Rhizoma Rhei, Bie Jia Carapax Tryonicis, Hu Po Succinum (proportions 2:2:1). All treated with vinegar, ground and made into pills, 2.5 g twice a day. Three menstrual cycles forming a course. There were 76 women in the trial, age range 21–44, median age 36. Twenty-two came for infertility (31%); 63 for menorrhagia; 42 for pelvic pain; 25 for dyspareunia; 30 for irregular menstruation. The women should have had no hormonal treatment for at least 6 months prior to the trial. Li Xiang Yun 1991 Invigorating Blood and tonifying the Kidneys: strategies for the treatment of endometriosis, Shanghai Journal of Traditional Chinese Medicine (Shang Hai Zhong Yi Za Zhi) 7: 20–21
Dr Li adopts the treatment principle of tonifying the Kidneys and invigorating Blood with: Yin Yang Huo Herba Epimedii, Xian Mao Rhizoma Curculiginis, Shu Di Huang Radix Rehmanniae preparata, Shan Yao Rhizoma Dioscoreae, E Zhu Rhizoma Curcumae, San Leng Rhizoma Sparganii, Ji Xue Teng Endothelium Corneum gigeriae galli, Dan Shen Radix Salviae miltiorrhizae.
Clinical trials
Acupuncture
Japanese-style acupuncture for endometriosis-related pelvic pain in adolescents and young women: the results of a randomized shamcontrolled trial
– Journal of Paediatric and Adolescent Gynaecology 2008 21(5): 247– 257. – Wayne P M, Kerr C E, Schnyer R N et al. – Harvard Medical School, Osher Research Centre, Boston, Massachusetts, USA. Objective
To assess the feasibility and collect preliminary data for a subsequent randomized, sham-controlled trial to evaluate Japanese-style acupuncture for reducing chronic pelvic pain and improving health-related quality of life (HRQOL) in adolescents with endometriosis. Methods
This randomized, sham-controlled trial took place at a tertiary referral hospital and involved 18 patients, aged 13–22 years with laparoscopically diagnosed endometriosis-related chronic pelvic pain. The patients were split into two groups: the treatment group received Japanese-style acupuncture and the control group received sham acupuncture. The main outcome measures were: protocol feasibility, recruitment numbers, pain not associated
with menstruation or intercourse and multiple HRQOL instruments including Endometriosis Health Profile, Paediatric Quality of Life, Perceived Stress and Activity Limitation. Results
Fourteen patients out of the 18 completed the study per protocol. Participants in the active acupuncture group (n = 9) experienced an average 4.8 point reduction on an 11 point scale (62%) in pain after 4 weeks, which differed significantly from the control group’s (n = 5) average reduction of 1.4 points (P = 0.004). Reduction in pain in the active group persisted through a 6-month assessment; however, after 4 weeks, differences between the active and control group decreased and were not statistically significant. All HRQOL measures indicated greater improvements in the active acupuncture group compared to the controls, however the majority of these trends were not statistically significant. No serious adverse events were reported. Conclusion
Preliminary estimates indicate that Japanese-style acupuncture may be an effective, safe and well-tolerated adjunct therapy for endometriosis-related pelvic pain in adolescents. A more definitive trial evaluating Japanese-style acupuncture in this population is both feasible and warranted. An observation on the therapeutic effect of acupuncture and moxibustion on disorders of the myometrial gland
– Zhongguo Zhen Jiu, Chinese Acupuncture and Moxibustion 2008 28(8): 579–581.
– Yan H, Huang X H, Deng G F. – Jinwan District Sanzao Hospital, Zhuhai City Guangdong Province, Zhuhai, China. Objective
To explore the therapeutic effect of acupuncture on disorders of the myometrial gland (the myometrium is the layer of smooth muscle that lies beneath the endometrium in the uterine wall). Methods
Sixty-six cases were randomly divided into an acupuncture group (n = 33) and a Western medication group (n = 33) treated orally with danazol. The acupuncture group was treated with acupuncture using Ren-3 Zhongji, ST-28 Shuidao, ST-25 Tianshu, Ren-2 Qugu and Zigong as the main points. Changes of oestradiol (E2) level, haemoglobin (Hb) and blood platelet count (BPC) were observed in the acupuncture group, and the therapeutic effects of the two groups were compared. Results
The total effective rate was 97.0% in the acupuncture group and 72.7% in the medication group, which was a significant difference (P < 0.05). After treatment, E2 level decreased and Hb and BPC increased in the acupuncture group. Conclusion
Acupuncture has a positive therapeutic effect, which is more effective than danazol, and acupuncture can also decrease the E2 level. A controlled study on Shu-Mu acupuncture point combination for treatment of endometriosis
– Zhongguo Zhen Jiu, Chinese Acupuncture and Moxibustion 2006 26(12): 863–865. – Sun Y Z, Chen H L. – The 4th Internal Medicine Ward, The Second Affiliated Hospital, Heilongjiang Traditional Chinese Medicine University, Harbin, China. Objective
To compare the therapeutic effects of Shu-Mu point combination, routine needling method and Western medicine treatment on endometriosis (EM). Methods
Ninety cases were randomly divided into a Shu-Mu acupuncture point combination group (n = 30), a routine needling group (n = 30) and a Western medicine group. The Shu-Mu acupuncture group received acupuncture at BL-18 Ganshu, BL-20 Pishu, BL-23 Shenshu, LIV-14 Qimen, LIV-13 Zhangmen and G.B.-25 Jingmen. The routine needling group received acupuncture at L.I.-4 Hegu, Ren-3 Zhongji, Ren-4 Guanyuan and SP-6 Sanyinjiao, and the Western medicine group received danazol orally. Clinical symptoms and signs, tumour marker serum CA125 and adverse effects in the three groups were investigated before and after treatment.
Results
The total effective rate was similar in the three groups. The Shu-Mu point combination group was superior to other two groups in improvement of dysmenorrhoea, irregular menstruation, lumbago and sacrodynia (P < 0.01). After treatment, serum CA125 in the Shu-Mu point combination group significantly decreased (P < 0.01). Conclusion
Shu-Mu point combination needling method has a therapeutic effect on endometriosis, with lower adverse effects than that of the Western medicine group. A randomised controlled crossover trial to ascertain if acupuncture in addition to conventional medicine is effective in alleviating pain in endometriosis
– Focus on Alternative and Complementary Therapies 2006 11: 42. – Rubi-Klein K, Kucera-Sliutz E, Nissel H, Bijak M, Stockenhuber D, Wolkenstein E. – Department of Acupuncture, Kaiserin Elisabeth Hospital, Vienna, Austria (‘Johannes Bischko Institute of Acupuncture’). Objective
The aim of the study was to investigate if acupuncture treatment decreases pain level during menstruation or ovulation in patients with endometriosis.
Additional parameters such as reduction of pain medication and improvement of quality of life were also recorded. Methods
One-hundred and one females aged between 20 and 40 years with laprascopically diagnosed endometriosis were randomized into two groups. One group (A) received acupuncture according to traditional Chinese medicine (TCM) diagnosis and the other group (B) received acupuncture at points which were not chosen according to the diagnosis. All participants reported a minimum pain score of 5 according to the visual analogue scale (VAS). Each group received two treatments every week for a 10-week period. After a 2-month interval observation period, both groups changed according to the crossover design. Before, during and after treatment a questionnaire was used to examine the pain level and the quality of life (VAS, short form (SF)-36 and pain disability index (PDI)). Results
Eighty-three participants completed both treatment periods. The results showed a highly significant decrease of pain level in group A in comparison to group B where the pain level was nearly equal to the basic value. SF-36 and PDI showed highly significant improvement in physical and psychological health. Conclusion
The results suggest that acupuncture is effective for patients with endometriosis who are still suffering from high pain levels following conventional medical treatment.
Herbal treatment
The influence of Xiang Ling Wan on dysmenorrhoea and serum CA125 in treating patients with endometriosis
– China Journal of Chinese Materia Medica 2008 33(5): 567–569. – Yang C B, Chen Y, Jin H M, Ying W W. – Affiliated Obstetrics and Gynaecology Hospital, College of Medicine, Zhejiang University, Hangzhou, China. Objective
To observe the influence of Xiang Ling Wan on dysmenorrhoea and serum CA125 in treating patients with endometriosis. Methods
Fifty-four patients with endometriosis were given Xiang Ling Wan from the fifth day of their menstrual cycle for 3 weeks every month for a duration of 3 months. Pelvic type B ultrasonograph and a blood test for protein CA125 (a high level of which may be used to diagnosis endometriosis) were carried out pre- and post-treatment. A visual analogue scale was used to evaluate dysmenorrhoea. Results
After the treatment, the serum CA125 levels and dysmenorrhoea symptoms were both significantly reduced (P < 0.01 and P < 0.05 respectively). Conclusion
Xiang Ling Wan is an effective treatment for endometriosis with few adverse reactions. It may effectively reduce dysmenorrhoea and serum CA125. A clinical observation on the treatment of infertile patients with severe endometriosis by Kang Yi Zhong Yu Counteracting Endometriosis Planting Seed decoction combined with gonadotropin releasing hormone-a
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2007 27(11): 980–982. – Lu X N, Xu X R, Lin L J. – Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, China. Objective
To observe the therapeutic effect of Kang Yi Zhong Yu decoction (KZD) combined with gonadotropin releasing hormone-a (GnRH-a) on infertile patients with severe endometriosis. Methods
Seventy-five infertile patients with a diagnosis of endometriosis confirmed by
laparoscopy who were scheduled to undergo in vitro fertilization (IVF) and embryo transfer were randomly allocated to three groups. Group A was treated with KZD alone, Group B was treated with GnRH-a alone and Group C received a combination of both. After 3 months of treatment, all groups underwent the IVF cycle with embryo transfer. The clinical efficacy and adverse reactions in the three groups were observed and the changes of serum CA125 and endometrial antibody (EMAb) levels before and after treatment were tested. Results
Post-treatment, the dyspareunia score in Groups A and C was lower than that of Group B (P < 0.01). The pregnancy rate was higher in Group C than in Groups A and B (P < 0.05), and the adverse reactions were less than in group B (P <0.01). The positive rate of plasma EMAb was significantly reduced in Group C, with a lower level than in the other two groups (P < 0.05). Conclusion
The combined use of KZD and GnRH-a is a new method in treating infertile patients with severe endometriosis with significant effectiveness and fewer adverse reactions. There are positive implications for the combined use in increasing successful pregnancy rates in IVF. A clinical observation on the effect of Tiao Mian Hua Yu decoction in treating endometriosis
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2007 27(10): 929–932.
– Zhang F, Zhang Y, Zhang Y L. – Department of Microbiology and Immunology, Shanxi Medical University, Taiyuan, China Objective
To investigate the clinical efficacy of Tiao Mian Hua Yu decoction (THD) in treating patients with endometriosis. Methods
Ninety-six patients were allocated to a treatment group and a control group. The treatment group received THD (n = 66) and the control group received Provera (n = 30). T-cell sub-population including CD3, CD4, CD8 and CD4/CD8 ratio, and natural killer (NK) cells in peripheral blood were determined in the two groups before and after treatment. Results
In the treatment group versus the control group, the results showed that 10 versus 2 were cured, 22 versus 6 had significantly effective results, 25 versus 12 had effective results and 9 versus 10 had an ineffective outcome. The total effective rate was 86.4% versus 66.7%, proving that the treatment group had a significant total effective rate (P < 0.05). The levels of CD4 and CD4/CD8 ratio were higher and the levels of CD8 and NK were lower in the treatment group before treatment (P < 0.01). Post-treatment, these indices were partly restored but did not reach normal levels after treatment. All the abovementioned indexes in the control group were insignificantly changed after treatment (P > 0.05).
Conclusion
THD has a definite effect in treating endometriosis, and it can also regulate the immune function of patients. Expressions of vascular endothelial growth factor (VEGF) and cell proliferative nucleoprotein antigen in eutopic endometrium of patients with endometriosis and the effect of the formula Qu Yu Jie Du Expel Stasis and Resolve Toxicity on the VEGF expression
– Chinese Journal of Integrative Medicine 2007 13(2): 109–114. – Lian F, Liu H P, Wang Y X et al. – Reproduction Centre, Affiliated Hospital of Shandong University of TCM, Jinan, China. Objective
To observe the clinical efficacy of Qu Yu Jie Du decoction (QYJD) in treating endometriosis (EM), and to explore the levels of vascular endothelial growth factor (VEGF) and cell proliferative nucleoprotein antigen (Ki-67), their changes before and after treatment and the clinical significance in the trial. Methods
Fifty patients with a diagnosis of EM were randomly assigned to two groups. One group was treated with QYJD (n = 26) and the other group was treated with Gestrinone (GT; n = 24). There was also a control group (n = 20). The
therapeutic effects in the two treatment groups were compared. Expressions of VEGF and Ki-67 in eutopic endometrium of all subjects were determined by the immunohistochemical stain method before treatment at the median secretive phase, and the procedure in the two treated groups was repeated in the same phase after 3 months of treatment. Results
Before treatment, the VEGF and Ki-67 expression positive rates and their mean optic density (MOD) were higher in patients than in healthy women (P < 0.05). After treatment, the positive rate and MOD of VEGF expression lowered significantly compared with before treatment (P < 0.05), but those of Ki-67 changed insignificantly, and comparison between the two treated groups showed no significant difference (P > 0.05). Conclusion
QYJD could markedly improve the symptoms of menorrhagia and menstrual disorders, and its mechanism might be related with the lowering of eutopic endometrial VEGF expression. VEGF and Ki-67 show a high expression in eutopic endometrium of patients with EM. A comparative study on the efficacy of Yi Wei Ning and Gestrinone for post-operational treatment of stage III endometriosis
– Chinese Journal of Integrative Medicine 2006 12(3): 218–220. – Yang D X, Ma W G, Qu F, Ma B Z. – Department of Gynaecology, Affiliated Hospital of Heilongjiang University of Traditional Chinese Medicine, Harbin, China.
Objective
To observe the clinical efficacy and safety of Yi Wei Ning (YWN) and Gestrinone (GT) in treating post-operational patients of stage III endometriosis (EM-III). Methods
Fifty-two patients diagnosed with EM-III were randomly assigned into three groups post-operation. The YWN group (n = 20) was treated orally with 200 ml of YWN twice per day; the GT group (n = 19) was treated with Gestrinone 2.5 mg twice per week. In both groups, the medication was administered from the seventh post-operational day for 6 months. The control group (n = 13) was untreated. A follow-up study was carried out 6– 30 months after the end of the medication. Results
The recurrence rates in the YWN group and the GT group were 5% and 5.3% respectively, showing insignificant difference between the two groups, but they were lower than that in the control group (30.7%; P < 0.05). The adverse reaction rate in the YWN group was lower than that in the GT group (10.0% vs. 31.6%; P < 0.05). Conclusion
Application of YWN to prevent the post-operational recurrence of endometriosis is effective and safe, and its efficacy is similar to that of GT. An observation on the effect of combined therapy of Nei Yi
Endometriosis pill and Nei Yi Endometriosis enema on endometriosis
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2006 26(6): 557–559. – Wu S Z, Chen X L, Huang Y C. – Gynaecology Department, Foshan Hospital of Traditional Chinese Medicine, China. Objective
To observe the effect of combined therapy of Nei Yi pill (NP) and Nei Yi enema (NE) on endometriosis and the effect of the therapy on serum levels of endometrial antibody (EMAb) and serum levels of CA125. Methods
In this single-blind trial, 58 patients diagnosed with endometriosis were randomly divided into three groups. Group A was treated with NP (n = 16); group B was treated with both NP and NE (n = 24) and group C was given danazol (n = 18). All three groups were treated for three menstrual cycles. Serum levels of both EMAb and CA125 were recorded before and after treatment. Results
Comparison of the efficacy between the three groups showed that there was no remarkable difference between group A and B (P > 0.05), but the results from both groups were superior to that of group C (P < 0.05). The levels of
EMAb and CA125 had no significant changes in all the three groups after treatment. Conclusion
Combined therapy of NP and NE could improve the curative effect on endometriosis, but without obvious effects on serum levels of EMAb and CA125. A clinical study on endometrial ovarian cyst treated by integrated laparoscopy and Chinese herbal medicine
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2006 20(3): 183–186. – Wu Y, Hua L, Jin Y. – Beijing Hospital of Traditional Chinese Medicine, Beijing, China. Objective
To investigate a new method of integrated laparoscopy with Chinese herbal medicine (CHM) in treating endometrial ovarian cyst. Methods
One-hundred and fifty-two patients with endometrial ovarian cysts were randomly divided into three groups. The combination group underwent integrated treatment with laparoscopy and CHM; the TCM group was administered CHM and the Western medicine (WM) group was given
danazol. The aim was to compare the clinical efficacy and side effects of the three groups and to understand the therapeutic mechanism by detecting serum CA125 among other markers. Results
The shrinking and disappearance rate of the cysts, and markedly effective rate of the combination group were higher than those of TCM group and WM group (P < 0.05 and P < 0.01 respectively). The pregnancy rate of the combination group was also higher than that of the WM group (P < 0.05). Few side effects were the most prominent advantages for both the combination group and the TCM group. Serum CA125 was reduced in all groups (P < 0.05). Conclusion
The integrated laparoscopy and CHM combination therapy is a new method in treating endometrial ovarian cyst with significant efficacy, minimal adverse effects and maximal preservation of reproductive function. A clinical and experimental study on the treatment of endometriosis with Dan’e decoction
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 1999 19(3): 159–161. – Cai L, Shu Y, Xie H. – Second Affiliated Hospital, Kunming Medical College, Yunnan, China. Objective
To find a medicine to effectively treat endometriosis that produces minimal side effects. Methods
One-hundred and eighty-nine cases of endometriosis were treated by Dan’e decoction (DED) which consists of Dan Shen Radix Salviae miltiorrhizae and E Zhu Rhizoma Zedoariae. One-hundred and sixty cases were treated with danazol as a control. Changes in symptoms and signs were monitored along with the B-ultrasonograph, the anti-endometrium antibody and endometriosis quantitative diagnostic index. Both groups were treated for 9 months. Results
In the DED group, 39 cases (20.6%) were cured, 67 cases (35.4%) were markedly effective, 67 cases (35.4%) were effective and 16 cases (8.4%) were ineffective. The total effective rates of the DED group versus the danazol group were 95% versus 91.5% respectively, showing an insignificant difference. Conclusion
DED is a safe and effective medicine to treat endometriosis, which deserves further study and development. It is particularly effective for the treatment and prevention of early-stage endometriosis. End notes 1.
Clement P B 2007 The Pathology of Endometriosis, Advances in Anatomical Pathology 14(4): 252..
2. USA Endometriosis Association web site (accessed August 2009): http://www.endometriosisassn.org/.
3. He Xian Lin, Frosolone S 1989 The Treatment of Endometriosis with Traditional Chinese Medicine, Journal of the American College of Traditional Chinese Medicine 7(1–2): 31–48..
CHAPTER 66 Polycystic Ovary Syndrome
WESTERN MEDICAL PERSPECTIVE 889 CHINESE MEDICAL PERSPECTIVE 896 TREATMENT OF THE EXTRAORDINARY VESSELS AND OF PHLEGM 898 IDENTIFICATION OF PATTERNS AND TREATMENT 899 Damp-Phlegm in the Uterus 899 Dampness or Damp-Heat 900 Spleen- and Kidney-Yang deficiency 901 Blood stasis 902 Liver-Fire and Damp-Heat in the Liver channel 903 Blood deficiency 904 COMBINED PATTERNS 905 Damp-Phlegm and Kidney-Yang deficiency 905 Damp-Phlegm, Kidney-Yang deficiency and Blood stasis 905 Damp-Phlegm, Kidney-Yin deficiency and Blood stasis 906 Dampness and Kidney-Yang deficiency 907 Dampness, Kidney-Yin deficiency and Blood stasis 907 MODERN CHINESE LITERATURE 908 CASE HISTORIES 910 CLINICAL TRIALS 914
Acupuncture 914 Herbal treatment 916
Western medical perspective
Description Originally described by Stein and Leventhal, polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in women of reproductive age. According to the initial description by Stein and Leventhal in 1935, the diagnosis of PCOS was based on the presentation of histologically verified polycystic ovaries together with the four clinical symptoms of: 1. oligo/amenorrhoea 2. infertility 3. hirsutism 4. obesity. In particular, the triad of amenorrhoea, hirsutism and obesity in the presence of polycystic ovaries was considered to be the essential feature of this disease.1 Nowadays it is widely recognized that PCOS is more than the classic Stein–Leventhal syndrome, as women with polycystic ovaries exhibit a wide spectrum of clinical presentations. Moreover, it is now apparent that the above triad of manifestations (amenorrhoea, hirsutism and obesity) together with bilateral polycystic ovaries is associated with a number of other endocrine disorders of diverse aetiology.2 These may include Cushing’s syndrome, congenital adrenal hyperplasia, ovarian hyperthecosis, hypothyroidism and chronic anovulation in association with hyperprolactinaemia.3 There is no general agreement even on the very definition of PCOS.
Polycystic ovary syndrome is defined most commonly according to the proceedings of an expert conference sponsored by the National Institutes of Health (NIH) in April 1990, which noted the disorder as having three features: 1. Hyperandrogenism and/or hyperandrogenaemia. 2. Oligo-ovulation. 3. Exclusion of known disorders. Alternatively, another expert conference held in Rotterdam in May 2003 defined PCOS, after the exclusion of related disorders, by two of the following three features: 1. Oligo- or anovulation. 2. Clinical and/or biochemical signs of hyperandrogenism. 3. Polycystic ovaries. Clinical Note A Rotterdam expert conference, in 2003, defined PCOS by two of the following three features: 1. Oligo- or anovulation 2. Clinical and/or biochemical signs of hyperandrogenism 3. Polycystic ovaries
In essence, the Rotterdam 2003 conference expanded the NIH 1990 definition, creating two new phenotypes: 1. Ovulatory women with polycystic ovaries and hyperandrogenism.
2. Oligo-anovulatory women with polycystic ovaries, but without hyperandrogenism.4 PCOS accounts for 75% of women with anovulatory infertility, 30% to 49% of secondary amenorrhea, and 85% to 90% of women with oligomenorrhoea. The majority of patients with PCOS are hirsute. Obesity is also a frequent finding among women with PCOS. Thirty to 60% of PCOS patients are overweight. PCOS often comes to light during puberty due to menstrual problems, which affect around 75% of those with the disease. Infrequent, irregular or absent periods are all common variations, many finding their periods particularly heavy when they do arrive. Indeed, a study of 100 women with PCOS found that case histories suggest endocrine aberrations occurring before puberty, prior to the final establishment of the hypothalamic–pituitary– ovarian system.5 Many teenagers use the contraceptive pill to control their periods as irregularity or heaviness is a common complaint at this time, even in the absence of PCOS. This often leads to a delay in the diagnosis of PCOS, many not presenting until the pill is stopped and finding periods cease or become irregular. The American Association of Clinical Endocrinologists lists the following facts about PCOS: • An estimated 10% of reproductive-age women (more than six million) in the United States have PCOS; many do not know they do. • PCOS is the most common metabolic disorder of reproductive-age women in the US. • PCOS is the most common cause of female infertility. • Increasingly, girls as young as 11 are diagnosed with PCOS, which may be due in part to the increase in both childhood obesity and type 2 diabetes in children.
• Premature puberty in young girls may be an early marker of future PCOS. • Women with PCOS are the largest group of women at risk for the development of cardiovascular disease and diabetes. • PCOS is generally considered a syndrome rather than a disease because it manifests itself through a group of signs and symptoms that can occur in any combination. • PCOS is often considered a purely gynecological disorder since many PCOS symptoms involve a woman’s reproductive system. It is, however, a systemic disorder involving hormones, sugar metabolism, lipids and blood vessels. • PCOS is diagnosed by a blood test for a variety of hormones, including those produced by the ovaries, adrenal glands, pituitary gland and thyroid gland. A full physical examination and screening for cholesterol, triglycerides and glucose should also be part of a complete evaluation. • PCOS is treatable, but not curable, by medications, changes in diet and exercise.6 Of particular note in the above list of features of PCOS is the fact that it should be considered a systemic (rather than purely gynecological) disease with many dysfunctions involving glucose metabolism, lipids, blood vessels and liver disease. This is one feature that makes it somewhat more difficult to treat than endometriosis. Clinical Note PCOS is a systemic (rather than purely gynecological) disease with many dysfunctions involving glucose metabolism, lipids, blood vessels and liver disease.
Endocrinology Endocrinologically, PCOS is also heterogeneous; classically it is characterized by hyperandrogenism, inappropriate pituitary gonadotropin secretion (which causes an elevated luteinizing hormone (LH) to folliclestimulating hormone (FSH) ratio) and hyperinsulinism (see Fig. 66.1).
Figure 66.1 Endocrinology of PCOS.
The degree of hirsutism associated with PCOS does not always correlate closely with the magnitude of androgen excess. Severe hirsutism may be associated with a slight elevation of androgens, while a substantial elevation of androgens may not always result in hirsutism.7 A major feature of PCOS is chronic anovulation with elevated levels of LH with low levels of FSH (Fig. 66.2). This abnormality in the LH and FSH is the result of a disruption in the feedback mechanism of the hypothalamic– pituitary–ovarian axis. The cyclical changes in ovarian oestrogen normally responsible for appropriate feedback regulation of cyclical gonadotropin release are overruled by a constant outpouring of oestrogen from extraglandular sources. Thus, the secretion of excessive amounts of androgens and their subsequent conversion to oestrogen constitute the basis for the development of chronic anovulation in PCOS (Fig. 66.3).8
Figure 66.2 Elevated LH and hyperinsulinism in PCOS. GnRH, gonadotropin-
releasing hormone.
Figure 66.3 Liver and pancreas pathology in PCOS. Yen summarizes the endocrinology of PCOS as follows: The pathophysiology of chronic anovulation is not related to an inherent defect of the hypothalamic–pituitary–ovarian axis. Inappropriate gonadotrophin secretion with a high LH/FSH ratio is causally related to an elevated and relatively constant oestrogen feedback on the hypothalamic–pituitary–ovarian system. The LHdependent hyperplasia of the theca cells and the associated hypersecretion of ovarian androgens are responsible for the high oestrogen levels through conversion of androgen to oestrogen by extra-ovarian tissues and inhibit sex-hormone binding globulin (SHBG) production. The low SHBG levels facilitate the rapid tissue uptake of free androgens for peripheral formation of oestrogen, and the increased adipose tissue provides excessive sites for androgen to oestrogen conversion. The high levels of oestrogen, in turn, augment pituitary sensitivity to luteinizing hormone-releasing hormone (LHRH) with the secretion favouring LH over FSH and results in selfperpetuating acyclicity with chronic anovulation.9 While Yen focuses on the anovulatory feature of PCOS, some patients with this disease do ovulate normally. Other authors have performed studies on ovaries which were microscopically dissected and morphological distinctions identified in order to come to a definition of PCOS. Ovaries were classified into three groups according to menstrual cycle history and macroscopic morphological features at the time of dissection. A polycystic ovary had at least three of the following criteria: 1. Increased volume (>9 ml). 2. Ten or more follicles of 2–18 mm in diameter. 3. An increase in the amount and density of stroma and thickening of the
tunica. Patients with a history of anovulatory infertility and/or oligomenorrhoea or amenorrhoea and no evidence of recent corpora lutea were designated ‘anovulatory PCO’, and those ovaries from women reporting regular cycles which met the above morphological criteria, but in which a dominant follicle and/or a recent corpus luteum was observed, were designated ‘ovulatory PCO’. Normal morphology was assigned when the ovary was of normal size with soft, pliable stroma and contained not more than five follicles greater than 2 mm in diameter in a woman with regular menstrual cycles.10 Aetiology and pathology The pathogenesis of PCOS is difficult to ascertain in view of the many subsets and different phenotypes of the syndrome. However, at least two major pathogenetic mechanisms are involved. First, there is an inherent defect in the regulation of gonadotropin secretion. Second, there is an altered regulation of folliculogenesis and/or ovarian steroid genesis. The latter may be related to hyperinsulinaemia, or auto/paracrine abnormalities of the ovaries which amplify the effects of LH in inducing ovarian hyperandrogenism: this further results in the formation of follicular atresia. Hyperandrogenaemia, in turn, perpetuates the inappropriate gonadotropin secretion, which promote a vicious cycle. The synergistic effect of obesity aggravating these mechanisms is important but obviously not primary. The late consequences of PCOS, such as risk of endometrial cancer, cardiovascular disease and infertility, warrant an early and effective diagnosis of the syndrome. The long-term risks of PCOS are related to both the insulin problem and the high androgen levels. High levels of insulin are associated with an increased risk of developing type 2 diabetes. Twenty-five to 35% of overweight PCOS women show signs of disruption of the insulin metabolism by their 30s and it probably becomes more common in the 40s and beyond. The hormone changes described increase the chance of developing high blood pressure and high cholesterol levels, both of which can lead to a
greater risk of heart disease. Irregular or infrequent periods over a long period of time lead to an increased risk of endometrial cancer. This is in part due to high levels of oestrogen, which overstimulates the lining of the uterus. Absence of ovulation, and the resulting progesterone deficiency, also contributes to this risk. Diagnosis
Ultrasound scan
This is usually done as an internal scan, i.e. a small ultrasound probe is placed just inside the vagina, giving the best view of the ovaries and pelvic organs. In PCOS, the ovaries are found to have multiple, small cysts around the edge of the ovary. These cysts are only a few millimetres in size, do not in themselves cause problems and are partially developed eggs that were not released (Plate 66.1). The cysts are usually lined with a few layers of granulosa cells and there is marked hyperplasia of the theca interna surrounding the many cystic follicles. It has been assumed that the hyperplastic theca cells are the result of chronic LH stimulation and the associated excessive androgen production.11 Clinical Note The marked hyperplasia of the theca interna surrounding the many cystic follicles in the ovaries of women with PCOS is a sign of Phlegm from the point of view of Chinese medicine. The follicular cysts in the ovaries of women with PCOS do not mature fully and the absence of mature follicles results in low oestradiol production. Blood tests
Two main blood tests will assist in making the diagnosis: one to check the level of androgens, such as testosterone, and another to measure the hormones involved in egg development. In PCOS there is a characteristic rise in LH. A progesterone blood test 7 days before the expected menstrual period can check if one is ovulating. Although 60 years have passed since the first description of the syndrome, its definition and diagnostic criteria are still controversial. Several hormonal assays have been widely used to support the diagnosis, and are essential for exclusion of specific disorders which can cause polycystic ovaries. Accurate endocrine characterization of patients enables the recognition of biochemically more homogeneous subgroups of PCOS, which further provides facilities to better evaluate the pathogenesis of each of these subsets, and provides data necessary for formulating specific therapy. Clinical manifestations The main clinical manifestations of PCOS are as follows: • Obesity, especially characterized by an increased waist:hip ratio (Fig. 66.4). • Amenorrhoea or oligomenorrhoea. • Infertility. • Hirsutism. • Ovaries are enlarged and smooth. The tunica albuginea is thickened and beneath it are numerous small cystic follicles, varying in size but seldom exceeding 0.5 cm (about 0.2 inches) in diameter (Plate 66.2). • Failure of the ovarian enzyme system which is necessary for the production of oestrogen.
• Raised testosterone. • Raised ratio of LH:FSH.
Figure 66.4 Increased waist:hip ratio in PCOS. With regard to infertility, as PCOS is due to irregular or absent ovulation, it is a common cause of infertility. Not every woman with PCOS will be infertile as some will ovulate normally while some will ovulate less frequently (leading to a delay of pregnancy). Difference between polycystic ovary and PCOS
The term ‘polycystic ovaries’ describes the ovaries, as seen on the ultrasound scan. Many women have ovaries that are polycystic, but do not have any of the other symptoms or hormone findings as described previously. Overall, around 20% of women of the general population have ovaries with this appearance, and what is not yet known from current research is whether this is one end of a long scale including the full polycystic ovary syndrome or a sign that symptoms are more likely to develop in the future. Diabetes, insulin and PCOS
In recent years, it has become clear that PCOS is closely related to a problem with insulin metabolism. Insulin is a hormone released from the pancreas after a meal and it allows the organs of the body to take up energy in the form of glucose. In PCOS, there is a ‘resistance’ of cells in the body to insulin, so the pancreas makes more insulin to try and compensate. The excessively high levels of insulin have an effect on the ovary, preventing ovulation and causing a rise in androgen (testosterone) levels. One study found that 30% of slim women with PCOS have insulin resistance, however it affects as many as 75% of those who are overweight. This explains why overweight women with PCOS are more likely to suffer with excessive hairiness and infertility related to not ovulating.
Risks associated with PCOS
Endometrial hyperplasia and endometrial cancer are risks associated with PCOS, due to over-accumulation of uterine lining, and also lack of progesterone resulting in prolonged stimulation of uterine cells by oestrogen. It is however unclear if this risk is directly due to the syndrome or from the associated obesity, hyperinsulinaemia and hyperandrogenism. Other risks associated with PCOS include: • insulin-resistant type 2 diabetes • high blood pressure • dyslipidaemia (disorders of lipid metabolism – cholesterol and triglycerides) • cardiovascular disease • strokes • non-alcoholic fatty liver disease (two out of three women) • weight gain • miscarriage • acanthosis nigricans (patches of darkened skin under the arms, in the groin area, on the back of the neck) • autoimmune thyroiditis. Treatment Periods may be controlled by the use of the contraceptive pill, which is most
suitable for women under the age of 35 who also require contraception. The other type of drug used is a progesterone-like hormone. Progestagens are taken as tablets in a cyclical way, for example between days 12 and 26, the exact type and timing depending upon the woman’s individual cycle problem. Some women have no periods at all, and either the contraceptive pill or cyclical progestagens are given to avoid the risk of endometrial cancer. From the Western perspective, around six periods per year are adequate to protect against the risk of endometrial cancer. Infertility treatment
Polycystic ovary syndrome is found in around 70% of women who have ovulation difficulties leading to infertility. This is more common in women who are overweight, and as a first-line treatment, weight reduction can be very successful in restarting spontaneous ovulation. The amount that needs to be lost is small – around 5% of loss from the current weight is associated with an increased number of ovulatory cycles. Ovarian stimulation Clomifene citrate is the most commonly used drug to stimulate ovulation. It is taken in the early days of the cycle (usually days 2–6) and results in ovulation in around 80% of women overall, and a 6-month successful pregnancy rate of 45–50%. When clomifene is unsuccessful, there are two main approaches. The first is to use injectable hormones to stimulate the ovary to produce eggs. This is known as ovarian stimulation and, where there is an additional sperm problem, is combined with insemination of sperm through the cervix around the time of ovulation (intra-uterine insemination, or IUI). The hormone treatment must be monitored by blood tests and ultrasound scans to avoid overstimulation. Live birth rates after ovarian stimulation following failed clomifene treatment reach 54% after 6 months and 62% after 12 cycles.
Multiple pregnancy is always a risk with this type of treatment, but especially so for women with PCOS whose ovaries are particularly sensitive to the hormones. If ovarian stimulation is unsuccessful, many women resort to in vitro fertilization (IVF), success rates of which depend very much upon individual characteristics such as age, length of infertility and weight. Neither IVF nor ovarian stimulation is likely to be successful if a woman is overweight (body mass index greater than 30 kg/m2 ). This is why most hospitals restrict these treatments until a woman’s weight is within the normal range. It should be noted that assisted-reproduction technology based on the use of ovarian stimulation is associated with an increased risk of multiple pregnancies, pregnancy complications, low birth weight, major birth defects and long-term disability among surviving infants.12 Clinical Note From a Chinese medicine perspective, strong ovarian stimulation by hormones such as clomifene damages the ovaries in the long run. Laparoscopic ovarian diathermy The alternative to ovarian stimulation is an operation called laparoscopic ovarian diathermy (LOD), also known as ‘ovarian drilling’. This involves a day case operation, a short general anaesthetic and a laparoscopy. The ovaries are identified and several small holes made in each ovary, either with a fine hot diathermy probe or via laser. It is not actually known how this works, but it can restore regular ovulation, or make the ovary more sensitive to clomifene. By 12 months after LOD, the average pregnancy rate is around 60– 80%, the greatest success rates being in women with a shorter length of infertility (less than 3 years) and a higher level of the hormone LH (>10 iu/l). Advantages of LOD include the fact that it may improve other symptoms of
PCOS, such as menstrual disturbance, as well as avoiding the need for stimulatory drugs and their increased risk of overstimulation and multiple pregnancy. Treatment of hirsutism
Hirsutism is usually due to above-average levels of androgens which are normally present in women at low levels. Initial treatments include bleaching and electrolysis. If these do not produce an acceptable result, drugs may be used to reduce the high androgen levels, if that is the cause. The contraceptive pill contains oestrogen, which reduces androgen levels and will improve hirsutism. A formulation is available which includes a specific drug to reduce these further, known as Dianette®. Dianette® contains ethinyloestradiol and cyproterone acetate which is specific to treat the hirsutism. Cyproterone acetate is also used on its own at a higher dose than that contained in the Dianette® pill, but must be combined with adequate contraception, as it can cause fetal abnormality if taken during early pregnancy. Spironolactone is another alternative, but this frequently causes erratic periods, so is often given with a low-dose contraceptive pill. A newer drug is called flutamide, an anti-androgen drug, but its safety profile has not been fully established. Side effects of the anti-androgens include tiredness, mood changes and reduced sex drive. Both flutamide and higher dose cyproterone acetate have the rare but serious side effect of causing problems with liver function, and so regular blood tests are advised. All hirsutism treatments must be continued for 8–18 months before a response can be expected, due to the slow rate of hair growth.
Chinese medical perspective In Chinese medicine, PCOS may correspond to several different gynecological diseases (Fig. 66.5): • Infertility. • Scanty periods. • No periods (amenorrhoea). • Flooding and Trickling (Beng Lou). • Irregular periods.
Figure 66.5 Correspondence between PCOS and Chinese disease-symptoms. This means that the pattern differentiation within each of the above Chinese disease-entities may be applied to the treatment of PCOS. In particular, the Chinese disease-entity that most closely corresponds to PCOS is ‘Infertility’. However, we cannot blindly apply the pattern differentiation of ‘Infertility’ (or other Chinese diseases) to PCOS without an understanding of the pathology of this disease from the Chinese perspective. The purpose of
this chapter is precisely to discuss and interpret the Western pathology in terms of Chinese medicine. In other words, there is a huge difference between treating a woman suffering from unexplained infertility with a completely normal menstrual function and ovulation, and treating a woman with infertility deriving from PCOS. Clinical manifestations From a purely Chinese medicine perspective, i.e. ignoring hormonal changes and histological changes in the ovaries, the clinical manifestations are: • amenorrhoea or scanty periods • irregular periods • hirsutism • obesity • infertility. Amenorrhoea or scanty periods
Amenorrhoea or oligomenorrhoea indicate a deficiency of Blood of the Penetrating Vessel (Chong Mai) and a Kidney deficiency as they are the origin of Tian Gui. In some cases, amenorrhoea or scanty periods may also be due to Blood stasis within the Penetrating Vessel. Hirsutism
Hirsutism is due to a dysfunction of the Penetrating Vessel with imbalance between Qi and Blood. A deficiency of Blood in the Uterus leads to
amenorrhoea, but this would mean that there is more Blood available in the Penetrating Vessel at the skin level in the chin to promote the growth of hair. According to Chapter 65 of the Spiritual Axis, the Penetrating Vessel brings Qi and Blood to the chin area and, in women, losing some blood with menstruation, the Penetrating Vessel has relatively less Blood than Qi in this area compared to men. The lack of Blood in this area is the reason why women do not have a beard; as men have relatively more Blood in the head branch of the Penetrating Vessel, this Blood promotes the growth of hair on the face.13 Obesity
Obesity always indicates Damp-Phlegm. In the case of PCOS, it affects both the Penetrating Vessel and the Directing Vessel (Ren Mai). Zhu Dan Xi (1281–1358) mentions obesity as a sign of Phlegm and a factor in infertility in women in his book The Heart of Dan Xi’s Treatment Methods (Dan Xi Zhi Fa Xin Yao): “Inability to conceive in obese women is caused by the fat blocking the Uterus and leading to amenorrhoea: one must use herbs that resolve Phlegm”.14 This passage clearly equates obesity with Phlegm. Ovarian cysts
Ovarian cysts are a typical form of ‘Abdominal Masses’ (Zheng Jia) from Phlegm. In the case of PCOS, they indicate Damp-Phlegm in the Penetrating and Directing Vessels. Hormonal imbalance, raised testosterone
The deep hormonal imbalance of PCOS reflects from the Chinese point of view a dysfunction of the Governing Vessel (Du Mai), the Yang aspect of the
menstrual cycle, and of the Penetrating and Directing Vessels. Hormonal imbalance, raised LH
The increase in LH may be seen in Chinese medicine as an increase in Yang (but only relative to Yin, oestrogen) and therefore a condition of Heat in the Liver and Penetrating Vessel. Patterns The main patterns appearing in PCOS are as follows: • Damp-Phlegm: there is nearly always Damp-Phlegm. Damp-Phlegm obstructs the Uterus and ovaries and it has two effects: on the one hand, it interferes with normal hormonal function in the ovaries and, on the other hand, it obstructs the Uterus preventing implantation of the ovum. The ovarian cysts are due to Damp-Phlegm. • Kidney deficiency: there is always a Kidney deficiency in PCOS causing the hormonal imbalance. This can be a deficiency of Kidney-Yin or KidneyYang, more often Yang. ‘Kidney deficiency’ also involves a dysfunction of the three Extraordinary Vessels that influence the Uterus and ovaries, i.e. Governing, Directing and Penetrating Vessels (Du, Ren and Chong Mai). • Blood stasis: there may be Blood stasis especially if the ovarian cysts are palpable and the periods painful. • Damp-Heat in the Liver channel: there often is Dampness in PCOS. Frequently this is associated with Heat and affecting the Liver channel. • Blood deficiency: there may be Blood deficiency which contributes to the scanty periods or amenorrhoea and infertility.
• Liver-Fire: there occasionally may be Liver-Fire. Clinical Note The two most important patterns in PCOS are Damp-Phlegm in the Uterus and Kidney deficiency. The two most important patterns in PCOS are Damp-Phlegm in the Uterus and a Kidney deficiency. There is nearly always Damp-Phlegm in the Uterus which causes the ovarian cysts and the obesity and which contributes to the infertility by obstructing the Uterus and by interfering with hormone production by the ovaries. Damp-Phlegm is the Manifestation (Biao). The main clinical manifestations of Damp-Phlegm in the Uterus are: • ovarian cysts • obesity • excessive vaginal discharge • abdominal fullness and heaviness • mid-cycle problems (pain, bleeding, feeling of heaviness) • Swollen tongue with sticky coating • Slippery pulse. The second important pattern is Kidney deficiency, which may be of Yin or Yang but more often the latter. From the perspective of Chinese medicine, the deep hormonal imbalance points to a Kidney deficiency and an imbalance of the Governing, Directing and Penetrating Vessels (Du, Ren and Chong Mai). We could see the hyperandrogenism and the disruption of oestrogen metabolism of PCOS as a reflection of the imbalance between the Governing Vessel (controlling androgens in women) and the Directing Vessel
(controlling oestrogen). If there is Blood stasis and/or Blood deficiency, then the Penetrating Vessel is also involved. The Kidney deficiency is therefore the Root (Ben) in PCOS. Apart from the two fundamental patterns of Damp-Phlegm in the Uterus and Kidney deficiency, other possible patterns are: • Blood stasis • Blood deficiency • Dampness • Damp-Heat in the Liver channel. Thus, the main patterns in PCOS are: Root (Ben)
• Kidney deficiency. • Spleen deficiency. • Liver-Qi stagnation. Manifestation (Biao)
• Damp-Phlegm in the Uterus. • Blood stasis. • Dampness. • Damp-Heat in Liver channel.
• Liver-Fire. Comparison between PCOS and endometriosis PCOS is a deeper, more difficult condition than endometriosis from the Chinese point of view. This is for various reasons: • In PCOS, there is a deep hormonal imbalance that is not found in endometriosis. The hyperandrogenism, the change in pulsatility of the gonadotropin-releasing hormone (GnRH) and the elevated LH to FSH all point to a deep dysfunction of the Kidneys, the Kidney-Essence and of the Governing, Directing and Penetrating Vessels. • The peri-pubertal and even genetic aetiology of the disease points to a dysfunction of Kidney-Essence. • The disruption of the insulin metabolism points to a general disharmony involving Kidneys, Liver and Spleen. • The release of free fatty acids by the liver and the decreased sex hormone binding all point to a deep Liver disharmony.
Treatment of the extraordinary vessels and of phlegm The following are examples of point combinations to open and regulate the Extraordinary Vessels in PCOS. Treatment of the Extraordinary Vessels is absolutely essential in the treatment of PCOS both to resolve Damp-Phlegm from the Uterus and to tonify the Kidneys (and therefore regulate hormones). Directing Vessel (Ren Mai) LU-7 Lieque (on the right) and KI-6 Zhaohai (left), Ren-4 Guanyuan, ST-28 Shuidao, Zigong. This treatment regulates the Directing Vessel, it tonifies the Kidneys and resolves Phlegm from the Uterus. Penetrating Vessel (Chong Mai) SP-4 Gongsun (right) and P-6 Neiguan (left), KI-14 Siman, SP-10 Xuehai, ST-28 Shuidao, LIV-3 Taichong. This treatment regulates the Penetrating Vessel, invigorates Blood and resolves Phlegm from the Uterus. I use the Penetrating Vessel more to invigorate Blood than to tonify the Kidneys (for which I use more the Directing Vessel). Governing Vessel (Du Mai) SI-3 Houxi (right) and BL-62 Shenmai (left), Ren-4 Guanyuan, Du-3 Yaoyangguan. This treatment regulates the Governing Vessel and tonifies Kidney-Yang. Governing and Directing Vessel in combination SI-3 Houxi (right), BL-62 Shenmai (left), LU-7 Lieque (left), KI-6 Zhaohai (right), Ren-4 Guanyuan, Du-20 Baihui, Du-3 Yaoyangguan. This treatment
regulates the Governing and Directing Vessels and tonifies both Kidney-Yang and Kidney-Yin. Besides treating the Extraordinary Vessels, in PCOS it is essential to resolve Damp-Phlegm from the Uterus. Herbal medicine resolves Dampness with herbs that are actual diuretics (Fu Ling Poria, Zhu Ling Polyporus, Yi Yi Ren Semen Coicis, etc.) and it resolves Phlegm with herbs that are drying (and therefore dry up Phlegm). Acupuncture works in a different way and it can only resolve Dampness and Phlegm by regulating Qi in a way that it stimulates the movement, transformation and excretion of fluids. I feel that the Phlegm-resolving action of ST-40 Fenglong is overemphasized (and its many other functions underestimated). One of the main functions of the Triple Burner is that of transforming, moving and excreting fluids. In order to affect the transformation, movement and excretion of fluids with acupuncture, it is necessary to mobilize all three Burners, albeit in differing proportions. For example, if the problem is in the Lower Burner, I would use quite a few points from the Lower Burner but also one or two from the Middle and Upper Burner. The main points that regulate the fluid metabolism in each Burner are as follows: • Upper Burner: Du-26 Renzhong (alternative name Shuigou), LU-7 Lieque, L.I.-4 Hegu, L.I.-6 Pianli, T.B.-4 Yangchi, Ren-17 Shanzhong. • Middle Burner: Ren-9 Shuifen, Ren-12 Zhongwan, ST-22 Guanmen, Ren-11 Jianli. • Lower Burner: ST-28 Shuidao, BL-22 Sanjiaoshu, Ren-5 Shimen, Ren6 Qihai, Ren-3 Zhongji, ST-40 Fenglong, BL-39 Weiyang, SP-9 Yinlingquan, SP-6 Sanyinjiao, KI-7 Fuliu. Two sets of three points for each Burner stand out: 1. Du-26 Shuigou for the Upper, Ren-9 Shuifen for the Middle and ST28 Shuidao for the Lower Burner. These three names have the word Shui
(‘water’) in their name. This means that they transform ‘Water’, i.e. fluids (Fig. 66.6). 2. Ren-17 Shanzhong for the Upper, Ren-9 for the Middle and Ren-5 for the Lower Burner. These are the three points on the Directing Vessel that have the most direct action on fluids (although there are others) (see Fig. 66.7).
Figure 66.6 Points that move and transform fluids with ‘Water’ in their names.
Figure 66.7 Points to move and transform fluids on the Directing Vessel. Interestingly, although the metabolism of fluids is a major function of the Triple Burner, the three Burners’ action on fluids has little to do with the Triple Burner channel: it is activated not so much by Triple Burner points (although T.B.-4 moves fluids) as by points of the Directing Vessel. The three
main points have been indicated above but there are others such as Ren-6 Qihai, Ren-11 Jianli and Ren-3 Zhongji. Thus, an example of point combination to resolve Damp-Phlegm in the Uterus in PCOS would be: ST-28 Shuidao, Ren-5 Shimen, BL-22 Sanjiaoshu, SP-6 Sanyinjiao, ST-40 Fenglong, KI-7 Fuliu (Lower Burner points), Ren-9 Shuifen (Middle Burner point) and LU-7 Lieque or Ren-17 Shanzhong (Upper Burner points). In addition to these points, in PCOS I would also regulate either the Directing or the Penetrating Vessel.
Identification of patterns and treatment
Damp-Phlegm in the Uterus
Clinical manifestations Scanty periods, no periods, obesity, excessive hair, feeling of oppression of the chest, abdominal masses, excessive vaginal discharge. Tongue: Swollen with sticky coating. Pulse: Slippery. Treatment principle Resolve Damp-Phlegm, move Qi, soften masses. Acupuncture LU-7 Lieque on the right with KI-6 Zhaohai on the left, ST-28 Shuidao, Ren-9 Shuifen, Ren-3 Zhongji, SP-9 Yinlingquan, ST-40 Fenglong, BL-22 Sanjiaoshu. Reducing or even method on all points except LU-7 and KI-6 which should be needled with even method. Explanation
– LU-7 and KI-6 open the Directing Vessel and treat the Uterus and ovaries. – ST-28, Ren-9, Ren-3, SP-9, ST-40 and BL-22 resolve Damp-Phlegm. Herbal treatment
a Prescription
– RUAN JIAN HUA TAN FANG – Softening Hardness and Resolving Phlegm Formula Explanation
– Hai Zao, Bie Jia and Zhe Bei Mu soften masses. – Ban Xia, Fu Ling, Chen Pi and Dan Nan Xing resolve Phlegm. – Dang Gui and Chuan Xiong invigorate Blood. b Prescription
– QI GONG WAN – Arousing the Uterus Pill Explanation
– Ban Xia, Cang Zhu, Chen Pi and Fu Ling resolve Dampness and Phlegm. – Xiang Fu moves Qi which helps to resolve Dampness and Phlegm. – Chuan Xiong invigorate Blood.
– Shen Qu resolves food retention which helps to resolve Phlegm. c Prescription
– DAO TAN ZHONG ZI TANG – Conducting Phlegm and Planting Seeds Decoction Women’s Treasure remedy
– CLEAR THE PALACE Clear the Palace is a variation of Qi Gong Wan Arousing the Uterus Pill to resolve Damp-Phlegm from the Uterus. Summary Damp-Phlegm in the Uterus
Clinical manifestations
Scanty periods, no periods, obesity, excessive hair, feeling of oppression of the chest, abdominal masses, excessive vaginal discharge. Tongue: Swollen with sticky coating. Pulse: Slippery. Treatment principle
Resolve Damp-Phlegm, move Qi, soften masses. Acupuncture
LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), ST-28 Shuidao, Ren-9 Shuifen, Ren-3 Zhongji, SP-9 Yinlingquan, ST-40 Fenglong, BL-22 Sanjiaoshu. Reducing or even method on all points except LU-7 and KI-6 which should be needled with even method. Herbal treatment
Pre scriptions
• RUAN JIAN HUA TAN FANG Softening Hardness and Resolving Phlegm Formula • QI GONG WAN Arousing the Uterus Pill • DAO TAN ZHONG ZI TANG Conducting Phlegm and Planting Seeds Decoction Women’s Treasure remedy
• CLEAR THE PALACE
Dampness or Damp-Heat
Clinical manifestations Feeling of heaviness of the abdomen, mid-cycle pain and heaviness and/or bleeding, excessive vaginal discharge, acne, feeling of fullness of the abdomen, overweight. Tongue: sticky coating. Pulse: Slippery or Soggy. Damp-Heat
In case of Damp-Heat, there would be thirst, dry mouth, a feeling of heat, yellow vaginal discharge, sticky,yellow tongue coating and Rapid pulse. Treatment principle Resolve Dampness from the Uterus. Acupuncture LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-3 Zhongji, ST-28 Shuidao, Zigong, KI14 Siman, BL-22 Sanjiaoshu, Ren-9 Shuifen, BL-32 Ciliao. Reducing or even method on all points except LU-7 and KI-6 which should be needled with even method. Explanation
– LU-7 and KI-6 open and regulate the Directing Vessel.
– SP-9, SP-6, Ren-3, ST-28, Zigong, KI-14, BL-22, Ren-9 and BL-32 resolve Dampness from the Uterus and ovaries. Herbal treatment
a Prescription
– SI MIAO SAN – Four Wonderful Powder Explanation This formula resolves Dampness and clears Heat from the Lower Burner. It has already been explained. b Prescription
– QING GAN ZHI LIN TANG – Clearing the Liver Stopping ‘Lin’ Decoction Explanation
– Dang Gui invigorates Blood. – Bai Shao and E Jiao nourish Blood.
– Hei Xiao Dou and Huang Bo resolve Dampness and clear Heat. – Sheng Di Huang and Mu Dan Pi clear Heat and cool Blood. – Huai Niu Xi directs the formula to the Lower Burner. – Xiang Fu moves Qi which helps to resolve Dampness. – Hong Zao harmonizes. c Prescription
EMPIRICAL PRESCRIPTION by Dr Liu Geng Wu Women’s Treasure remedy
– DRAIN THE JADE VALLEY Drain the Jade Valley is a variation of Si Miao San to resolve DampHeat from the Uterus and the genital system. Summary Dampness or Damp-Heat
Clinical manifestations
Feeling of heaviness of the abdomen, mid-cycle pain and heaviness and/or bleeding, excessive vaginal discharge, acne, feeling of fullness of the abdomen, overweight. Tongue: sticky coating. Pulse: Slippery or Soggy. Damp-Heat
Thirst, dry mouth, a feeling of heat, yellow vaginal discharge, sticky, yellow tongue coating and Rapid pulse. Treatment principle
Resolve Dampness from the Uterus. Acupuncture
LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-3 Zhongji, ST-28 Shuidao, Zigong, KI14 Siman, BL-22 Sanjiaoshu, Ren-9 Shuifen, BL-32 Ciliao. Reducing or even method on all points except LU-7 and KI-6 which should be needled with even method. Herbal treatment
Pre scriptions
• SI MIAO SAN Four Wonderful Powder • QING GAN ZHI LIN TANG Clearing the Liver Stopping ‘Lin’ Decoction • EMPIRICAL PRESCRIPTION by Dr Liu Geng Wu Women’s Treasure remedy
• DRAIN THE JADE VALLEY
Spleen- and Kidney-Yang deficiency
Clinical manifestations Scanty periods, no periods, irregular bleeding, underdeveloped breasts, backache, dizziness, tiredness, poor appetite, feeling cold, frequent, pale urination. Tongue: Pale, wet. Pulse: Weak and Deep. Treatment principle Tonify Yang, strengthen the Spleen and Kidneys. Acupuncture LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), BL-20 Pishu, BL-23 Shenshu, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, KI-7 Fuliu, Ren-4 Guanyuan (direct moxa), KI-13 Qixue. Reinforcing method. Explanation
– LU-7 and KI-6 open and regulate the Directing Vessel. – BL-20 and BL-23 tonify Spleen- and Kidney-Yang. – Ren-12, ST-36 and SP-6 tonify the Spleen. – KI-3 and KI-7 tonify the Kidneys. – Ren-4 (with moxa) and KI-13 tonify Kidney-Yang, strengthen the
Original Qi (Yuan Qi) and consolidate the Directing and Penetrating Vessels. Herbal treatment
a Prescription
– YOU GUI WAN and BAI ZHU – Restoring the Right [Kidney] Pill and Rhizoma Atractylodis macrocephalae b Prescription
– JIN GUI SHEN QI WAN and BAI ZHU – Golden Cabinet Kidney-Qi Pill and Rhizoma Atractylodis macrocephalae Women’s Treasure remedy
– UNICORN PEARL Unicorn Pearl tonifies Spleen- and Kidney-Yang and consolidates the Directing and Penetrating Vessels. Summary Spleen- and Kidney-Yang deficiency
Clinical manifestations
Scanty periods, no periods, irregular bleeding, underdeveloped breasts, backache, dizziness, tiredness, poor appetite, feeling cold, frequent, pale urination. Tongue: Pale, wet. Pulse: Weak and Deep. Treatment principle
Tonify Yang, strengthen the Spleen and Kidneys. Acupuncture
LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), BL-20 Pishu, BL-23 Shenshu, Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, KI-7 Fuliu, Ren-4 Guanyuan (direct moxa), KI-13 Qixue. Reinforcing method. Herbal treatment
Pre scriptions
• YOU GUI WAN and BAI ZHU Restoring the Right [Kidney] Pill and Rhizoma Atractylodis macrocephalae • JIN GUI SHEN QI WAN and BAI ZHU Golden Cabinet Kidney-Qi Pill and Rhizoma Atractylodis macrocephalae Women’s Treasure remedy
• UNICORN PEARL
Blood stasis
Clinical manifestations Painful periods, palpable ovaries, dark menstrual blood with clots, abdominal pain, irregular periods, mental restlessness. Tongue: Purple in general or only Purple sides. Pulse: Wiry, Choppy or Firm pulse. Treatment principle Invigorate Blood, eliminate stasis, regulate the Penetrating Vessel. Acupuncture SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), LIV-3 Taichong, SP-10 Xuehai, BL-17 Geshu, KI-14 Siman, ST-29 Guilai, Zigong, ST-30 Qichong. Reducing or even method on all points except SP-4 and P-6 which should be needled with even method. Explanation
– SP-4 and P-6 open and regulate the Penetrating Vessel and invigorate Blood. – LIV-3 is a Penetrating Vessel point and it invigorates Blood. – SP-10 and BL-17 invigorate Blood in general. – KI-14 is an important point of the Penetrating Vessel to invigorate Blood in the Uterus.
– ST-29 and Zigong invigorate Blood in the Uterus. – ST-30 is a Penetrating Vessel point and it invigorates Blood. Herbal treatment
a Prescription
– GE XIA ZHU YU TANG – Eliminating Stasis below the Diaphragm Decoction b Prescription
– SHAO FU ZHU YU TANG – Eliminating Stasis in the Lower Abdomen Decoction Explanation This formula is chosen if there is Cold in the Uterus. Women’s Treasure remedies
– STIR FIELD OF ELIXIR – INVIGORATE BLOOD AND STEM THE FLOW
If the period is heavy. – HARMONIZING THE MOON If the Blood stasis is very pronounced. Summary Blood stasis
Clinical manifestations
Painful periods, palpable ovaries, dark menstrual blood with clots, abdominal pain, irregular periods, mental restlessness. Tongue: Purple in general or only Purple sides. Pulse: Wiry, Choppy or Firm pulse. Treatment principle
Invigorate Blood, eliminate stasis, regulate the Penetrating Vessel. Acupuncture
SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), LIV-3 Taichong, SP-10 Xuehai, BL-17 Geshu, KI-14 Siman, ST-29 Guilai, Zigong, ST-30 Qichong. Reducing or even method on all points except SP-4 and P-6 which should be needled with even method. Herbal treatment
Pre scriptions
• GE XIA ZHU YU TANG Eliminating Stasis below the Diaphragm Decoction
• SHAO FU ZHU YU TANG Eliminating Stasis in the Lower Abdomen Decoction Women’s Treasure remedies
• STIR FIELD OF ELIXIR • INVIGORATE BLOOD AND STEM THE FLOW • HARMONIZING THE MOON
Liver-Fire and Damp-Heat in the Liver channel
Clinical manifestations Amenorrhoea or irregular bleeding, excessive hair growth, spots on buttocks, thirst, headaches, breast distension or pain, yellow vaginal discharge, feeling of heat. Tongue: Red on the sides, sticky, yellow coating. Pulse: Wiry-Rapid. Treatment principle Resolve Dampness, clear Heat, drain Liver-Fire. Acupuncture LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), LIV-2 Xingjian, L.I.-11 Quchi, Ren-3 Zhongji, KI-14 Siman, ST-28 Shuidao, SP-6 Sanyinjiao, LIV-5 Ligou, BL-22 Sanjiaoshu. Reducing or even method on all points except LU-7 and KI-6 which should be needled with even method. Explanation
– LU-7 and KI-6 open and regulate the Directing Vessel. – LIV-2 drains Liver-Fire. – L.I.-11 clears Heat in general. – Ren-3, KI-14 and ST-28 resolve Dampness from the genital system. – SP-6 and LIV-5 resolve Damp-Heat from the Liver channel.
– BL-22 resolves Dampness from the Lower Burner. Herbal treatment
a Prescription
– LONG DAN XIE GAN TANG – Gentiana Draining the Liver Decoction b Prescription
– DANG GUI LONG HUI WAN – Angelica-Gentiana-Aloe Pill Women’s Treasure remedies
– DRAIN FIRE Drain Fire is a variation of Long Dan Xie Gan Tang to drain LiverFire. – DRAIN THE JADE VALLEY Drain the Jade Valley is a variation of Si Miao San to resolve DampHeat from the genital system. Summary
Liver-Fire and Damp-Heat In the Liver channel
Clinical manifestations
Amenorrhoea or irregular bleeding, excessive hair growth, spots on buttocks, thirst, headaches, breast distension or pain, yellow vaginal discharge, feeling of heat. Tongue: Red on the sides, sticky, yellow coating. Pulse: Wiry-Rapid. Treatment principle
Resolve Dampness, clear Heat, drain Liver-Fire. Acupuncture
LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), LIV-2 Xingjian, L.I.-11 Quchi, Ren-3 Zhongji, KI-14 Siman, ST-28 Shuidao, SP-6 Sanyinjiao, LIV-5 Ligou, BL-22 Sanjiaoshu. Reducing or even method on all points except LU-7 and KI-6 which should be needled with even method. Herbal treatment
Pre scriptions
• LONG DAN XIE GAN TANG Gentiana Draining the Liver Decoction • DANG GUI LONG HUI WAN Angelica-Gentiana-Aloe Pill Women’s Treasure remedies
• DRAIN FIRE
• DRAIN THE JADE VALLEY
Blood deficiency
Clinical manifestations Amenorrhoea, scanty periods, underdeveloped breasts, dizziness, tiredness, dull, pale complexion, blurred vision, tingling limbs. Tongue: Pale and possibly Thin. Pulse: Choppy or Thin. Treatment principle Nourish Blood, strengthen the Liver and Kidneys. Acupuncture LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan. Reinforcing method. Explanation
– LU-7 and KI-6 open and regulate the Directing Vessel. – Ren-4 nourishes Liver-Blood, tonifies the Tian Gui of the Kidneys and consolidates Directing and Penetrating Vessels. – ST-36, SP-6 and LIV-8 nourish Liver-Blood. Herbal treatment
Prescription
– BA ZHEN TANG – Eight Precious Decoction Women’s Treasure remedy
– PRECIOUS SEA Precious Sea is a variation of Ba Zhen Tang which tonifies Qi and nourishes Blood. Summary Blood deficiency
Clinical manifestations
Amenorrhoea, scanty periods, underdeveloped breasts, dizziness, tiredness, dull, pale complexion, blurred vision, tingling limbs. Tongue: Pale and possibly Thin. Pulse: Choppy or Thin. Treatment principle
Nourish Blood, strengthen the Liver and Kidneys. Acupuncture
LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan. Reinforcing method. Herbal treatment
Pre scription
• BA ZHEN TANG Eight Precious Decoction Women’s Treasure remedy
• PRECIOUS SEA
Combined patterns The patterns listed above are individual patterns appearing in PCOS: some pertain to the Manifestation (Biao), such as Damp-Phlegm in the Uterus, and some to the Root (Ben), such as Kidney-Yang deficiency. In clinical practice, however, the above patterns occur simultaneously usually with two or three patterns. Moreover, the combination usually involves both the Manifestation and the Root. The combinations of patterns described below are only examples of the most common combinations: in practice, there may be a large variety of combinations, some of which may not be listed below. The combinations of patterns discussed are: • Damp-Phlegm and Kidney-Yang deficiency • Damp-Phlegm, Kidney-Yang deficiency and Blood stasis • Damp-Phlegm, Kidney-Yin deficiency and Blood stasis • Dampness and Kidney-Yang deficiency • Dampness, Kidney-Yin Deficiency and Blood Stasis.
Damp-Phlegm and Kidney-Yang deficiency
Clinical manifestations Obesity, hirsutism, excessive vaginal discharge, feeling of fullness and heaviness of the abdomen, irregular periods, scanty periods, amenorrhoea, backache, dizziness, tinnitus, feeling cold, cold knees and back, frequent, pale urination, tiredness, low spirits. Tongue: Pale and Swollen with sticky coating. Pulse: Weak and slightly Slippery or Soggy. Treatment principle
– Phase 2: tonify Kidney-Yang, consolidate the Directing Vessel. – Phases 3 and 4: resolve Damp-Phlegm from the Uterus, regulate the Penetrating Vessel. Acupuncture
– Phase 2: LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-13 Qixue, ST-36 Zusanli, KI-3 Taixi, SP-6 Sanyinjiao, BL-23 Shenshu. – Phases 3 and 4: SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), KI-14 Siman, Ren-4 Guanyuan, ST-28 Shuidao, Ren-3 Zhongji, SP-6 Sanyinjiao, ST-40 Fenglong. Herbal treatment
– Phase 2: You Gui Wan Restoring the Right [Kidney] Pill. – Phases 3 and 4: Qi Gong Wan Arousing the Uterus Pill. Summary Damp-Phlegm and Kidney-Yang deficiency
Treatment principle
• Phase 2: tonify Kidney-Yang, consolidate Directing Vessel • Phases 3 and 4: resolve Damp-Phlegm from the Uterus, regulate the Penetrating Vessel
Herbal treatment
• Phase 2: You Gui Wan Restoring the Right [Kidney] Pill • Phases 3 and 4: Qi Gong Wan Arousing the Uterus Pill
Damp-Phlegm, Kidney-Yang deficiency and Blood stasis
Clinical manifestations Obesity, hirsutism, excessive vaginal discharge, feeling of fullness and heaviness of the abdomen, irregular periods, scanty periods, amenorrhoea, painful periods with dark, clotted blood, abdominal pain, backache, dizziness, tinnitus, feeling cold, cold knees and back, tiredness, frequent, pale urination, low spirits. Tongue: Pale, Bluish-Purple and Swollen with sticky coating. Pulse: Weak and slightly Slippery or Firm (if Blood stasis is pronounced). Treatment principle
– Phase 1: invigorate Blood. – Phase 2: tonify Kidney-Yang. – Phases 3 and 4: resolve Damp-Phlegm. Acupuncture
– Phase 1: SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), KI-14 Siman, Ren-6 Qihai, SP-10 Xuehai, LIV-3 Taichong. – Phase 2: LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-13 Qixue, ST-36 Zusanli, KI-3 Taixi, SP-6 Sanyinjiao, BL-23 Shenshu.
– Phases 3 and 4: SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), KI-14 Siman, Ren-4 Guanyuan, ST-28 Shuidao, Ren-3 Zhongji, SP-6 Sanyinjiao, ST-40 Fenglong. Herbal treatment
– Phase 1: Ge Xia Zhu Tang Eliminating Stasis below the Diaphragm Decoction. (If the period is heavy, add Pu Huang Pollen Typhae and San Qi Radix Notoginseng.) Stir Field of Elixir (Invigorate Blood and Stem the Flow if the period is heavy). – Phase 2: You Gui Wan Restoring the Right [Kidney] Pill, Unicorn Pearl. – Phases 3 and 4: Qi Gong Wan Arousing the Uterus Pill, Clear the Palace. Summary Damp-Phlegm, Kidney-Yang deficiency and Blood stasis
Treatment principle
• Phase 1: invigorate Blood • Phase 2: tonify Kidney-Yang • Phases 3 and 4: resolve Damp-Phlegm
Herbal treatment
• Phase 1: Ge Xia Zhu Tang Eliminating Stasis below the Diaphragm Decoction. (If the period is heavy, add Pu Huang Pollen Typhae and San Qi Radix Notoginseng.) Stir Field of Elixir (Invigorate Blood and Stem the Flow if the period is heavy) • Phase 2: You Gui Wan Restoring the Right [Kidney] Pill, Unicorn Pearl • Phases 3 and 4: Qi Gong Wan Arousing the Uterus Pill, Clear the Palace
Damp-Phlegm, Kidney-Yin deficiency and Blood stasis
Clinical manifestations Obesity, hirsutism, excessive vaginal discharge, feeling of fullness and heaviness of the abdomen, irregular periods, scanty periods, amenorrhoea, painful periods with dark, clotted blood, abdominal pain, backache, dizziness, tinnitus, night sweating, feeling of heat in the evening, tiredness, low spirits. Tongue: Swollen tongue with sticky, rootless coating but also partially missing a coating, slightly Purple on the sides. Pulse: Floating-Empty and slightly Slippery. Treatment principle
– Phase 1: invigorate Blood, eliminate stasis, regulate the Penetrating Vessel. – Phase 2: nourish Kidney-Yin. – Phases 3 and 4: resolve Damp-Phlegm. Acupuncture
– Phase 1: SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), KI-14 Siman, Ren-6 Qihai, SP-10 Xuehai, LIV-3 Taichong. – Phase 2: LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-13 Qihai, ST-36 Zusanli, SP-6 Sanyinjiao.
– Phases 3 and 4: SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), KI-14 Siman, Ren-4 Guanyuan, ST-28 Shuidao, Ren-9 Shuifen, Ren-3 Zhongji, SP-6 Sanyinjiao, ST-40 Fenglong. Herbal treatment
– Phase 1: Ge Xia Zhu Tang Eliminating Stasis below the Diaphragm Decoction. – Phase 2: Zuo Gui Wan Restoring the Left [Kidney] Pill. – Phases 3 and 4: Qi Gong Wan Arousing the Uterus Pill. Summary Damp-Phlegm, Kidney-Yin deficiency and Blood stasis
Treatment principle
• Phase 1: invigorate Blood, eliminate stasis, regulate the Penetrating Vessel • Phase 2: nourish Kidney-Yin • Phases 3 and 4: resolve Damp-Phlegm
Herbal treatment
• Phase 1: Ge Xia Zhu Tang Eliminating Stasis below the Diaphragm Decoction
• Phase 2: Zuo Gui Wan Restoring the Left [Kidney] Pill • Phases 3 and 4: Qi Gong Wan Arousing the Uterus Pill
Dampness and Kidney-Yang deficiency
Clinical manifestations Feeling of fullness and heaviness of the abdomen, excessive vaginal discharge, acne, hirsutism, turbid urine, scanty periods, amenorrhoea, midcycle bleeding and/or pain, backache, dizziness, tinnitus, feeling cold, cold knees and back, frequent, pale urination, tiredness, low spirits. Tongue: Pale and Swollen tongue with sticky coating on the root. Pulse: Weak and slightly Slippery or Soggy. Treatment principle
– Phase 2: tonify Kidney-Yang. – Phases 3 and 4: resolve Dampness. Acupuncture
– Phase 2: LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-13 Qixue, ST-36 Zusanli, KI-3 Taixi, SP-6 Sanyinjiao, BL-23 Shenshu. – Phases 3 and 4: SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), KI-14 Siman, Ren-4 Guanyuan, ST-28 Shuidao, Ren-9 Shuifen, Ren-3 Zhongji, SP-6 Sanyinjiao, SP-9 Yinlingquan. Herbal treatment
– Phase 2: tonify Kidney-Yang. You Gui Wan Restoring the Right [Kidney] Pill. – Phases 3 and 4: resolve Dampness. Si Miao San Four Wonderful Powder. Summary Dampness and Kidney-Yang deficiency
Treatment principle
• Phase 2: tonify Kidney-Yang • Phases 3 and 4: resolve Dampness
Herbal treatment
• Phase 2: You Gui Wan Restoring the Right [Kidney] Pill • Phases 3 and 4: Si Miao San Four Wonderful Powder
Dampness, Kidney-Yin deficiency and Blood stasis
Clinical manifestations Feeling of fullness and heaviness of the abdomen, excessive vaginal discharge, acne, hirsutism, turbid urine, scanty periods, amenorrhoea, midcycle bleeding and/or pain, backache, dizziness, tinnitus, night sweating, feeling of heat in the evening, painful periods with dark, clotted blood. Tongue: without coating or with a sticky, rootless coating, slightly Purple on the sides. Pulse: Floating-Empty or Soggy. Treatment principle
– Phases 1: invigorate Blood, eliminate stasis and regulate the Penetrating Vessel. – Phase 2: nourish Kidney-Yin. – Phases 3 and 4: resolve Dampness from the Uterus. Acupuncture
– Phases 1: SP-4 Gongsun (on the right) with P-6 Neiguan (on the left), KI-14 Siman, Ren-6 Qihai, SP-10 Xuehai, LIV-3 Taichong. – Phase 2: LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left), Ren-4 Guanyuan, KI-13 Qihai, ST-36 Zusanli, SP-6 Sanyinjiao. – Phases 3 and 4: SP-4 Gongsun (on the right) with P-6 Neiguan (on the
left), KI-14 Siman, Ren-4 Guanyuan, ST-28 Shuidao, Ren-9 Shuifen, Ren-3 Zhongji, SP-6 Sanyinjiao, SP-9 Yinlingquan. Herbal treatment
– Phase 1: Ge Xia Zhu Tang Eliminating Stasis below the Diaphragm Decoction. – Phase 2: Zuo Gui Wan Restoring the Left [Kidney] Pill. – Phases 3 and 4: Si Miao San Four Wonderful Powder. Summary Dampness, Kidney-Yin deficiency and Blood stasis
Treatment principle
• Phases 1: invigorate Blood, eliminate stasis and regulate the Penetrating Vessel • Phase 2: nourish Kidney-Yin • Phases 3 and 4: resolve Dampness from the Uterus
Herbal treatment
• Phase 1: Ge Xia Zhu Tang Eliminating Stasis below the Diaphragm Decoction • Phase 2: Zuo Gui Wan Restoring the Left [Kidney] Pill
• Phases 3 and 4: Si Miao San Four Wonderful Powder
Modern chinese literature
Cao Wen Zhong, Xu Hui Qing 1996 Some difficult cases treated by acupuncture: acupuncture treatment of polycystic ovary syndrome, Journal of Chinese Medicine (Zhong Yi Za Zhi
) 51: 9
Dr Cao and Dr Xu report the acupuncture treatment of PCOS. The points they use are reported below together with the authors’ explanation. • LU-7 Lieque (to activate the Directing Vessel). • BL-32 Ciliao to invigorate Blood. • ST-25 Tianshu to move Qi and invigorate Blood. • Du-1 Changqiang to invigorate Blood. • ST-40 Fenglong to resolve Phlegm and Dampness. • SP-6 Sanyinjiao ‘for a moderating effect to avoid injury to Qi’. • L.I.-4 Hegu and LIV-3 Taichong to tonify and regulate Qi and Blood and to balance Yin and Yang. • BL-31 Shangliao, BL-32 Ciliao, BL-33 Zhongliao, BL-34 Xialiao every
third treatment with hot needle (i.e. the insertion of a previously heated needle). Comments There are several things to note in this article. First, the authors use LU-7 Lieque on its own (without KI-6 Zhaohai) to regulate the Directing Vessel. I personally always use two points to open an Extraordinary Vessel, but there is such an opinion that they can be opened only by the main point. Second, the authors seem to adopt the treatment principle of tonifying the Kidneys, invigorating Blood, resolving Phlegm and moving Qi. Invigorating Blood seems to take priority over resolving Phlegm. I personally would disagree with this approach as I would consider resolving Phlegm as the priority compared to invigorating Blood. Third, the authors seem to overemphasize (in my opinion) the Phlegmresolving effect of ST-40 Fenglong: in my experience, it takes a lot more points to resolve Phlegm than just ST-40. Fourth, the authors seem to attribute certain actions to acupuncture points that mimic exactly those of herbs. I personally do not think this is always possible. Certainly acupuncture points have actions just the same way as herbs do (e.g. LIV-2 Xingjian drains Fire) but we cannot say that LIV-2 drains Fire in the same way as Long Dan Cao Radix Gentianae does. Long Dan Cao is bitter and cold and, as such, its long-term administration may result in injury to the Spleen: the same cannot be said of LIV-2. Thus, the authors say they use SP-6 Sanyinjiao to ‘prevent injury to Qi’ but it is not clear from which points would injury to Qi derive. Finally, as usual in Chinese clinics, a lot of stress is placed on Qi stagnation and I personally do not think this plays a large role in PCOS. Xia Gui E, Zhao Wen Ming, Ma Ren Hai 1999 Clinical observations on the treatment of 76 cases of premature ovarian failure with acupuncture, Journal of Chinese Acupuncture (Zhong Yi Zhen Jiu
) 4: 199
The authors treated 76 women suffering from premature ovarian failure with acupuncture. There was a total of 151 women of which 76 were assigned to the acupuncture group and 75 to the control group who took a placebo pill. The pattern differentiation in both groups was as follows: • Liver- and Kidney-Yin deficiency (103 of which 55 in the acupuncture group). • Spleen- and Kidney-Yang deficiency (48 of which 21 in the acupuncture group). The acupuncture points used were as follows: Ren-4 Guanyuan, Ren-3 Zhongji, KI-12 Dahe, BL-23 Shenshu. This is the basic formula which was then modified according to pattern as follows: • Liver- and Kidney-Yin deficiency: SP-6 Sanyinjiao, SP-9 Yinlingquan, BL-18 Ganshu, HE-6 Yinxi, KI-7 Fuliu. • Spleen- and Kidney-Yang deficiency: BL-20 Pishu, Du-4 Mingmen, SP8 Diji, BL-32 Ciliao. Comments The most interesting feature of this article is the choice of KI-12 Dahe to promote ovulation. This point appears consistently in formulae to promote
ovulation by many doctors. Apart from this, the study is, in my opinion, open to criticism. My main criticism would be the attribution of the pathology of PCOS only to a deficiency. This completely ignores the role of Phlegm and Blood stasis in this disease. Sang Hai Li 2000 Clinical observations on 45 cases of PCOS treated by tonifying the Kidneys and acupuncture, Journal of Chinese Medicine (Zhong Yi Za Zhi
) 7: 412
In this clinical trial, there were 75 women suffering from PCOS: they were assigned to two groups with 45 assigned to the treatment group. The age of the patients ranged from 23 to 38 and the duration of the disease ranged from 1 to 10 years. Seventeen suffered from scanty periods, 18 from amenorrhoea and 10 from irregular periods. There were 30 women in the control group (taking a placebo capsule) ranging in age from 24 to 36 with a duration of the disease ranging from 1 to 10 years. Ten suffered from scanty periods, 13 from amenorrhoea and 7 from irregular periods. The pattern differentiation identified by Dr Sang was three-fold: 1. Kidney deficiency (15 cases). 2. Kidney deficiency with Blood stasis (17 cases). 3. Kidney deficiency with Heat in the Liver and Gall Bladder (13 cases). Dr Sang used four formulae in capsule form as follows:
– Capsules I: Yin Yang Huo Herba Epimedii, Lu Jiao Jiao Colla Cornu Cervi, Zi He Che Placenta Hominis and sheep’s penis. – Capsules II: Rou Cong Rong Herba Cistanches, Ba Ji Tian Radix Morindae officinalis, Gui Ban Plastrum Testudinis, Nu Zhen Zi Fructus Ligustri lucidi, Tu Si Zi Semen Cuscutae, Huai Niu Xi Radix Achyranthis bidentatae and Chong Wei Zi Fructus Leonuri. – Capsules III: Chuan Shan Jia Squama Manitis, Zao Jiao Ci Spina Gleditsiae, Kun Bu Thallus Eckloniae and Hai Zao Sargassum. – Capsules IV: Chai Hu Radix Bupleuri, Xia Ku Cao Spica Prunellae, Da Huang Radix et Rhizoma Rhei, Sheng Di Huang Radix Rehmanniae. The capsules were taken by mouth and acupuncture was also applied. Capsules I were taken for 12 days before the period and Capsules II for 16 days after the period. Women suffering from Kidney deficiency only (first type) took only Capsules I and II. Women with Kidney deficiency combined with Blood stasis, Phlegm or Liver-Heat were given either Capsules III or IV combined with Capsules I and II. The dosage was six capsules three times a day. Acupuncture consisted in needling Ren-4 Guanyuan, Ren-3 Zhongji, Zigong and SP-6 Sanyinjiao for 5 successive days starting from the twelfth day after the period to promote ovulation. If women had very long cycles or amenorrhoea, they were given progesterone in addition to Chinese herbs and acupuncture. The treatment outcome parameters were as follows: • Successful treatment: the woman ovulates within one to two courses for six successive cycles or she conceives. • Some results: the woman ovulates for three successive cycles. • No results: no change in periods or ovulation. On the basis of the above parameters, the results in the treatment group
were as follows: • Successful: 26. • Some results: 16. • No results: 3. Comments The article is interesting as it confirms that Kidney deficiency and Blood stasis are often seen together in PCOS. However, the article surprisingly mentions Phlegm only in passing. The treatment according to phases is also interesting although the timing is questionable. From my perspective, one major flaw of the trial is the use of progesterone in conjunction with Chinese herbs and acupuncture which renders the evaluation of the effects of acupuncture and herbs difficult. He Wen Yang 2000 The treatment of premature ovarian failure with acupuncture, Journal of Chinese Acupuncture (Zhong Guo Zhen Jiu
) 7: 399
Dr He used an acupuncture formula for ovarian failure based on treating the Governing Vessel (Du Mai): Du-14 Dazhui, Du-13 Taodao, Du-12 Shenzhu, Du-10 Lingtai, Du-9 Zhiyang, KI-1 Yongquan. The explanation given by Dr He is interesting and it is worth reporting. She says that the Kidneys store Essence and control reproduction and Tian
Gui. The Governing Vessel (Du Mai) flows through the Uterus and it originates from the Kidneys. After passing through the Uterus, the Governing Vessel emerges at Ren-1 Huiyin and flows up the spine connecting with the Heart. The Penetrating and Directing Vessels also connect the Heart and Kidneys. Comments The choice of points on the Governing Vessel (rather than the Directing Vessel) is interesting. It shows, first, that the Governing Vessel is as important as the Directing Vessel in gynecology (I call it the ‘forgotten vessel of gynecology’). Second, it shows that Dr He uses the Governing Vessel to activate the Yang energy needed to promote ovulation. Third, Dr He mentions the connection between the Heart and Kidneys to regulate the menstrual cycle. This converges with Dr Xia Gui Cheng’s view according to which, during ovulation, Heart-Qi needs to go down and connect with the Kidneys to promote the release of ova. Li Xiao Qing, Shi Xiao Lin 1999 Clinical observations on the treatment of ovarian dysfunction with moxibustion, Journal of Chinese Acupuncture (Zhong Guo Zhen Jiu
) 12: 727
The authors of the study treated 82 women suffering from ovarian dysfunction. They ranged in age from 20 to 36 and the duration of the disease ranged from 6 to 11 years. The women suffered from various
conditions such as stoppage of the menses, menorrhagia, scanty periods, PCOS or amenorrhoea. The pattern differentiation was as follows: • Kidney-Yang deficiency: 53. • Kidney-Yin deficiency: 7. • Liver-Qi stagnation: 14. • Damp-Phlegm in the Uterus: 8. Forty-two women had moxibustion and 40 had Chinese herbs. The points used were Ren-4 Guanuan, Zigong, SP-6 Sanyinjiao. This was the basic formula used with additions according to pattern as follows: • Kidney deficiency: BL-23 Shenshu. • Liver-Qi stagnation: BL-18 Ganshu. • Damp-Phlegm: BL-20 Pishu, ST-40 Fenglong. The points were treated with moxibustion with the moxa cigar for 20 minutes. The women in the herbal group received the following herbal prescriptions: • Kidney-Yang deficiency: You Gui Wan Restoring the Right [Kidney] Pill. • Kidney-Yin deficiency: Zuo Gui Wan Restoring the Left [Kidney] Pill. • Liver-Qi stagnation: Kai Yu Zhong Yu Tang Opening Stagnation and Planting Jade Decoction. • Damp-Phlegm in the Uterus: Cang Fu Dao Tan Wan AtractylodesCyperus Conducting Phlegm Decoction.
The results in the moxibustion and herbal group were practically the same.
Case histories
Case history 1 A 29-year-old woman had been diagnosed with PCOS. Her period came only every 3 months on average. Her menarche occurred at 14 and her periods had always been late. She had been on the contraceptive pill from the age of 20 to 25. When they did come, her periods lasted 5 days, and were rather painful. She suffered from pre-menstrual tension manifesting with irritability, depression, thirst and breast distension. She often had an excessive and sticky, thick vaginal discharge and a feeling of heaviness of the lower abdomen. She now wanted to have a baby. Apart from the gynecological symptoms, she also suffered from abdominal distension and constipation. Her pulse was Weak on the right and especially on the Kidney position, and slightly Slippery and Firm on the left. Her tongue was slightly Pale but with a Red tip. There was a sticky, dirty coating on the root.
Diagnosis I diagnosed Kidney-Yang deficiency and Damp-Phlegm in the Uterus. The symptoms of Damp-Phlegm in the Uterus can be quite subtle and, in her case, they are feeling of heaviness of the lower abdomen, vaginal discharge, Slippery pulse. The ovarian cysts themselves are a symptom of DampPhlegm.
Treatment principle In such cases, I usually try to adapt the treatment principle to the four phases of the menstrual cycle as follows: – Phase 1 (bleeding): invigorate Blood or invigorate Blood and stop bleeding if the period is heavy. – Phase 2 (post-menstrual phase, about 5–8 days): nourish Blood and/or tonify the Kidneys (Yin or Yang). – Phase 3 (mid-cycle, ovulatory phase, about 7–10 days): tonify the Kidneys, tonify the Spleen, if necessary resolve Dampness and Phlegm. – Phase 4 (pre-menstrual phase, about 5–7 days): move Qi, warm the Uterus, if necessary resolve Damp-Phlegm.
Obviously, as this patient’s periods came only every 3 months, I could not adapt the treatment principle to the four phases. I had to make a decision whether I should concentrate on tonifying the Kidneys or on resolving DampPhlegm (or both): I decided on the latter on the basis of my experience and inclination. I find that in most cases of a combined Empty and Full condition, it is usually better to start the treatment by eliminating pathogenic factors so as to rid the body of the encumbrance of the pathogenic factors. I therefore gave her a formula (in concentrated powders) primarily to resolve Damp-Phlegm, based on Qi Gong Wan Arousing the Uterus Pill as follows: • Huang Bo Cortex Phellodendri • Cang Zhu Rhizoma Atractylodis • Yi Yi Ren Semen Coicis • Chuan Niu Xi Radix Cyathulae • Tu Si Zi Semen Cuscutae • Dang Gui Radix Angelicae sinensis
• Ze Lan Herba Lycopi • Ban Xia Rhizoma Pinelliae preparatum • Xiang Fu Rhizoma Cyperi • Lu Lu Tong Fructus Liquidambaris.
Lu Lu Tong is an important herb to invigorate Blood in the Uterus and to treat ovarian cysts. She took this formula for about 3 months, after which she had four periods one after the other at the correct times. While the periods were coming regularly, I tailored the treatment principle to the four phases as follows: – Phase 1: no herbs. – Phase 2: tonify the Kidneys with Unicorn Pearl to tonify Kidney-Yang. – Phase 3: resolve Damp-Phlegm from the Uterus with the powdered prescription above. – Phase 4: move Qi with Freeing the Moon (variation of Xiao Yao San Free and Easy Wanderer Powder).
After that, she skipped a period: this did not surprise me as, when the periods have always been irregular, it takes time to re-establish a normal cycle. Whenever she skipped her period, I reverted to using only the formula to resolve Damp-Phlegm from the Uterus. Her periods started returning again albeit with a long cycle of about 6–7 weeks. At this time, I reverted to using Unicorn Pearl (Kidney-Yang tonic) in phase 2, the powdered formula in phase 3 and Freeing the Moon in phase 4. However, I changed the approach as I also prescribed a simple formula to stimulate ovulation and to be given only for a few days as soon as the clear cervical secretion appears. This formula contained only Tu Si Zi Semen Cuscutae, Gou Qi Zi Fructus Lycii and Lu Lu Tong Fructus Liquidambaris. She took this formula for about 3 months after which she had four periods one after the other at the correct times. After another 6 months of treatment, she conceived and, 9 months later, gave birth to a healthy boy.
Case history 2 A 42-old-woman had been diagnosed with PCOS. She took the contraceptive pill between the ages of 25 and 30. After that, she had no periods for 2 years. When she came to me, the bleeding was chaotic, with heavy bleeding for 2 weeks with clots and pain for 1 week (Flooding, Beng), and nearly constant spotting the rest of the time (Trickling, Lou) with bright red blood. She was overweight and suffered from tiredness, backache and night sweating. Her pulse was Deep and Weak and her tongue was of a normal colour but lacked coating on the root (slightly). She was vegetarian.
Diagnosis My initial diagnosis was deficiency of the Kidneys as the Root of the problem. This is confirmed by the tiredness, backache, night sweating and Deep and Weak pulse. I thought there was a deficiency of Kidney-Yang primarily but with some Kidney-Yin deficiency too (lack of tongue coating, night sweating). Her weight would also confirm Kidney-Yang deficiency. Although she did not have many symptoms of Phlegm, the obesity by itself is a sign of Phlegm. My diagnosis of her excessive bleeding was therefore deficient Qi (both Yang and Yin but primarily Yang) not holding Blood.
Treatment principle I treated her with acupuncture and some herbal remedies. With acupuncture, I used primarily the following points to tonify the Kidneys and consolidate the Directing Vessel (Ren Mai): LU-7 Lieque with KI-6 Zhaohai (Ren Mai), Ren-4 Guanyuan, KI-13 Qixue, SP-6 Sanyinjiao, KI-3 Taixi. With herbal medicine, initially I used Restrain the Flow during the Trickling phase and Cool the Menses during the Flooding phase. Restrain the Flow tonifies Spleen- and Kidney-Qi to hold Blood and stop bleeding; Cool the Menses cools Blood and stops bleeding. This combination produced no results. Thinking that maybe the Yin deficiency was more important, I prescribed Nourish Yin and Restrain the Flow during the Trickling phase and Clear Empty-Heat and Cool the Menses during the Flooding. This combination still produced no results. When I do not achieve results after a couple of months, I usually check the diagnosis again to see if there is anything I have missed. On re-examining her case history, I noticed a glaring omission in my diagnosis, i.e. Blood stasis (her menstrual blood was dark with large clots and very painful during the Flooding phase). I therefore changed my approach, prescribing Growing Jade (a Kidney-Yin tonic) during the Trickling phase and Invigorate Blood and Stem the Flow (a remedy that simultaneously invigorates Blood and stops bleeding) during the Flooding phase. This combination of tonification of the Kidneys and invigoration of Blood worked best. I continued along these lines for 6 months and her periods returned completely to normal, i.e. they were regular and she bled for 7 days. Case history 3 A 28-year-old woman had been diagnosed with PCOS when she was 26. She had been on the contraceptive pill from 16 to 23. After that she had 4 periods a year. She also suffered from vaginal irritation and itching. She
also suffered from irritability. She occasionally suffered from backache and frequent, pale urination. Her pulse was Rapid and Slippery; her tongue was Red with Red sides and with a sticky, yellow coating.
Diagnosis This is a clear case of Damp-Heat in the Uterus. The Damp-Heat is also in the Liver channel (Red sides of the tongue, irritability). As the patient is young, the condition is almost entirely Full as there was only a slight Kidney deficiency.
Treatment principle My treatment was focused on resolving Dampness and clearing Heat. I used a variation of Si Miao San Four Wonderful Powder as follows: • Cang Zhu Rhizoma Atractylodis • Huang Bo Cortex Phellodendri • Yi Yi Ren Semen Coicis • Chuan Niu Xi Radix Cyathulae • Long Dan Cao Radix Gentianae • Dang Gui Radix Angelicae sinensis • Fu Ling Poria • Lu Lu Tong Fructus Liquidambaris • Yuan Zhi Radix Polygalae • Suan Zao Ren Semen Ziziphi spinosae • Tu Si Zi Semen Cuscutae • Gou Qi Zi Fructus Lycii.
I added Long Dan Cao to the formula to enter the Liver channel and also to calm irritability. I added Yuan Zhi and Suan Zao Ren to calm the Mind and settle the Ethereal Soul. Tu Si Zi and Gou Qi Zi were added to tonify the Kidneys. I treated her with variations of this formula for 6 months, after which her periods started to come regularly. Case history 4
A 37-year-old woman had been diagnosed with PCOS. She suffered from hirsutism on her face and infertility. Her periods were regular but they were heavy (lasting up to 10 days) and painful with dark clots. She also suffered from constant tiredness, lack of libido, lower backache, tinnitus, night sweating, feeling cold, migraine, tingling of the limbs and blurred vision. Her tongue was Bluish-Purple; her pulse was Choppy on the left.
Diagnosis She has clear symptoms of Kidney-Yang deficiency: tiredness, lack of libido, lower backache, tinnitus, night sweating, feeling cold, Pale tongue (BluishPurple tongue is a development of the Pale tongue). There are some symptoms of Blood deficiency (tingling of the limbs, blurred vision, Choppy pulse) and of Blood stasis (painful periods with dark clots, Bluish tongue). Compared to the previous patient, in this patient the Kidney deficiency is primary.
Treatment principle I gave her two prescriptions according to phases. During phase 1, I gave her a formula to invigorate Blood and stop bleeding; during phases 2 and 3, I gave her a Kidney tonic, as follows: Phase 1
• Dang Gui Radix Angelicae sinensis • Chi Shao Radix Paeoniae rubra • Yi Mu Cao Herba Leonuri • San Qi Radix Notoginseng • Pu Huang Pollen Typhae • Qian Cao Gen Radix Rubiae • Bai Zhu Rhizoma Atractylodis macrocephalae • Xian He Cao Herba Agrimoniae • Yan Hu Suo Rhizoma Corydalis
Phases 2 and 3
• Shu Di Huang Radix Rehmanniae preparata • Shan Yao Rhizoma Dioscoreae • Shan Zhu Yu Fructus Corni • Dang Gui Radix Angelicae sinensis
• Gui Zhi Ramulus Cinnamomi • Gui Ban Plastrum Testudinis • Lu Jiao Cornu Cervi • Tu Si Zi Semen Cuscutae • Gou Qi Zi Fructus Lycii • Yi Mu Cao Herba Leonuri • Fu Ling Poria • Bai Zhu Rhizoma Atractylodis macrocephalae
This patient was treated with variations of these two formulae for a long time. Her periods became less heavy and less painful after 3 months. She conceived after 2 years. Case history 5 A 32-year-old woman had been diagnosed with PCOS. Her period came every 3 months. Her menarche was at 14, but her periods had always been irregular (i.e. coming every 3 months). The period lasted 5 days and it was heavy, painful and occasionally with clots. She experienced premenstrual tension. She also experienced hot flushes, abdominal distension/heaviness, constipation, feeling cold. Her pulse was Weak on the right, Slippery on the left and slightly Firm. Her tongue was Pale with a sticky coating.
Diagnosis There is a Kidney deficiency (irregular periods, hot flushes, feeling cold, Weak pulse, Pale tongue); Dampness (abdominal heaviness, Slippery pulse); and some Qi stagnation and Blood stasis (painful periods with clots, abdominal distension, Firm pulse).
Treatment principle Although her periods came every 3 months, I treated her according to the four phases in the following way: – Phase 4 (identified when pre-menstrual tension appeared): move Qi and Blood. – Phase 1: invigorate Blood and stop bleeding. – Phase 2 (i.e. for a week after the end of bleeding): tonify Kidney-Yang. – Phase 3 (i.e. for 2 weeks starting 1 week after the end of the period): resolve Dampness.
I used the following formulae: – Phase 4: Freeing the Moon (a variation of Xiao Yao San Free and Easy Wanderer Powder). – Phase 1: Invigorate Blood and Stem the Flow (a formula that invigorates Blood and stops bleeding). – Phase 2: Unicorn Pearl (to tonify Kidney-Yang). – Phase 3: a powdered variation of Si Miao San Four Wonderful Powder (Cang Zhu Rhizoma Atractylodis, Huang Bo Cortex Phellodendri, Yi Yi Ren Semen Coicis, Chuan Niu Xi Radix Cyathulae, Tu Si Zi Semen Cuscutae, Gou Qi Zi Fructus Lycii, Dang Gui Radix Angelicae sinensis, Yi Mu Cao Herba Leonuri, Ze Lan Herba Lycopi, Ban Xia Rhizoma Pinelliae preparatum, Xiang Fu Rhizoma Cyperi, Lu Lu Tong Fructus Liquidambaris).
After 6 months of treatment along these lines, her periods began to come more frequently and it took 18 months before her periods came regularly every month.
Clinical trials
Acupuncture
Low-frequency electroacupuncture and physical exercise decrease high muscle sympathetic nerve activity in polycystic ovary syndrome
– American Journal of Physiology: Regulatory, Integrative and Comparative Physiology 2009 297(2):R387–R395. – Stener-Victorin E, Jedel E, Janson P O, Sverrisdottir Y B. – Institute of Neuroscience and Physiology, Department of Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden. Background
It has been shown that PCOS is associated with high muscle sympathetic nerve activity. Animal studies support the concept that low-frequency electro-acupuncture (EA) and physical exercise, via stimulation of ergoreceptors and somatic afferents in the muscles, may modulate the activity of the sympathetic nervous system. Objective
To investigate the effect of low-frequency electro-acupuncture (EA) and physical exercise on sympathetic nerve activity in women with PCOS. Methods
This was a randomized, controlled trial that took place at Sahlgrenska University Hospital, Gothenburg, Sweden. Twenty women with PCOS were randomly allocated to one of three groups: a group receiving low-frequency EA (EA, n = 9), a physical exercise group (n = 5) or a control group which received no treatment (n = 6). The duration was 16 weeks. Outcome measures were direct recordings of multi-unit efferent post-ganglionic muscle sympathetic nerve activity (MSNA) in a muscle fascicle of the peroneal nerve before and after the 16 weeks. Biometric, haemodynamic, endocrine and metabolic parameters were also measured. Results
In both the EA and physical exercise group, MSNA was decreased compared with the control group (P = 0.036) and (P = 0.030) respectively. Sagittal diameter was reduced in the EA group (P = 0.001), and body weight and body mass index (BMI) were decreased in the physical exercise group (P = 0.004 for both) compared to the untreated control group. Sagittal diameter was related to MSNA in the EA group (P < 0.005). No correlation was found for BMI and MSNA in the exercise group. There were no differences between the groups in haemodynamic, endocrine and metabolic variables. Conclusion
This trial demonstrated for the first time that low-frequency EA and physical exercise lowers high sympathetic nerve activity in women with PCOS. Thus, treatment with low-frequency EA or physical exercise with the aim to reduce MSNA may be of importance for women with PCOS. An observation on the therapeutic effect of acupuncture combined with Chinese herbs on polycystic ovary syndrome due to Kidney deficiency and Phlegm
– Zhongguo Zhen Jiu, Chinese Acupuncture and Moxibustion 2009 29(2): 99–102. – Shi Y, Feng H J, Liu H R, Zhu D. – Shanghai Institute of Acupuncture-Moxibustion and Meridian, Shanghai, China. Objective
To observe the therapeutic effect of acupuncture combined with Chinese herbs on PCOS due to Kidney deficiency and Phlegm and to understand the mechanism. Methods
Sixty-three patients with a diagnosis of PCOS due to Kidney deficiency and Phlegm were randomly divided into one of two groups. Group A received a combination of acupuncture at Ren-6 Qihai and Ren-4 Guanyuan among other points and Chinese herbs orally (n = 32) and Group B was administered the same Chinese herbs orally (n = 31). The therapeutic effects and changes of follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone (T) and LH/FSH were compared between the two groups. Results
The total effective rate was 93.8% in Group A and 80.6% in Group B, which was a significant difference (P < 0.05). The decrease of T in Group A was significantly superior to that in Group B (P < 0.01).
Conclusion
Acupuncture combined with Chinese herbal medicine is superior to pure administration of Chinese herbs in the decrease of T level and clinical therapeutic effect on PCOS due to Kidney deficiency and Phlegm. Clinical study on needle-pricking therapy for treatment of polycystic ovarial syndrome
– Zhongguo Zhen Jiu, Chinese Acupuncture and Moxibustion 2007 27(2): 99–102. – Chen D, Chen S R, Shi X L et al. – The First Affiliated Hospital of Jinan University, Guangzhou, China. Objective
To understand the clinical effect of acupuncture for treatment of PCOS. Methods
This trial was a randomized controlled trial involving 121 cases of PCOS which were divided into one of two groups. Group A received acupuncture at sacral plexus stimulating points on both sides of the spine and points lateral to Ren-14 Juque (n = 61), and Group B received oral administration of domiphen and intramuscular injection of human chorionic gonadotropin (hCG). Levels of hormones and symptoms in the patients at baseline, after three cycles of treatment and after the sixth cycle were investigated.
Results
After three cycles, the level of hormone and B-ultrasound examination were significantly improved in both groups (P < 0.01). After the sixth cycle, the conditions of the patients in Group B were returned to the original levels before treatment, while the conditions in Group A maintained the posttherapeutic level. In Group A, menstruation and ovulation were restored to normal levels, and the ovulation mucosa and the pregnancy rate were significantly higher than those in Group B (all P < 0.01). Conclusion
Acupuncture has a positive and long-term therapeutic effect on PCOS. The effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome
– Acta Obstetricia et Gynecologica Scandinavica, 2000 79(3): 180–188. – Stener-Victorin E, Waldenström U, Tägnfors U, Lundeberg T, Lindstedt G, Janson P O. – Department of Obstetrics and Gynaecology, Göteborg University, Sweden. Objective
To ascertain if electro-acupuncture (EA) could affect oligo/anovulation and related endocrine and neuroendocrine parameters in women with PCOS.
Methods
Twenty-four women (between the ages of 24 and 40 years) with PCOS and oligo/amenorrhoea were included in this non-randomized, longitudinal, prospective study. Nineteen of the women were resistant to clomifene. The study period started 3 months before the first EA treatment, to 3 months after the last EA treatment (10–14 treatments), over 8–9 months. Electroacupuncture was performed at the points BL-23 Shenshu, BL-28 Pangguangshu, SP-6 Sanyinjiao, SP-9 Yinlingquan, P-6 Neiguan, T.B.-5 Waiguan and Du-20 Baihui. The menstrual and ovulation patterns were confirmed by recording vaginal bleedings and by daily registration of the basal body temperature. Blood samples were collected within a week before the first EA, within a week after the last EA and 3 months after the last EA. Results
Nine women (38%), of whom 7 were clomifene-resistant, experienced a good effect. They displayed a mean of 0.66 ovulations/woman and month in the period during and after the EA period compared to a mean of 0.15 before the EA period (P = 0.004). Before EA, women with a good effect had a significantly lower body mass index (P < 0.001), waist:hip circumference ratio (P = 0.0058), serum testosterone concentration (P = 0.0098), serum testosterone:sex hormone binding globulin (SHBG) ratio (P = 0.011) and serum basal insulin concentration (P = 0.0054), and a significantly higher concentration of serum SHBG (P = 0.040) compared to the women with no effect. Conclusion
Repeated EA treatments induced regular ovulations in more than one-third of the women with PCOS. The group of women with good effect had a less
androgenic hormonal profile before treatment and a less pronounced metabolic disturbance compared to the group with no effect. For this selected group, EA offers an alternative to pharmacological ovulation induction. Changes in serum FSH, LH and ovarian follicular growth during electro-acupuncture for the induction of ovulation
– Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Modern Developments in Traditional Medicine 1989 9(4): 199–202. – Yu J, Zheng H M, Ping S M. Objective
To observe changes in FSH, LH and follicular size in chronically anovulatory patients during electro-acupuncture (EA) for the induction of ovulation. Methods
Eleven chronically anovulatory women participated. Seven cases were diagnosed with PCOS, 3 with dysfunctional uterine bleeding and 1 with hypogonadotropic amenorrhoea. Among them, 8 cases were infertile for 2.7 years on average. Ovulation was confirmed by pregnancy or the combination of biphasic basal body temperature and ultrasonographic evidence. Results
During one cycle with EA performed over 3 days on Ren-3 Zhongji, Ren-4 Guanyuan, SP-6 Sanyinjiao and Anmian, ovulation resulted in 5 patients
(ovulatory group). Four of these 5 had been infertile, 3 of whom became pregnant. The other 5 cases remained in anovulation (anovulatory group), 3 of whom obtained biphasic basal body temperature, but no typical ovulatory signs were found on ultrasonography; 2 cases remained in monophasic BBT. Serum FSH and LH values were elevated in the ovulatory group, and FSH pulsatile frequency increased significantly during ET but not in the anovulatory group. No apparent changes were found in serum LH pulsatile frequency and pulsatile amplitudes of FSH and LH in this study. In the ovulatory group, diameters of ovarian follicles increased markedly, while diameters within the anovulatory group did not grow beyond 14–16 mm. Conclusion
It is suggested that ovulation may be induced by ET via regulation of the hypothalamic–pituitary function leading to normal secretion of FSH and LH.
Herbal treatment
The treatment of refractory polycystic ovary syndrome with Bu Shen Huo Xue Tonify the Kidneys and Invigorate Blood medicine combined with ultrasound-guided follicle aspiration
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2008 28(4): 314–317. – Liang R N, Liu J, Lu J. – Department of Gynaecology, Affiliated Hospital of Jiangxi Traditional Chinese Medicine College, Nanchang, China. Objective
To observe the clinical effect of traditional Chinese herbal medicine Bu Shen Huo Xue (BSHX) was combined with ultrasound-guided follicle aspiration (MFA) in treating refractory PCOS. Methods
Forty-four women diagnosed with PCOS were randomly assigned to one of two groups. The treatment group (n = 20) was given a daily dose of BSHX decoction for 14 days every menstrual cycle. The decoction consisted of: • Tu Si Zi Semen Cuscutae 20 g • Shi Di Huang Radix Rehmanniae preparata 10 g
• Sang Ji Sheng Herba Taxilli 20 g • Yin Yang Huo Herba Epimedii 15 g • Bu Gu Zhi Fructus Psoraleae 10 g • Yu Zhu Rhizoma Polygonati odorati 10 g • Zao Jiao Ci Spina Gleditsiae 15 g • Tao Ren Semen Persicae 10 g • Shan Ci Gu Pseudobulbus Cremastrae 10 g • Dan Shen Radix Salviae miltiorrhizae 20 g • Gan Cao Radix Glycyrrhizae 6 g The control group (n = 24) was not given any Chinese herbal medication. MFA was performed on both groups. Changes of follicle stimulating hormone (FSH), luteinizing hormone (LH) and testosterone (T) were determined before and after MFA. The impacts on quantity of human menopausal gonadotropins (HMG) used, number of sinus follicles, mature follicles, incidence of ovarian hyperstimulation syndrome (OHSS), luteinized unruptured follicular syndrome (LUFS) and pregnancy rate were also observed. Results
MFA was performed for 42 cycles in the observation group and 56 cycles in the control group. Levels of T, LH and LH:FSH ratio markedly reduced after aspiration in both groups, showing a significant difference compared with baseline in both groups (P < 0.01). The difference of LH:FSH between groups was of statistical significance (P <0.01). In the observation group, the number of follicles decreased to <10 in 18
patients (90.0%) following MFA, while in the control group, the number decreased to <10 in 22 patients (91.70%); all were different to pretreatment levels (P < 0.01). In the observation group, the quantity of HMG needed for promoting ovulation and the number of mature follicles at the day of HCG injection were significantly different to those in the control group (P < 0.01). In the observation group, there were no cases of OHSS and 1 case of LUFS, versus 1 mild OHSS and 2 LUFS in the control group. After ovulation-promoting therapy and in the 3-month follow-up period, pregnancy was recorded in 8 out of the 18 patients in the observation group (1 twin and 7 single), with a pregnancy rate of 44.4%; while in the control group, 7 in 22 became pregnant (2 twins and 5 single) with a pregnancy rate of 31.8%. Conclusion
BSHX combined with MFA is a safe and effective treatment for refractory PCOS, with few adverse affects. The combined usage of Chinese herbal medicine could significantly reduce the dosage of HMG used for stimulating follicle development and the production of multiple mature follicles, thus avoiding the risk of OHSS. A clinical study on the effect of Bu Shen Hua Yu Qu Tan Tonify the Kidneys, Eliminate Stasis and Expel Phlegm therapy in treating polycystic ovary syndrome
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2007 27(10): 883–886. – Wu J H, Yu C Q, Zhou Q L. – Department of Traditional Chinese Medicine, Changhai Hospital, Second Military Medical University, Shanghai, China.
Objective
To investigate the therapeutic effect and the possible mechanism of Bu Shen Hua Yu Qu Tan (BHQR) in treating patients with PCOS. Methods
BHQR was used, both internally and topically, to treat 46 patients with PCOS, and combined with diformin if necessary. Six successive months of treatment was regarded as a course. The clinical symptoms and signs, including obesity, polytrichia, acne and acanthosis, were observed and scored before and after treatment. Serum levels of hormones and insulin were also measured. Results
After treatment, the scores of symptoms and signs were significantly lowered (P < 0.05 for obesity and P < 0.01 for others); a significant decrease was also found in the serum level of testosterone (P < 0.05) and fasting serum insulin (P < 0.01). Conclusion
BHQR not only significantly relieved the symptoms and signs of PCOS, but also effectively regulated ovarian function. A clinical observation of treatment of 43 women with polycystic ovary syndrome with different diagnoses
– Zhong Xi Yi Jie He Xue Bao, Journal of Chinese Integrative Medicine 2006 4(6): 585–588. – Jia L N, Wang X J. – Department of Gynaecology of Integrative Medicine, Huashan Hospital, Fudan University, Shanghai, China. Objective
To investigate the therapeutic effect of treatment based on syndrome differentiation and its influence on the serum levels of testosterone and insulin in women with PCOS. Methods
Forty-three women with a diagnosis of PCOS due to Kidney-Yin deficiency or Spleen-Qi deficiency took part in the study. The women with a diagnosis of Kidney-Yin deficiency (n = 25) were treated with Chinese herbal medicine to nourish Yin and drain Fire (Yin group); the women with Spleen-Qi deficiency were treated with Chinese herbal medicine to tonify the Spleen and Qi (Qi group). Body mass index (BMI), waist:hip ratio (WHR), waist circumference (WC) and the serum levels of insulin and testosterone before and after treatment were recorded. Results
Among the 43 cases, 20 cases had high serum testosterone levels (13 with a diagnosis of Kidney-Yin deficiency and 7 with a diagnosis of Spleen-Qi deficiency), but the difference had no statistical significance; 17 cases had high serum insulin levels (11 from the Qi group and 6 from the Yin group)
with a statistical significance (P < 0.05). In the Yin group, the serum levels of insulin and testosterone decreased after treatment (P < 0.05), and BMI, WHR and WC showed no significant changes. In the Qi group, the serum level of insulin decreased after treatment (P < 0.01), and BMI, WHR, WC and the serum level of testosterone showed no significant changes. Conclusion
Chinese herbal medicine to nourish Yin and drain Fire can significantly reduce the serum levels of testosterone and insulin in PCOS women with a diagnosis of Kidney-Yin deficiency. Herbs to tonify the Spleen and Qi can significantly reduce the serum level of insulin in PCOS women with a diagnosis of SpleenQi deficiency. The therapeutic effects of Jin Qi Jiang Tang on women with polycystic ovary syndrome
– Zhong Xi Yi Jie He Xue Bao, Journal of Chinese Integrative Medicine 2006 4(6): 579–584. – Hou L H, Yang X M, Erkkola R, Wu X K. – Department of Obstetrics and Gynaecology, The First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang Province, China. Objective
To observe the therapeutic effects of Jin Qi Jiang Tang (JQJT), a commonly prescribed Chinese herbal formula for type 2 diabetes, on obese women with PCOS.
Methods
Twenty-four obese women with a diagnosis of PCOS were prescribed JQJT for 3 months and the changes of carbohydrate metabolism and biochemical indicators, including menstrual cycle, body mass index (BMI), the level of blood sex hormone, area under curve (AUC) of glucose and insulin during oral glucose tolerance test (OGTT) and testosterone responses during human chorionic gonadotropin (hCG) stimulation ovary test were observed. Results
After treatment, there were significant reductions in BMI (P < 0.05), serum glucose level at 30 minutes during OGTT (P < 0.05) and testosterone levels at 18 hours during the hCG stimulation ovary test (P < 0.05). In addition, 9 out of 16 women who completed the treatment had improved cycles and 1 patient with clomifene resistance became pregnant following clomifene treatment. Conclusion
The beneficial effects of JQJT may result from improvement of carbohydrate metabolism and reduction in androgen biosynthesis in women with PCOS. The effects of modified Long Dan Xie Gan Tang Gentiana Drain the Liver Decoction on hyperandrogenism in patients with polycystic ovary syndrome due to Damp-Heat in the Gall Bladder channel
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2006 26(9): 838–841.
– Tao L L, Zhang Y Z, Sang X. – The First Affiliated Hospital of Guangzhou University of TCM. Objective
To observe the therapeutic effect of modified Long Dan Xie Gan Tang (LXD) on hyperandrogenism in patients with PCOS due to Damp-Heat in the Gall Bladder channel. Methods
Forty-eight patients were divided into one of two groups and treated for 3 months. Group A was treated with LXD (n = 25) and Group B was treated with Diane-35 (n = 23). (Diane-35 is used in the treatment of androgendependent diseases in women and it is also used as a contraceptive pill by women with this diagnosis.) Menstruation, acne and body hair covering were observed; basal body temperature (BBT) was measured, and the serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL), free testosterone (FT) and androstenedione (A) were recorded before and after 3 months of treatment. Any adverse reactions were also recorded. Results
After treatment, menstrual disorders, acne and single-phase BBT were improved significantly, and serum levels of LH, LH:FSH, FT and A decreased in both groups (P < 0.05), with an insignificant difference between the two groups (P > 0.05). The PRL level dropped in the LXD group (P < 0.05), which was a significantly lower level than that in the Diane-35 group (P < 0.05). There were 3 cases of adverse reactions of irregular
colporrhagia and 5 cases with nausea and vomiting in the Diane-35 group. No adverse reaction occurred in the LXD group. Conclusion
Modified LXD could significantly improve the condition of hyperandrogenism in PCOS patients due to Damp-Heat in the Gall Bladder channel. Clinical research on the combined therapy of Diane-35 with modified You Gui Wan Restore the Right Kidney Pill on polycystic ovary syndrome
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine, 2005 25(9): 794–796. – Chen L S, Zhou J T. – Fujian Provincial People’s Hospital, Fuzhou, China. Objective
To investigate the clinical efficacy of integrative traditional Chinese and Western medicine on PCOS. Methods
Sixty-three women with a diagnosis of PCOS were randomly allocated into one of two groups. The Western medicine group (WMG) was orally administered Diane-35 (n = 31) and the integrated medicine group (IMG) was treated with conventional medicine and modified You Gui Wan (n = 32).
Changes of relevant hormones and clinical syndromes in patients were detected at baseline, after three cycles of treatment and after the sixth cycle. Results
The levels of relevant hormones and the indices of B-ultrasound were improved after treatment in both groups. However, after six cycles of treatment, these changes returned to baseline levels in the WMG but were maintained in the IMG (P < 0.01). The normalization of menstruation, ovulation and pregnancy rates in the IMG were significantly higher than those in the WMG (P < 0.01). Conclusion
Diane-35 combined with modified You Gui Wan shows a marked short-term effect in treating PCOS, and may consolidate the curative effect. A clinical study of Yi Shen Jian Pi Yang Xue Tong Li Benefit the Kidneys, Strengthen the Spleen, Nourish Blood and Eliminate Stagnation therapy in treating polycystic ovary syndrome
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2003 23(11): 819–822. – Hua L, Wu Y N, Zhang J M. – Department of Gynaecology, Beijing Hospital of TCM, Beijing, China. Objective
To observe the effect and explore the therapeutic mechanism of Yi Shen Jian Pi Yang Xue Tong Li Therapy (YJYTT) in treating PCOS. Methods
One-hundred and seven women with a diagnosis of PCOS due to Spleenand Kidney-Yang deficiency were randomly divided into one of two groups. The treatment group received Chinese herbal medicine (n = 76), while the control group was given clomifene (n = 31). The therapeutic effect in both groups and the change of body mass index (BMI), Ferriman–Gallway (F–G) score, serum sex hormones and serum oral glucose tolerance test (OGTT) before and after treatment were observed. Results
The comparison of the total effective rate between the two groups was insignificantly different, but the pregnancy rate of the treated group (65.7%) was markedly higher than that of the control group (25.0%; P < 0.01). Significant differences were shown in BMI, F–G score, serum testosterone, luteinizing hormone and OGTT between the two groups (P < 0.05). Conclusion
YJYTT could markedly improve the clinical symptoms and pregnancy rate of PCOS patients, particularly showing good effect on clomifene-resistant patients. The mechanism was possibly due to its regulation on the hypothalamus–pituitary–ovarian axis and the reduction of insulin resistance. A study on the treatment of hyperandrogenism and hyperinsulinism in polycystic ovary syndrome with the Chinese herbal formula Tian Gui Fang
– Zhongguo Zhong Xi Yi Jie He Za Zhi, Chinese Journal of Integrated Traditional and Western Medicine 2000 20(8): 589–592. – Hou J, Yu J, Wei M. – Gynaecology and Obstetrics Hospital, Shanghai Medical University, Shanghai, China. Objective
To observe the efficacy of the Chinese herbal formula Tian Gui Fang (TGF) in hyperandrogenism and hyperinsulinism patients with PCOS, and to compare the formula with the Western medicine metformin. Methods
Twenty-two anti-clomifene citrate patients were divid-ed into one of two treatment groups. One group was give TGF (n = 10) and the other metformin (n = 12) for 3 months. Insulin response during an oral glucose tolerance test and serum levels of LH, FSH, testosterone (T), oestradiol (E2), waist:hip ratio (WHR) and body mass index (BMI) were measured before and after treatment. Results
In both groups, after 3 months of treatment, the fasting and integrated insulin response to the glucose load decreased. Six out of the 8 patients in the TGF group saw a return of their menstrual cycle, and double-phase basal body temperature (BBT). This was accompanied by significant lowering in serum T, logT/E2 and BMI (P < 0.05). The serum LH:FSH ratio was not changed.
Four of the 8 metformin-treated patients had restoration of their menstrual cycles and 2 of them had double BBT. This was accompanied by a decrease in serum logT/E2 but without significant difference. The BMI, WHR, serum E2 and LH:FSH ratio were not changed. Conclusion
Both metformin and TGF can reduce the high concentration of insulin in PCOS patients and induce ovulation, but the herbal formula showed a better efficacy. The effects of the Japanese herbal medicine Unkeito (Wen Jing Tang; Warm the Menses Decoction) on endocrine function and ovulation in women with high basal levels of luteinizing hormone secretion
– Journal of Reproductive Medicine 2001 46(5): 451–456. – Ushiroyama T, Ikeda A, Sakai M, Hosotani T, Suzuki Y, Tsubokura S, Ueki M. – Department of Obstetrics and Gynaecology, Osaka Medical College, 27 Daigaku-machi, Takatsuki, Osaka, Japan. Objective
To treat anovulatory women with high plasma LH levels with Unkeito Warm the Menses decoction. Methods
One-hundred women suffering from anovulation or irregular menstruation with high plasma LH levels, 38 of whom had PCOS and 62 of whom did not, were randomly allocated to one of two groups. The treatment group received Unkeito (n = 52) for 8 weeks, and the control group did not receive any medication (n = 48). Endocrine levels (FSH, LH and oestradiol) and follicle growth were compared. Results
The treatment group saw significant decreases in plasma LH in both the PCOS and non-PCOS patients who had high LH levels at baseline. Plasma oestradiol levels increased significantly (43.5%) during the treatment period. A significant development of the dominant follicle was also observed in patients in the treatment group. When women with high plasma LH concentration suffering from anovulation or irregular menstruation were treated with Unkeito for 8 weeks, a reduction in the serum LH level of at least 1 SD from baseline was noted in 45.5% of PCOS patients and in 80.0% of non-PCOS patients. The mean rate of reduction of serum LH was 22.2 ± 35.7% in the PCOS patients and 49.7 ± 15.3% in the non-PCOS patients. This reduction was significant in the latter (P = 0.030). The rate of menstrual cycle improvement, including successful ovulation, was 50.0% in the PCOS patients and 60.0% in the non-PCOS patients, with no significant difference between the two groups. Conclusion
Treatment with Unkeito is effective in decreasing high plasma levels of LH. The effect of Shakuyakukanzoto (Shao Yao Gan Cao Tang; Peony and Licorice Decoction) on polycystic ovary syndrome
– International Journal of Fertility and Menopausal Studies 1994 39(2): 69–76. – Takahashi K, Kitao M. – Department of Obstetrics and Gynaecology, Shimane Medical University, Izumo, Japan. Objective
To investigate the effect of the Japanese herbal medicine, Shakuyakukanzoto (SKT) Peony and Licorice decoction on endocrine variables in patients with PCOS. Methods
This trial took place at a university hospital and involved 34 women with a diagnosis of PCOS. The women received 7.5 g daily of SKT for a total of 24 weeks. Levels of testosterone (T), free testosterone (free-T), sex hormone-binding globulin (SHBG), LH, FSH, estrone, 17β-oestradiol, 3,4dihydroxyphenylglycol (DOPEG) and 3,4-dihydroxyphenylacetic acid (DOPAC) were examined before, throughout and at the end of the treatment period. Results
Four weeks after treatment began, serum T and free-T levels significantly decreased, while SHBG was not significantly elevated. After 12 weeks of treatment, the mean serum T level of the patients who became pregnant decreased to 35% of that before the treatment, but levels did not change in
the patients who failed to conceive. There was no significant difference in oestrone:oestradiol ratio before and after treatment, but the oestradiol:testosterone ratio increased significantly after 4 weeks of treatment. The LH:FSH ratio after 24 weeks of treatment was significantly lower than that before treatment. DOPEG and the DOPEG:DOPAC ratio significantly decreased after 4 weeks of treatment. No side effects were observed in any cases. Conclusion
It is suggested that SKT acts directly on the ovaries first by increasing the activity of aromatase, which promotes the synthesis of oestradiol from testosterone, thus lowering serum T levels. Furthermore, the effect on catecholamines results in gradually improving the dissociate phenomenon of the LH:FSH ratio. Therefore, SKT is an effective herbal medicine for decreasing serum free-T levels and achieving pregnancy in patients with PCOS. End notes 1. Yen S S C 1980 The Polycystic Ovary Syndrome, Clinical Endocrinology 12: 177–208..
2. Ibid., p. 178..
3. Ibid., pp 178–179..
4. Azziz R 2006 The Rotterdam 2003 Criteria for Defining PCOS, Journal of Clinical Endocrinology and Metabolism 12: 2005–2153..
5. The Polycystic Ovary Syndrome, p. 179..
6. Web site of the American Association of Clinical Endocrinologists 2009 (accessed September
2009): http://www.aace.com/public/awareness/pcos/pdf/WhatPCOS.pdf..
7. The Polycystic Ovary Syndrome, p. 185..
8. Ibid., p. 186..
9. Ibid., p. 192..
10. Mason H, Colao A, Blume-Peytavi U et al 2008 Polycystic Ovary Syndrome (PCOS) Trilogy: A Translational and Clinical Review, Clinical Endocrinology 69(6): 831–844..
11. The Polycystic Ovary Syndrome, p. 188..
12. Medscape Medical News 2002 Assisted Reproduction should be Postponed for Healthy Women, 9 July (accessed September 2009): http://www.medscape.com/viewarticle/438081..
13. Tian Dai Hua 2005 Spiritual Axis (Ling Shu Jing
), People’s Health Publishing House, Beijing, p. 129. First published c. 100 BC..
14. Zhu Dan Xi 1983 The Heart and Essence of Dan Xi’s Methods of Treatment (Dan Xi Zhi Fa Xin Yao
), People’s Health Publishing House, Beijing, p.129. (Zhu Dan Xi, 1280–1358.).
Chapter 67 Myoma
WESTERN MEDICINE VIEW 923 CHINESE MEDICINE VIEW 924 IDENTIFICATION OF PATTERNS AND TREATMENT 929 Blood stasis from Qi stagnation 929 Blood stasis from Cold 930 Blood stasis with Phlegm 931 Blood stasis with Qi and Blood deficiency 931 Blood stasis with Kidney-Yang deficiency 932 MODERN CHINESE LITERATURE 933 CLINICAL TRIALS 933 Herbal treatment 933 Myomas (or ‘fibroids’) are very common benign uterine tumours in women.
Western medicine view
Description Uterine myomas (also referred to as myoma, leiomyoma, leiomyomata and fibromyoma) are benign tumours that grow within the muscle tissue of the uterus. They are commonly called ‘fibroids’. Between 20% and 50% of women of childbearing age have uterine myomas. While many women do not experience any problems, symptoms can be severe enough to require treatment. Myomas range in size from very small to larger than a melon. A very large uterine myoma can cause the uterus to expand to the size of a six- or seven-month pregnancy. There can either be one dominant myoma or a cluster of many small myomas. There are several types of myomas differentiated according to their location (Fig. 67.1): • Sub-serous myomas develop in the outer wall of the uterus and continue to grow outward. • Intramural (or interstitial) myomas develop within the uterine wall and expand, making the uterus feel larger than normal. This is the most common type of myoma. • Sub-mucous myomas develop just under the lining of the uterine cavity. These are the myomas that, more than others, tend to cause heavy menstrual bleeding and the ones that can cause problems with infertility and miscarriage.
Figure 67.1 Types of myoma. Myomas are sometimes attached to the uterine wall by a long stalk which is called a ‘pedicle’: if a myoma has a pedicle, it is called pedunculated. Uterine myomas are the most common pelvic tumour in women. Myomas may be seen in as many as 1 in every 5 women of childbearing age. Myomas usually affect women over 30. They are rare in women under 20 or in those who have gone through menopause. They are more common in African-Americans than Caucasians. The cause of uterine myoma tumours is unknown. However, myoma growth seems to depend on oestrogen. As long as a woman with myomas is menstruating, a myoma will probably continue to grow, usually slowly. Myomas can be so tiny that they can only be seen under a microscope. However, they can also grow very large. They may fill the entire uterus, and may weigh several pounds. Although it is possible for just one myoma to
develop, usually there is more than one. Clinical manifestations The main clinical manifestations are as follows: • Very heavy and prolonged menstrual periods, clots. • Pain in the back of the legs. • Pelvic pain or pressure. • Pain during sexual intercourse. • Pressure on the bladder with a frequent need to urinate, incontinence or the inability to empty the bladder. • Pressure on the bowel which can lead to constipation, bloating or feeling of fullness. • Bleeding between periods. • Sudden, severe pain due to a pedunculated myoma. However, most of the above symptoms and signs appear only when the myoma is large. In many cases, there are no symptoms and no pain. The treatment options for myomas are detailed in Table 67.1. Table 67.1 Treatment options for myomas
Complications A pedunculated myoma can become twisted and cause a kink in the blood vessels feeding the tumor. This type of myoma causes pain and may require surgery. A myoma sometimes blocks the fallopian tubes and prevents sperm from reaching and fertilizing eggs, which may cause fertility problems. In some cases, myomas may prevent a fertilized egg from implanting in the uterine lining. However, proper treatment may restore fertility. After a pregnancy develops, existing myomas may grow due to the increased blood flow and oestrogen levels. The myomas usually return to their original size after the baby is delivered. Most women are able to carry their babies to term, but some end up delivering prematurely because there is not enough room in the uterus. Some pregnant women with myomas may need a Caesarean section because myomas can occasionally block the birth canal or cause the baby to be positioned wrongly. Summary Complications of myomas
• A pedunculated myoma can become twisted which causes pain and may require surgery • Blockage of the Fallopian tubes may prevent sperm from reaching and fertilizing eggs • May prevent a fertilized egg from implanting in the uterine lining
• During pregnancy, myomas may grow and cause premature delivery • May need a Caesarean section if myomas block the birth canal
Chinese medicine view In Chinese medicine, myomas are a type of ‘Abdominal Masses’ (in women called Zheng Jia) which were discussed in Chapter 60. ‘Abdominal Masses’ are called Ji Ju. Ji indicates actual abdominal masses which are immovable; if there is an associated pain, its location is fixed. These masses are due to stasis of Blood. Ju indicates abdominal masses which come and go, do not have a fixed location and are movable; if there is an associated pain, it too comes and goes and changes location. Such masses are due to stagnation of Qi. Actual abdominal tumours therefore pertain to the category of Abdominal Masses and specifically Ji masses, i.e. Blood masses. Another name for ‘Abdominal Masses’ was Zheng Jia, Zheng being equivalent to Ji, i.e. actual, fixed masses and Jia to Ju, i.e. non-substantial masses from stagnation of Qi. Zheng Jia is normally used in referring to abdominal masses that generally occur only in women; but they do occur in men as well, though rarely. Aetiology
External Cold
External Cold is a frequent cause of abdominal masses in women. During puberty, after childbirth and during every period, the Uterus is particularly vulnerable to invasions of external Cold: external Cold generates internal Cold and this leads to Blood stasis. Blood stasis, in turn, may lead to the formation of masses. As discussed in Chapter 65, endometriosis may also be considered a form of abdominal masses and external Cold plays a role also in its aetiology. The formation of internal Cold from external Cold is also facilitated by the excessive consumption of cold, raw foods and especially cold, iced
drinks. Emotional stress
Emotional stress plays a role in the aetiology of myomas. Most emotions lead to stagnation of Qi (which may affect not only the Liver but also the Lungs and Heart). In time, Qi stagnation leads to Blood stasis and this to the formation of abdominal masses. The most common emotions that may lead to stagnation of Liver-Qi and eventually Liver-Blood stasis are anger, frustration, resentment, worry, guilt and fear. Irregular diet
By ‘irregular diet’ I mean two separate causes of disease. The first is the excessive consumption of fats, greasy, fried foods, sugar and dairy foods which leads to the formation of Phlegm. The other is eating irregularly, i.e. eating in a hurry, eating at one’s desk while working, eating late at night, etc. This irregularity of eating also leads to Phlegm, no matter what one eats. It is important to note that irregular eating may lead not only to Phlegm but also to Blood stasis especially when it is combined with emotional stress. Irregular eating initially leads to stagnation of Qi which, in time, may lead to Blood stasis. Although, as we shall discuss below, in myomas there is practically always Blood stasis, some may be due to a combination of Blood stasis with Phlegm. Excessive physical exercise
Excessive physical work or exercise can weaken the Spleen, Liver and Kidneys and adversely affect the Directing and Penetrating Vessels. This is
especially the case during puberty when these two vessels are in a state of change and not yet fully developed. Depending on the constitution of the girl, excessive physical work or exercise will either weaken these two vessels or cause stagnation in the lower abdomen. Excessive physical exercise includes physical work (such as by girls who are brought up on a farm), sports, running, weight-lifting and also ballet. Excessive physical work affects the Uterus more at its vulnerable times, i.e. during puberty, after childbirth and during every period. This cause of disease usually starts at a young age but its consequences may cause problems later in life. Overwork
By ‘overwork’ I mean not physical work but working long hours, leaving home early in the morning and returning late in the evening, working for long periods without rest, etc. This is a common cause of disease affecting especially women over 30. Summary Aetiology
• External Cold • Emotional stress • Irregular diet • Excessive physical exercise • Overwork
Pathology As always, one must differentiate between Root (Ben) and Manifestation (Biao) and between Emptiness and Fullness. The main aspect of the Manifestation in myomas is definitely Blood stasis. The Root leading to Blood stasis may be Empty or Full. The most common Empty type is Spleen- and Kidney-Yang deficiency: in every mass, there must be initially a deficiency of Upright Qi (Zheng Qi). In fact, if Upright Qi is normal and abundant, it circulates vigorously and prevents the formation of stagnation and therefore masses. However, the Root may also be of the Full type and Liver-Qi stagnation is an example of it. Liver-Qi stagnation (deriving from emotional problems and/or dietary irregularity) may lead to Blood stasis. Blood stasis in the Uterus may also frequently derive from Cold. Internal Cold (that develops from invasion of external Cold) is a Full condition: this is manifested by a Full-Tight pulse and a Pale tongue with thick, white coating, signs of Full-Cold. Internal Cold, however, may also arise from a deficiency of Spleen- and Kidney-Yang, in which case it is Empty-Cold. It should be noted that Empty-Cold may also develop from Full-Cold: this happens when the retention of Full-Cold injures Yang and this, in turn, leads to Empty-Cold. Thus the Full-Cold is transformed into EmptyCold (Fig. 67.2).
Figure 67.2 Full-Cold and Empty-Cold. Cold in the Uterus (whether Full or Empty) is a common cause of
Blood stasis in the pathology of myomas. Full-Cold is more commonly seen in young women (as in older women, Full-Cold will have a strong tendency to turn into Empty-Cold by depleting Yang). Apart from Blood stasis, some types of myomas may be due to a combination of Blood stasis with Phlegm: when this is the case, the myoma (if palpable) feels relatively softer than one from Blood stasis (Fig. 67.3). Figure 67.4 summarizes the pathology of myomas and highlights the interactions among the various aspects of the Root and Manifestation.
Figure 67.3 Root (Ben) and Manifestation (Biao) in myomas.
Figure 67.4 Pathology of myomas.
Summary Pathology
• Must differentiate between Root (Ben) and Manifestation (Biao) and between Emptiness and Fullness • The main aspect of the Manifestation in myomas is Blood stasis • The Root leading to Blood stasis may be Empty or Full • The most common Empty type is Spleen- and Kidney-Yang deficiency • Full types of Root may include Liver-Qi stagnation or Cold • Some types of myomas may be due to a combination of Blood stasis with Phlegm
Treatment principle Before discussing the treatment principle, it is important to discuss the question of Bian Bing, i.e. identifying the Chinese disease corresponding to myoma. Two investigations are usually carried out when diagnosing a patient. The first is Bian Bing i.e. identifying to which Chinese medicine ‘disease’ the patient’s disharmony pertains to. As one of the main symptoms of myoma is heavy menstrual bleeding, one of the Chinese diseases it may correspond to is Flooding and Trickling (Beng Lou) which was discussed in Chapter 17. If the myoma is palpable, then it would correspond to Abdominal Masses (Zheng Jia) (see Fig. 67.5).
Figure 67.5 Importance of Bian Bing (identifying the disease) in the treatment of myomas.
However, in order to identify the Chinese disease, we need to also take into account Western diagnostic tests: if a woman has heavy menstrual bleeding and she has a myoma, then the Bian Bing is Abdominal Masses (Zheng Jia), not Flooding and Trickling (Beng Lou). It would be a significant mistake to blindly treat a middle-aged woman complaining of heavy periods as a case of Flooding and Trickling without ascertaining whether she has a myoma or not. This elicits the question whether it is therefore legitimate to make an identification of Chinese disease (Bian Bing) on the basis of Western diagnostic tests. In other ! In order to identify the Chinese disease, we need to also take into account Western diagnostic tests: if a woman has heavy menstrual bleeding and she has a myoma, then the Bian Bing is Abdominal Masses (Zheng Jia), not Flooding and Trickling (Beng Lou). It would be a significant mistake to blindly treat a middle-aged woman complaining of heavy periods as a case of Flooding and Trickling without ascertaining whether she has a myoma or not. words, if a woman has a very small myoma that is not palpable, should we say that the Chinese disease is Abdominal Masses (Zheng Jia) even though
the myoma is not palpable? My opinion is – yes, it is legitimate to identify a Chinese disease on the basis of Western tests. Therefore I would treat a woman with a non-palpable myoma as a case of Abdominal Masses (with all its consequent treatment principles). However, there is an important caveat here: although I would treat a woman with non-palpable masses (whether it be a myoma or an ovarian cyst) as a case of Abdominal Masses, the identification of patterns (Bian Zheng) is still crucial to choose the appropriate treatment. In other words, even though a woman has a non-palpable mass, we should still make a careful analysis of Root and Manifestation and Emptiness versus Fullness and treat her accordingly. Just because a woman has an abdominal mass from Blood stasis (for example), that does not mean that we should go all out to vigorously ‘break Blood’. The following brief case history illustrates this principle. Case history A 35-year-old woman suffered from left-sided abdominal pain. She had been diagnosed as having an ovarian cyst on the left side. She had other symptoms of Dampness and Phlegm: it was therefore a clear case of abdominal mass from Damp-Phlegm. I therefore diagnosed the Chinese disease of Abdominal Masses and the pattern of Damp-Phlegm in the lower abdomen. I prescribed a variation of Si Miao San Four Wonderful Powder with the addition of herbs to resolve Phlegm (such as Dan Nan Xing Rhizoma Arisaematis preparatum and Ban Xia Rhizoma Pinelliae preparatum) and herbs that dissolve masses such as Ze Lan Herba Lycopi. After 3 months of treatment, she was not better. At that time, one of my Chinese teachers from Nanjing came to England and I asked him to look at my patient. He went through the usual questions but attached great important to the reaction of the abdominal pain to pressure (which I had overlooked): her pain was alleviated by pressure. This indicates a deficiency condition and he prescribed a different formula that primarily tonified the Spleen and only secondarily resolved Phlegm and
dissolved masses. This formula produced an immediate improvement in the symptoms and a disappearance of the cyst after 3 months. As far as treatment principle is concerned, my approach is to concentrate on the Biao and ‘attacking’ pathogenic factors, i.e. invigorate Blood, dissolve masses, resolve Phlegm (if present), soften masses. Summary Treatment principles
• The Bian Bing in myomas is Abdominal Masses (Zheng Jia), not Flooding and Trickling (Beng Lou) • Although a case of Abdominal Masses, in a myoma the identification of patterns (Bian Zheng) is still crucial to choose the appropriate treatment
Herbs and formulae A myoma is a mass from Blood stasis and therefore the treatment principle is to use herbs that ‘break’ Blood to dissolve masses. The main ones are E Zhu Rhizoma Curcumae, San Leng Rhizoma Sparganii and Ze Lan Herba Lycopi. Other ‘attacking’ herbs that dissolve masses include Ban Zhi Lian Herba Scutellariae barbatae, Shi Jian Chuan Radix Salviae chinensis and Shan Ci Gu Pseudobulbus Cremastrae. When dissolving masses (whether from Blood stasis or Phlegm), it is necessary to use herbs that soften masses. The following is a partial list of softening herbs: • Yi Yi Ren Semen Coicis
• Zhe Bei Mu Bulbus Fritillariae thunbergii • Hai Zao Sargassum • Kun Bu Thallus Eckloniae • Hai Dai Thallus Laminariae • Chuan Shan Jia Squama Manitis • Xia Ku Cao Spica Prunellae • Gui Ban Plastrum Testudinis • Mu Li Concha Ostreae • Bie Jia Carapax Tryonicis • Jiang Can Bombyx batrycatus • Wa Leng Zi Concha Arcae As can be observed, the softening herbs pertain to various different categories. Therefore they can be chosen according to the presenting pattern. For example, among the softening herbs, Zhe Bei Mu resolves Phlegm and it would therefore be best for a mass from Phlegm; Chuan Shan Jia invigorates Blood and would therefore be best for masses from Blood stasis. Before discussing treatment according to patterns, I shall list some of the commonly used formulae to dissolve masses from Blood stasis. All these formulae are specific for abdominal masses deriving from Blood stasis. – GUI ZHI FU LING WAN – Ramulus Cinnamomi-Poria Pill This is one of the main formulae to dissolve masses from Blood stasis. I nearly always use modifications of this formula to treat myomas. Common
modifications are as follows: • Dang Gui Radix Angelicae sinensis in every case. • E Zhu Rhizoma Curcumae and San Leng Rhizoma Sparganii to ‘break’ Blood. I always add these two herbs to treat myomas. • Yi Yi Ren Semen Coicis, Hai Zao Sargassum and Zhe Bei Mu Bulbus Fritillariae thunbergii to soften masses. • Xiang Fu Rhizoma Cyperi in case of Qi stagnation. • Da Huang Radix et Rhizoma Rhei to move downwards (thick, yellow tongue coating). • Ban Xia Rhizoma Pinelliae preparatum and Dan Nan Xing Rhizoma Arisaematis preparatum if there is Phlegm. • Xia Ku Cao Spica Prunellae and Pu Gong Ying Herba Taraxaci in case of Toxic-Heat. • Huang Qi Radix Astragali and Bai Zhu Rhizoma Atractylodis macrocephalae in case of Spleen deficiency. • Xu Duan Radix Dipsaci and Tu Si Zi Semen Cuscutae in case of Kidney-Yang deficiency. • Bie Jia Carapax Tryonicis and Sheng Di Huang Radix Rehmanniae in case of Yin deficiency. Gui Zhi Fu Ling Wan (with modifications) is one of the formulae of choice to treat myomas. One modification I would always apply is the addition of herbs that ‘break’ Blood such as E Zhu and San Leng. – DA HUANG BIE CHONG WAN
– Rheum-Eupolyphaga Pill This is a strong prescription with toxic insects. I would personally use this formula very rarely. The use of animal products is illegal in the European Union. – TAO REN SAN (From Beneficial Formulae for Women Fu Ren Liang Fang, 1237, by Chen Zi Ming) – Persica Powder This formula strongly invigorates Blood: it contains animal and mineral ingredients, some of which are toxic (such as Nao Sha). – TAO REN WAN – Persica Pill Tao Ren Wan is another strong formula to ‘break’ Blood. It contains the insect Meng Chong which is toxic. – CHUAN SHAN JIA SAN – Squama Manitis Powder Chuan Shan Jia strongly invigorates and ‘breaks’ Blood: it has some toxic ingredients such as Gan Qi (lacquer) and She Xiang (musk). – E ZHU SAN – Curcuma Powder E Zhu San breaks Blood and it does not have toxic ingredients. There is also emphasis on softening masses. – XIANG LENG WAN – Aucklandia-Sparganium Pill Xiang Leng Wan invigorates Blood, ‘breaks’ Blood and moves Qi. It is indicated for cases where Blood stasis derives from Qi stagnation.
– GONG ZHENG TANG – Attacking Upright Decoction Gong Zheng Tang has the same actions as the previous formula, i.e. to move Qi, invigorate Blood and ‘break’ Blood. Compared to the previous formula, it has a stronger action in softening masses. – DA QI QI TANG – Big Seven Qi Decoction Da Qi Qi Tang moves Qi, expels Cold, invigorates and ‘breaks’ Blood. It is indicated when the Blood stasis derives from Qi stagnation and Cold. – XIAO LIU FANG – Dissolving and Flowing Formula Xiao Liu Fang moves Qi, invigorates and breaks Blood and softens masses.
Identification of patterns and treatment The patterns discussed are: • Blood stasis from Qi stagnation • Blood stasis from Cold • Blood stasis with Phlegm • Blood stasis with Qi and Blood deficiency • Blood stasis with Kidney-Yang deficiency.
Blood stasis from Qi stagnation
Clinical manifestations Myoma that feels hard on palpation, painful period with dark menstrual blood and clots, abdominal distension, irregular periods, pre-menstrual tension, irritability. Tongue: Purple in general or Purple sides. Pulse: Wiry. Treatment principle Move Qi, invigorate and ‘break’ Blood, soften masses. Acupuncture SP-4 Gongsun (on the right) with P-6 Neiguan (on the left) (Penetrating Vessel, Chong Mai), SP-10 Xuehai, LIV-3 Taichong, KI-14 Siman, SP-6 Sanyinjiao, G.B.-13 Benshen, Du-24 Shenting. Reducing or even method. Explanation
– SP-4 and P-6 regulate the Penetrating Vessel and invigorate Blood. – SP-10, LIV-3, KI-14 and SP-6 invigorate Blood and move Qi. – G.B.-13 and Du-24 calm the Mind and settle the Ethereal Soul, especially in Liver patterns. Herbal treatment
Prescription
– GUI ZHI FU LING WAN Variation – Ramulus Cinnamomi-Poria Pill Variation Summary Blood stasis from Qi stagnation
Clinical manifestations
Myoma that feels hard on palpation, painful period with dark menstrual blood and clots, abdominal distension, irregular periods, pre-menstrual tension, irritability. Tongue: Purple in general or Purple sides. Pulse: Wiry. Treatment principle
Move Qi, invigorate and ‘break’ Blood, soften masses. Acupuncture
SP-4 Gongsun (on the right) with P-6 Neiguan (on the left) (Penetrating Vessel, Chong Mai), SP-10 Xuehai, LIV-3 Taichong, KI-14 Siman, SP-6 Sanyinjiao, G.B.-13 Benshen, Du-24 Shenting. Reducing or even method. Herbal treatment
Pre scription
• GUI ZHI FU LING WAN Variation Ramulus Cinnamomi-Poria Pill Variation
Blood stasis from Cold
Clinical manifestations Hard myomas, painful periods with crampy, spastic pain and desire for hot water bottle, menstrual blood bright red but with small, stringy, dark clots, feeling cold (or colder) during the period, late cycle. Tongue: Pale-Bluish or Bluish-Purple. Pulse: Tight or Wiry. Treatment principle Invigorate and ‘break’ Blood, expel Cold from the Uterus, soften masses. Acupuncture LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left) (Directing Vessel, Ren Mai), Ren-3 Zhongji, Zigong (3 cun from Ren-3), KI-14 Siman, SP-10 Xuehai, LIV-3 Taichong. Reducing or even method, moxa on Ren-3 and Zigong. Explanation
– LU-7 and KI-6 regulate the Directing Vessel and treat masses in women. – Ren-3 and Zigong (with moxa) expel Cold from the Uterus. – KI-14, SP-10 and LIV-3 invigorate Blood. Herbal treatment
Prescription
– GUI ZHI FU LING WAN Variation – Ramulus Cinnamomi-Poria Pill Variation Summary Blood stasis from Cold
Clinical manifestations
Hard myomas, painful periods with crampy, spastic pain and desire for hot water bottle, menstrual blood bright red but with small, stringy, dark clots, feeling cold (or colder) during the period, late cycle. Tongue: Pale-Bluish or Bluish-Purple. Pulse: Tight or Wiry. Treatment principle
Invigorate and ‘break’ Blood, expel Cold from the Uterus, soften masses. Acupuncture
LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left) (Directing Vessel, Ren Mai), Ren-3 Zhongji, Zigong (3 cun from Ren-3), KI-14 Siman, SP-10 Xuehai, LIV-3 Taichong. Reducing or even method, moxa on Ren-3 and Zigong. Herbal treatment
Pre scription
• GUI ZHI FU LING WAN Variation Ramulus Cinnamomi-Poria Pill Variation
Blood stasis with Phlegm
Clinical manifestations Relatively soft myoma, often single, feeling of heaviness of the abdomen, vaginal discharge, obesity, painful periods. Tongue: Purple all over or Purple sides, Swollen. Pulse: Slippery-Wiry. Treatment principle Invigorate and ‘break’ Blood, resolve Phlegm, move Qi. Acupuncture LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left) (Directing Vessel, Ren Mai), Ren-3 Zhongji, KI-14 Siman, SP-10 Xuehai, LIV-3 Taichong, ST-28 Shuidao, Ren-5 Shimen, BL-22 Sanjiaoshu, SP-6 Sanyinjiao, ST-40 Fenglong, Ren-9 Shuifen. Reducing or even method. Explanation
– LU-7 and KI-6 regulate the Directing Vessel and help to resolve Phlegm. – Ren-3, KI-14, SP-10 and LIV-3 invigorate Blood in the Uterus. – ST-28, Ren-5, BL-22, SP-6 and ST-40 resolve Phlegm from the Lower Burner. – Ren-9 helps to resolve Phlegm in general.
Herbal treatment
a Prescription
– QI GONG WAN Variation – Arousing the Uterus Pill Variation b Prescription
– GUI ZHI FU LING WAN Variation – Ramulus Cinnamomi-Poria Pill Variation Summary Blood stasis with Phlegm
Clinical manifestations
Relatively soft myoma, often single, feeling of heaviness of the abdomen, vaginal discharge, obesity, painful periods. Tongue: Purple all over or Purple sides, Swollen. Pulse: Slippery-Wiry. Treatment principle
Invigorate and ‘break’ Blood, resolve Phlegm, move Qi.
Acupuncture
LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left) (Directing Vessel, Ren Mai), Ren-3 Zhongji, KI-14 Siman, SP-10 Xuehai, LIV-3 Taichong, ST-28 Shuidao, Ren-5 Shimen, BL-22 Sanjiaoshu, SP-6 Sanyinjiao, ST-40 Fenglong, Ren-9 Shuifen. Reducing or even method. Herbal treatment
Pre scriptions
• QI GONG WAN Variation Arousing the Uterus Pill Variation • GUI ZHI FU LING WAN Variation Ramulus Cinnamomi-Poria Pill Variation
Blood stasis with Qi and Blood deficiency
Clinical manifestations Chronic, multiple, small, hard myomas, painful and heavy periods, irregular periods, tiredness, blurred vision, dizziness. Tongue: Pale with Purple sides. Pulse: Weak-Choppy. Treatment principle Invigorate and ‘break’ Blood, tonify Qi and Blood. Acupuncture LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left) (Directing Vessel, Ren Mai), Ren-3 Zhongji, KI-14 Siman, SP-10 Xuehai, LIV-3 Taichong, BL-20 Pishu, BL-23 Shenshu, Ren-4 Guanyuan, SP-6 Sanyinjiao, ST-36 Zusanli, KI-3 Taixi. LU-7 and KI-6 with even method; Ren-3, KI-14, SP10 and LIV-3 with reducing or even method; the other points with reinforcing method. Explanation
– LU-7 and KI-6 regulate the Directing Vessel. – Ren-3, KI-14, SP-10 and LIV-3 invigorate Blood. – BL-20, BL-23, Ren-4, SP-6, ST-36 and KI-3 tonify Qi and Blood and strengthen Spleen, Liver and Kidneys.
Herbal treatment
Prescription
– GUI ZHI FU LING WAN Variation – Ramulus Cinnamomi-Poria Pill Variation Summary Blood stasis with Qi and Blood deficiency
Clinical manifestations
Chronic, multiple, small, hard myomas, painful and heavy periods, irregular periods, tiredness, blurred vision, dizziness. Tongue: Pale with Purple sides. Pulse: Weak-Choppy. Treatment principle
Invigorate and ‘break’ Blood, tonify Qi and Blood. Acupuncture
LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left) (Directing Vessel, Ren Mai), Ren-3 Zhongji, KI-14 Siman, SP-10 Xuehai, LIV-3 Taichong, BL-20 Pishu, BL-23 Shenshu, Ren-4 Guanyuan, SP-6 Sanyinjiao, ST-36 Zusanli, KI-3 Taixi. LU-7 and KI-6 with even method; Ren-3, KI-14, SP-
10 and LIV-3 with reducing or even method; the other points with reinforcing method. Herbal treatment
Pre scription
• GUI ZHI FU LING WAN Variation Ramulus Cinnamomi-Poria Pill Variation
Blood stasis with Kidney-Yang deficiency
Clinical manifestations Chronic, multiple, hard myomas, heavy periods, tiredness, backache, frequent urination, feeling cold, cold limbs, dizziness, tinnitus. Tongue: Pale with slightly Bluish sides. Pulse: Weak-Choppy. Treatment principle Invigorate and ‘break’ Blood, tonify Yang, strengthen the Kidneys. Acupuncture LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left) (Directing Vessel, Ren Mai), Ren-3 Zhongji, KI-14 Siman, SP-10 Xuehai, LIV-3 Taichong, BL-23 Shenshu, Ren-4 Guanyuan, KI-3 Taixi. LU-7 and KI-6 with even method; Ren-3, KI-14, SP-10 and LIV-3 with reducing or even method; BL-23, Ren-4 and KI-3 with reinforcing method and moxa. Explanation
– LU-7 and KI-6 regulate the Directing Vessel. – Ren-3, KI-14, SP-10 and LIV-3 invigorate Blood. – BL-23, Ren-4 and KI-3 strengthen the Kidneys. Herbal treatment
Prescription
– GUI ZHI FU LING WAN Variation – Ramulus Cinnamomi-Poria Pill Variation Summary Blood stasis with Kidney-Yang deficiency
Clinical manifestations
Chronic, multiple, hard myomas, heavy periods, tiredness, backache, frequent urination, feeling cold, cold limbs, dizziness, tinnitus. Tongue: Pale with slightly Bluish sides. Pulse: Weak-Choppy. Treatment principle
Invigorate and ‘break’ Blood, tonify Yang, strengthen the Kidneys. Acupuncture
LU-7 Lieque (on the right) with KI-6 Zhaohai (on the left) (Directing Vessel, Ren Mai), Ren-3 Zhongji, KI-14 Siman, SP-10 Xuehai, LIV-3 Taichong, BL-23 Shenshu, Ren-4 Guanyuan, KI-3 Taixi. LU-7 and KI-6 with even method; Ren-3, KI-14, SP-10 and LIV-3 with reducing or even method; BL-23, Ren-4 and KI-3 with reinforcing method and moxa. Herbal treatment
Pre scription
• GUI ZHI FU LING WAN Variation Ramulus Cinnamomi-Poria Pill Variation
Modern chinese literature
Hu Zhen Xia, Chen Zuo Lin 1996 Thirty cases of uterine myoma treated primarily by acupuncture, Journal of Chinese Medicine (Zhong Yi Za Zhi
) 51: 15
Thirty women with myoma ranging from 1.3 × 1.4 × 1.8 cm to 8.1 × 10.5 × 9 cm were treated with acupuncture. The outcome criteria were as follows: • Cure: disappearance of myoma. • Significantly effective: myoma reduced by more than 1.5 cm. • Effective: myoma reduced by up to 1.5 cm. • Ineffective: myoma not reduced or reduced by less than 0.3 cm. The results are reported in Table 67.2. Table 67.2 Result outcomes from Chinese clinical trial
Hao Ning 1996 Xu Shou Tian’s experience in the treatment of myoma, Journal of Chinese Medicine (Zhong Yi Za Zhi
) 51: 32
The author reports five treatment principles that can be adopted in the treatment of myomas: 1. Invigorate Blood and pacify the Liver (for Liver-Blood stasis and Qi stagnation). 2. Invigorate the Blood and clear the Uterus (for Liver-Blood stasis and Damp-Heat in the Uterus). 3. Invigorate Blood and tonify the Spleen (for Blood stasis and Spleen-Qi deficiency). 4. Invigorate Blood and strengthen the Kidneys (for Blood stasis and
Kidney deficiency). 5. Invigorate Blood and resolve Phlegm (Blood stasis and Damp- Phlegm in Uterus).
Clinical trials
Herbal treatment
A comparative study of the usefulness of Tokishakuyakusan (Dang Gui Shao Yao San) and an oral iron preparation in the treatment of hypochromic anaemia in cases of uterine myoma
– Yakugaku Zasshi, Journal of the Pharmaceutical Society of Japan 2003 123(9): 817–824. – Akase T, Akase T, Onodera S, Jobo T, Matsushita R, Kaneko M, Tashiro S. – Department of Clinical and Biomedical Sciences, Showa Pharmaceutical University, Higashi-Tamagawa-Gakuen, Machida, Tokyo, Japan. Objective
To ascertain the effectiveness of the Japanese medicine Tokishakuyakusan (Dang Gui Shao Yao San Angelica-Peonia Powder) and an oral iron preparation in the treatment of hypochromic anaemia in cases of uterine myoma. Methods
This prospective study involved 25 patients who were diagnosed as having hypochromic mild to moderate anaemia associated with menorrhagia attributable to uterine myoma. They were divided into the Tokishakuyakusan group (TSS; n = 10) and the oral iron group (OI; n = 15). Blood counts were monitored along with subjective symptoms, and the occurrence of side
effects after oral administration of either preparation at 4 and 8 weeks from baseline. Results
With regard to the blood counts and improvements of the laboratory parameters of anaemia, while marked improvement was observed in the OI group, no significant improvement was noted in the TSS group. However, in terms of improvement of the signs and symptoms of anaemia, such as facial pallor, spoon-shaped nails and dizziness, the TSS group also showed significant improvement. In addition, in the TSS group, resolution of symptoms such as hypermenorrhoea, dysmenorrhoea, feeling cold, dizziness, headache and shoulder stiffness was also noted. While side effects were encountered in 80% of patients in the OI group, no significant side effects were observed in the TSS group. Conclusion
From these findings, it is considered that TSS may be useful for resolving the symptoms of mild or moderate anaemia associated with uterine myoma.
APPENDIX 1 Herbal Prescriptions – AI FU NUAN GONG WAN – Artemisia-Cyperus Warming the Uterus Pill • Ai Ye Folium Artemisiae argyi 9 g • Wu Zhu Yu Fructus Evodiae 4.5 g • Rou Gui Cortex Cinnamomi 4.5 g • Xiang Fu Rhizoma Cyperi 9 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Bai Shao Radix Paeoniae alba 6 g • Huang Qi Radix Astragali 6 g • Sheng Di Huang Radix Rehmanniae 9 g • Xu Duan Radix Dipsaci 6 g – AN CHONG TANG – Calming the Penetrating Vessel Decoction • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Huang Qi Radix Astragali 9 g
• Long Gu Fossilia Ossis mastodi 12 g • Mu Li Concha Ostreae 12 g • Sheng Di Huang Radix Rehmanniae 6 g • Bai Shao Radix Paeoniae alba 6 g • Wu Zie Gu Endoconcha Sepiae 6 g • Qian Cao Gen Radix Rubiae 6 g • Xu Duan Radix Dipsaci 6 g – AN DIAN ER TIAN TANG – Calming and Settling the Two Heavens Decoction • Ren Shen Radix Ginseng 30 g • Shu Di Huang Radix Rehmanniae preparata 30 g • Bai Zhu Rhizoma Atractylodis macrocephalae 30 g • Shan Yao Rhizoma Dioscoreae 15 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Shan Zhu Yu Fructus Corni 15 g • Du Zhong Cortex Eucommiae 9 g • Gou Qi Zi Fructus Lycii 6 g • Bian Dou Semen Lablab album 15 g – AN TAI YIN – Calming the Fetus Decoction
• Huang Qi Radix Astragali 9 g • Tai Zi Shen Radix Pseudostellariae 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Dang Gui Radix Angelicae sinensis 4 g • Sheng Di Huang Radix Rehmanniae 6 g • Bai Shao Radix Paeoniae alba 6 g • Sang Ji Sheng Herba Taxilli 6 g • Du Zhong Cortex Eucommiae 6 g • Tu Si Zi Semen Cuscutae 6 g • Huang Qin Radix Scutellariae 6 g • Zhu Ma Gen Radix Boehmeriae 6 g – AN XIN TANG – Calming the Heart Decoction • Dang Gui Radix Angelicae sinensis 60 g • Chuan Xiong Rhizoma Chuanxiong 30 g • Sheng Di Huang Radix Rehmanniae 15 g • Mu Dan Pi Cortex Moutan 15 g • Pu Huang Pollen Typhae 6 g • He Ye Folium Nelumbinis 1 leaf – BA WEI DI HUANG WAN (or ZHI BO DI HUANG WAN)
– Eight-Ingredient Rehmannia Pill (Anemarrhena-Phellodendron-Rehmannia Pill) • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Ze Xie Rhizoma Alismatis 9 g • Fu Ling Poria 9 g • Mu Dan Pi Cortex Moutan 9 g • Zhi Mu Rhizoma Anemarrhenae 9 g • Huang Bo Cortex Phellodendri 9 g – BA WU TANG – Eight Substances Decoction • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Bai Shao Radix Paeoniae alba 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Yan Hu Suo Rhizoma Corydalis 6 g • Chuan Lian Zi Fructus Toosendan 4.5 g • Mu Xiang Radix Aucklandiae 3 g • Bing Lang Semen Arecae 6 g – BA WU TANG Variation (Chapter 21, Oedema During Periods, Stagnation of
Qi) – Eight Substances Decoction Variation • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Bai Shao Radix Paeoniae alba 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Yan Hu Suo Rhizoma Corydalis 6 g • Chuan Lian Zi Fructus Toosendan 4.5 g • Mu Xiang Radix Aucklandiae 3 g • Bing Lang Semen Arecae 6 g • Xiang Fu Rhizoma Cyperi 6 g • Fu Ling Pi Cutis Poriae 6 g – BA ZHEN TANG – Eight Precious Decoction • Dang Gui Radix Angelicae sinensis 10 g • Chuan Xiong Rhizoma Chuanxiong 5 g • Bai Shao Radix Paeoniae alba 8 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 10 g
• Fu Ling Poria 8 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g – BA ZHEN TANG Variation (Chapter 16, No Periods, Blood deficiency) – Eight Precious Decoction Variation • Dang Gui Radix Angelicae sinensis 10 g • Chuan Xiong Rhizoma Chuanxiong 4 g • Chi Shao Radix Paeoniae rubra 4 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Dang Shen Radix Codonopsis 10 g • Fu Ling Poria 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Tu Si Zi Semen Cuscutae 6 g • Sang Ji Sheng Ramulus Sangjisheng 4 g • Gou Qi Zi Fructus Lycii 6 g • Xiang Fu Rhizoma Cyperi 4 g – BA ZHEN TANG Variation (Chapter 16, No Periods, Spleen- and Kidney-Yang deficiency) – Eight Precious Decoction Variation • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Chi Shao Radix Paeoniae rubra 4.5 g
• Shu Di Huang Radix Rehmanniae preparata 9 g • Yin Yang Huo Herba Epimedii 6 g • Tu Si Zi Semen Cuscutae 6 g • Fu Pen Zi Fructus Rubi 6 g • Sang Ji Sheng Herba Taxilli 6 g • Huang Qi Radix Astragali 6 g • Dang Shen Radix Codonopsis 6 g • Xiang Fu Rhizoma Cyperi 6 g – BA ZHEN TANG Variation (Chapter 20, Headaches during Periods, Blood deficiency) – Eight Precious Decoction Variation • Dang Gui Radix Angelicae sinensis 10 g • Chuan Xiong Rhizoma Chuanxiong 5 g • Bai Shao Radix Paeoniae alba 8 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 10 g • Fu Ling Poria 8 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Gou Qi Zi Fructus Lycii 6 g • Shou Wu Radix Polygoni multiflori preparata 6 g
• Ju Hua Flos Chrysanthemi 3 g • Gou Teng Ramulus Uncariae cum Uncis 4 g – BA ZHEN TANG Variation (Chapter 23, Body Aches at Period Time, Blood deficiency) – Eight Precious Decoction Variation • Dang Gui Radix Angelicae sinensis 10 g • Chuan Xiong Rhizoma Chuanxiong 5 g • Bai Shao Radix Paeoniae alba 8 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 10 g • Fu Ling Poria 8 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Ji Xue Teng Caulis Spatholobi 6 g • Wu Jia Pi Cortex Acanthopanacis 6 g • Sang Ji Sheng Herba Taxilli 6 g – BA ZHEN TANG Variation (Chapter 28, Dizziness at Period Time, Blood deficiency) – Eight Precious Decoction Variation • Dang Gui Radix Angelicae sinensis 10 g • Chuan Xiong Rhizoma Chuanxiong 5 g
• Bai Shao Radix Paeoniae alba 8 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 10 g • Fu Ling Poria 8 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Shou Wu Radix Polygoni multiflori preparata 6 g • Gou Qi Zi Fructus Lycii 6 g – BA ZHEN TANG Variation (Chapter 51, Fever after Childbirth, Blood deficiency) – Eight Precious Decoction Variation • Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 8 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 10 g • Fu Ling Poria 8 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Huang Qi Radix Astragali 6 g – BA ZHEN YI MU TANG – Eight Precious Leonorus Decoction
• Dang Gui Radix Angelicae sinensis 10 g • Chuan Xiong Rhizoma Chuanxiong 5 g • Bai Shao Radix Paeoniae alba 8 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 10 g • Fu Ling Poria 8 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Yi Mu Cao Herba Leonuri 9 g – BA ZHEN YI MU TANG Variation (Chapter 57, Infertility, Kidney-Yang deficiency) – Leonorus Eight Precious Decoction Variation • Dang Gui Radix Angelicae sinensis 10 g • Chuan Xiong Rhizoma Chuanxiong 5 g • Bai Shao Radix Paeoniae alba 8 g • Shu Di Huang Radix Rehmannia preparata 15 g • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 10 g • Fu Ling Poria 8 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Yi Mu Cao Herba Leonuri 9 g
• Xiang Fu Rhizoma Cyperi 4.5 g • Hong Hua Flos Carthami 4.5 g • Fu Pen Zi Fructus Rubi 6 g • Yin Yang Huo Herba Epimedii 6 g – BA ZHENG TANG – Eight Corrections Powder • Bian Xu Herba Polygoni avicularis 6 g • Che Qian Zi Semen Plantaginis 9 g • Qu Mai Herba Dianthi 6 g • Mu Tong Caulis Akebiae 6 g • Hua Shi Talcum 9 g • Da Huang Radix et Rhizoma Rhei 6 g • Zhi Zi Fructus Gardeniae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 6 g – BA ZHENG TANG Variation (Chapter 15, Bleeding between Periods, DampHeat) – Eight Corrections Powder Variation • Bian Xu Herba Polygoni avicularis 6 g • Che Qian Zi Semen Plantaginis 9 g • Qu Mai Herba Dianthi 6 g
• Mu Tong Caulis Akebiae 6 g • Hua Shi Talcum 9 g • Zhi Zi Fructus Gardeniae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Bai Mao Gen Rhizoma Imperatae 6 g • Qian Cao Gen Radix Rubiae 6 g – BAI HE GU JIN TANG – Lilium Consolidating Metal Decoction • Bai He Bulbus Lilii 15 g • Mai Men Dong Radix Ophiopogonis 9 g • Xuan Shen Radix Scrophulariae 9 g • Sheng Di Huang Radix Rehmanniae 9 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 9 g • Jie Geng Radix Platycodi 6 g • Chuan Bei Mu Bulbus Fritillariae cirrhosae 6 g • Gan Cao Radix Glycyrrhizae 3 g – BAI ZHU SAN (from Formulary Illustrating the Way to Good Health, Quan Sheng Zhi Mi Fang)
– Atractylodes Powder • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Fu Ling Pi Sclerotium Poriae pararadicis 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Da Fu Pi Pericarpium Arecae 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices – BAI ZHU SAN Variation (Chapter 35, Dizziness during Pregnancy, Spleen deficiency with Liver-Yang rising and Phlegm) – Atractylodes Powder Variation • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Fu Ling Pi Cutis Poriae 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Da Fu Pi Pericarpium Arecae 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Gou Teng Ramulus Uncariae cum Uncis 6 g • Shi Jue Ming Concha Haliotidis 6 g – BAI ZI REN WAN – Platycladi Pill (from Effective Prescriptions for Women, Fu Ren Liang Fang, 1237) • Bai Zi Ren Semen Platycladi 15 g • Chuan Niu Xi Radix Cyathulae 15 g
• Juan Bai Herba Selaginellae 15 g • Ze Lan Herba Lycopi 30 g – BAI ZI REN WAN – Platycladi Pill (from Complete Works of Jing Yue, Jing Yue Quan Shu, 1624) • Bai Zi Ren Semen Platycladi 15 g • Chuan Niu Xi Radix Cyathulae 15 g • Juan Bai Herba Selaginellae 15 g • Ze Lan Herba Lycopi 60 g • Xu Duan Radix Dipsaci 60 g • Shu Di Huang Radix Rehmanniae preparata 90 g – BAI ZI YANG XIN WAN – Platycladi Nourishing the Heart Pill • Bai Zi Ren Semen Platycladi 120 g • Fu Shen Sclerotium Poriae pararadicis 30 g • Gou Qi Zi Fructus Lycii 90 g • Shu Di Huang Radix Rehmanniae preparata 60 g • Dang Gui Radix Angelicae sinensis 30 g • Xuan Shen Radix Scrophulariae 60 g • Mai Men Dong Radix Ophiopogonis 30 g • Shi Chang Pu Rhizoma Acori tatarinowii 30 g
• Gan Cao Radix Glycyrrhizae 15 g – BAN XIA BAI ZHU TIAN MA TANG – Pinellia-Atractylodes-Gastrodia Decoction • Ban Xia Rhizoma Pinelliae preparatum 9 g • Tian Ma Rhizoma Gastrodiae 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 15 g • Fu Ling Poria 6 g • Chen Pi Pericarpium Citri reticulatae 6 g • Gan Cao Radix Glycyrrhizae 4 g • Sheng Jiang Rhizoma Zingiberis recens 1 slice • Da Zao Fructus jujubae 2 pieces – BAN XIA HOU PO TANG – Pinellia-Magnolia Decoction • Ban Xia Rhizoma Pinelliae preparatum 12 g • Hou Po Cortex Magnoliae officinalis 9 g • Zi Su Ye Folium Perillae 6 g • Fu Ling Poria 12 g • Sheng Jiang Rhizoma Zingiberis recens 9 g – BAN XIA HOU PO TANG Variation (Chapter 18, Pre-Menstrual Syndrome, Lung-Qi stagnation with Phlegm) – Pinellia-Magnolia Decoction Variation
• Ban Xia Rhizoma Pinelliae preparatum 12 g • Hou Po Cortex Magnoliae officinalis 9 g • Zi Su Ye Folium Perillae 6 g • Fu Ling Poria 12 g • Bai He Bulbus Lilii 6 g • Chen Pi Pericarpium Citri reticulatae 4.5 g • Gua Lou Fructus Trichosanthis 6 g • He Huan Pi Cortex Albiziae 6 g • Sheng Jiang Rhizoma Zingiberis recens 9 g – BAN XIA HOU PO TANG Variation (Chapter 19, Pre-Menstrual Breast Distension, Lung-Qi stagnation) – Pinellia-Magnolia Decoction Variation • Ban Xia Rhizoma Pinelliae preparatum 12 g • Hou Po Cortex Magnoliae officinalis 9 g • Zi Su Ye Folium Perillae 6 g • Fu Ling Poria 12 g • Bai He Bulbus Lilii 6 g • He Huan Pi Cortex Albiziae 6 g • Qing Pi Pericarpium Citri reticulatae viride 4.5 g • Sheng Jiang Rhizoma Zingiberis recens 9 g – BAN XIA HOU PO TANG Variation (Chapter 59, Breast Lumps, Prevention,
Stagnation of Lung-Qi from emotional problems) – Pinellia-Magnolia Decoction Variation • Ban Xia Rhizoma Pinelliae preparatum 12 g • Hou Po Cortex Magnoliae officinalis 9 g • Zi Su Ye Folium Perillae 6 g • Fu Ling Poria 12 g • Sheng Jiang Rhizoma Zingiberis recens 9 g • Bai He Bulbus Lilii 6 g • Yu Jin Radix Curcumae 6 g • Yuan Zhi Radix Polygalae 6 g – BAN XIA TANG (from Spiritual Axis) – Pinellia Decoction • Ban Xia Rhizoma Pinelliae preparatum 10 g • Shu Mi Husked sorghum 10 g – BAN XIA TANG (from Thousand Golden Ducats Prescriptions) – Pinellia Decoction • Ban Xia Rhizoma Pinelliae preparatum 10 g • Rou Gui Cortex Cinnamomi 3 g • Gan Jiang Rhizoma Zingiberis 3 g • Gan Cao Radix Glycyrrhizae 3 g
• Ren Shen Radix Ginseng 6 g • Xi Xin Herba Asari 1.5 g • Fu Zi Radix Aconiti lateralis preparata 3 g • Chuan Jiao Pericarpium Zanthoxyli 3 g – BAN XIA TANG (from Secret Prescriptions of a Frontier Official) – Pinellia Decoction • Ban Xia Rhizoma Pinelliae preparatum 10 g • Sheng Jiang Rhizoma Zingiberis recens 6 g • Jie Geng Radix Platycodi 3 g • Wu Zhu Yu Fructus Evodiae 3 g • Qian Hu Radix Peucedani 6 g • Bie Jia Carapax Trionycis 6 g • Zhi Shi Fructus Aurantii immaturus 6 g • Ren Shen Radix Ginseng 6 g • Bing Lang Semen Arecae 14 nuts – BAO CHAN WU YOU SAN – Protecting Labour Worry-Free Powder • Dang Gui Radix Angelicae sinensis 4.5 g • Bai Shao Radix Paeoniae alba 3.6 g • Hou Po Cortex Magnoliae officinalis 2.1 g
• Tu Si Zi Semen Cuscutae 3 g • Zhi Ke Fructus Aurantii 1.8 g • Ai Ye Folium Artemisiae argyi 2.1 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Huang Qi Radix Astragali 2.4 g • Qiang Huo Rhizoma seu Radix Notopterygii 1.5 g • Chuan Bei Mu Bulbus Fritillariae cirrhosae 3 g • Jing Jie Herba Schizonepetae 2.4 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices – BAO HE WAN – Preserving and Harmonizing Pill • Shan Zha Fructus Crataegi 9 g • Shen Qu Massa medicata fermentata 6 g • Lai Fu Zi Semen Raphani 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Chen Pi Pericarpum Citri reticulatae 3 g • Fu Ling Poria 6 g • Lian Qiao Fructus Forsythiae 6 g – BAO SHENG TANG – Preserving Life Decoction
• Ren Shen Radix Ginseng 7.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 7.5 g • Bai Zhu Rhizoma Atractylodis macrocephalae 15 g • Xiang Fu Rhizoma Cyperi 15 g • Wu Yao Radix Linderae 15 g • Chen Pi Pericarpium Citri reticulatae 3 g – BAO SHENG WU YOU SAN – No-Worry Protecting Birth Powder • Dang Gui Radix Angelicae sinensis 9 g • Zhi Ke Fructus Aurantii 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Mu Xiang Radix Aucklandiae 3 g • Bai Shao Radix Paeoniae alba 6 g • Ru Xiang Olibanum 6 g • Xian He Cao Herba Agrimoniae 3 g • Gan Cao Radix Glycyrrhizae 3 g – BAO TAI AN – Protecting the Fetus’s Peace • Dang Shen Radix Codonopsis 9 g • Huang Qi Radix Astragali 6 g
• Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Dang Gui Radix Angelicae sinensis 4 g • Bai Shao Radix Paeoniae alba 9 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Ai Ye Folium Artemisiae argyi 6 g – BAO YIN JIAN – Protecting Yin Decoction • Sheng Di Huang Radix Rehmanniae 24 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Bai Shao Radix Paeoniae alba 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Huang Qin Radix Scutellariae 9 g • Huang Bo Cortex Phellodendri 9 g • Xu Duan Radix Dipsaci 6 g • Gan Cao Radix Glycyrrhizae 3 g – BAO YIN JIAN Variation (Chapter 11, Heavy Periods, Blood-Heat) – Protecting Yin Decoction Variation • Sheng Di Huang Radix Rehmanniae 24 g
• Shu Di Huang Radix Rehmanniae preparata 15 g • Bai Shao Radix Paeoniae alba 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Huang Qin Radix Scutellariae 9 g • Huang Bo Cortex Phellodendri 9 g • Xu Duan Radix Dipsaci 6 g • Gan Cao Radix Glycyrrhizae 3 g • Di Yu Radix Sanguisorbae 6 g • Huai Hua Flos Sophorae immaturus 6 g – BAO YIN JIAN Variation (Chapter 13, Long Periods, Blood-Heat) – Protecting Yin Decoction Variation • Sheng Di Huang Radix Rehmanniae 24 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Bai Shao Radix Paeoniae alba 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Huang Qin Radix Scutellariae 9 g • Huang Bo Cortex Phellodendri 9 g • Xu Duan Radix Dipsaci 6 g • Gan Cao Radix Glycyrrhizae 3 g • Di Yu Radix Sanguisorbae 6 g
• Huai Hua Flos Sohphorae immaturus 6 g – BAO YIN JIAN Variation (Chapter 17, Flooding and Trickling, Blood EmptyHeat) – Protecting Yin Decoction Variation • Sheng Di Huang Radix Rehmanniae 24 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Bai Shao Radix Paeoniae alba 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Huang Qin Radix Scutellariae 9 g • Huang Bo Cortex Phellodendri 9 g • Xu Duan Radix Dipsaci 6 g • Gan Cao Radix Glycyrrhizae 3 g • Han Lian Cao Herba Ecliptae 9 g • Qing Hao Herba Artemisiae annuae 6 g • Di Yu Radix Sanguisorbae 9 g • Qian Cao Gen Radix Rubiae 6 g – BAO YIN JIAN Variation (Chapter 17, Flooding and Trickling, Complex patterns, Empty with Empty, Qi and Yin deficiency) – Protecting Yin Decoction Variation • Sheng Di Huang Radix Rehmanniae 24 g • Shu Di Huang Radix Rehmanniae preparata 6 g
• Shan Yao Rhizoma Dioscoreae 12 g • Xu Duan Radix Dipsaci 6 g • Gan Cao Radix Glycyrrhizae 3 g • Di Yu Radix Sanguisorbae 9 g • Huang Qi Radix Astragali 6 g • Tai Zi Shen Radix Pseudostellariae 6 g • Huang Jing Rhizoma Polygonati 6 g • Gui Ban Plastrum Testudinis X g – BI XIE FEN QING YIN – Dioscorea Separating the Clear Decoction • Bi Xie Rhizoma Dioscoreae hypoglaucae 12 g • Yi Zhi Ren Fructus Alpiniae oxyphyllae 9 g • Wu Yao Radix Linderae 9 g • Shi Chang Pu Rhizoma Acori tatarinowii 9 g – BI XIE FEN QING YIN and LIU JUN ZI TANG Variation (Chapter 62, Vaginal Itching, Dampness with Spleen-Qi deficiency) – Dioscorea Separating the Clear Decoction and Six Gentlemen Decoction Variation • Bi Xie Rhizoma Dioscoreae hypoglaucae 12 g • Yi Zhi Ren Fructus Alpiniae oxyphyllae 9 g • Wu Yao Radix Linderae 9 g
• Shi Chang Pu Rhizoma Acori tatarinowii 9 g • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 4.5 g • Fu Ling Poria 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Chen Pi Pericarpium Citri reticulatae 3 g • Ban Xia Rhizoma Pinelliae preparatum 4.5 g • Ku Shen Radix Sophorae flavescentis 6 g – BI XIE SHEN SHI TANG – Dioscorea Draining Dampness Decoction • Bi Xie Rhizoma Dioscoreae hypoglaucae 6 g • Yi Yi Ren Semen Coicis 9 g • Huang Bo Cortex Phellodendri 6 g • Fu Ling Poria 6 g • Mu Dan Pi Cortex Moutan 6 g • Ze Xie Rhizoma Alismatis 6 g • Tong Cao Medulla Tetrapanacis 3 g • Hua Shi Talcum 6 g – BI XIE SHEN SHI TANG Variation (Chapter 62, Vaginal Itching, Damp-Heat in the Liver channel) – Dioscorea Draining Dampness Decoction Variation
• Bi Xie Rhizoma Dioscoreae hypoglaucae 6 g • Yi Yi Ren Semen Coicis 9 g • Huang Bo Cortex Phellodendri 6 g • Fu Ling Poria 6 g • Mu Dan Pi Cortex Moutan 6 g • Ze Xie Rhizoma Alismatis 6 g • Tong Cao Medulla Tetrapanacis 3 g • Hua Shi Talcum 6 g • Ku Shen Radix Sophorae flavescentis 6 g – BU FEI TANG – Tonifying the Lungs Decoction • Ren Shen Radix Ginseng 9 g • Huang Qi Radix Astragali 12 g • Shu Di Huang Radix Rehmanniae preparata 12 g • Wu Wei Zi Fructus Schisandrae 6 g • Zi Wan Radix Asteris 9 g • Sang Bai Pi Cortex Mori 6 g – BU GAN TANG – Tonifying the Liver Decoction • Shu Di Huang Radix Rehmanniae preparata 12 g
• Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Mu Gua Fructus Chaenomelis 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Mai Men Dong Radix Ophiopogonis 6 g • Suan Zao Ren Semen Zizyphi spinosae 3 g – BU GAN YI SHEN TANG – Tonifying the Liver and Benefiting the Kidneys Decoction • Sheng Di Huang Radix Rehmanniae 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Shan Zhu Yu Fructus Corni 4.5 g • Ze Xie Rhizoma Alismatis 6 g • Mu Dan Pi Cortex Moutan 6 g • Fu Ling Poria 6 g • Huang Bo Cortex Phellodendri 6 g • Bai Shao Radix Paeoniae alba 6 g • Wu Wei Zi Fructus Schisandrae 3 g • Shen Qu Massa medicata fermentata 6 g – BU PI AN TAI YIN
– Tonifying the Spleen and Calming the Fetus Decoction • Dang Shen Radix Codonopsis 6 g • Huang Qi Radix Astragali 6 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Shen Sclerotium Poriae pararadicis 6 g • Tu Si Zi Semen Cuscutae 6 g • Shan Zhu Yu Fructus Corni 4.5 g • Suan Zao Ren Semen Zizyphi spinosae 3 g • Shen Qu Massa medicata fermentata 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Da Zao Fructus jujubae 3 dates – BU QI GU JING WAN – Tonifying Qi and Consolidating the Menses Pill • Ren Shen Radix Ginseng 9 g • Fu Ling Poria 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Huang Qi Radix Astragali 9 g • Sha Ren Fructus Amomi 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g
– BU SHEN DI HUANG TANG – Tonifying the Kidneys Rehmannia Decoction • Shu Di Huang Radix Rehmanniae preparata 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Huang Bo Cortex Phellodendri 4.5 g • Ze Xie Rhizoma Alismatis 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Yuan Zhi Radix Polygalae 6 g • Fu Shen Sclerotium Poriae pararadicis 6 g • Mu Dan Pi Cortex Moutan 6 g • Suan Zao Ren Semen Zizyphi spinosae 4.5 g • Xuan Shen Radix Scrophulariae 6 g • Sang Piao Xiao Ootheca Mantidis 4.5 g • Shan Zhu Yu Fructus Corni 6 g • Zhu Ye Folium Phyllostachys nigrae 3 g • Gui Ban Jiao Colla Plastri Testudinis 6 g – BU SHEN FANG – Tonifying the Kidneys Formula • Sheng Di Huang Radix Rehmanniae 9 g
• Xuan Shen Radix Scrophulariae 6 g • Bai Shao Radix Paeoniae alba 6 g • Di Gu Pi Cortex Lycii 6 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Han Lian Cao Herba Ecliptae 6 g • Mu Dan Pi Cortex Moutan 6 g • Huang Qin Radix Scutellariae 4.5 g • Dong Gua Ren Semen Benincasae 4.5 g • Gui Ban Plastrum Testudinis 12 g – BU SHEN GU CHONG WAN – Tonifying the Kidneys and Consolidating the Penetrating Vessel Pill • Tu Si Zi Semen Cuscutae 6 g • Xu Duan Radix Dipsaci 6 g • Ba Ji Tian Radix Morindae officinalis 6 g • Du Zhong Cortex Eucommiae 6 g • Lu Jiao Shuang Cornu Cervi degelatinatum 6 g • Dang Gui Radix Angelicae sinensis 6 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Gou Qi Zi Fructus Lycii 9 g • E Jiao Colla Corii asini 6 g
• Dang Shen Radix Codonopsis 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Da Zao Fructus jujubae 3 dates • Sha Ren Fructus Amomi 3 g – BU YANG HUAN WU TANG – Tonifying Yang and Restoring Five-Tenths Decoction • Huang Qi Radix Astragali 18 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Chi Shao Radix Paeoniae rubra 4.5 g • Tao Ren Semen Persicae 3 g • Hong Hua Flos Carthami 3 g • Di Long Pheretima 3 g – BU ZHONG YI QI TANG – Tonifying the Centre and Benefiting Qi Decoction • Huang Qi Radix Astragali 12 g • Ren Shen Radix Ginseng 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Dang Gui Radix Angelicae sinensis 6 g • Chen Pi Pericarpium Citri reticulatae 6 g
• Sheng Ma Rhizoma Cimicifugae 3 g • Chai Hu Radix Bupleuri 3 g – BU ZHONG YI QI TANG Variation (Chapter 47, Persistent Lochial Discharge, Qi deficiency) – Tonifying the Centre and Benefiting Qi Decoction Variation • Huang Qi Radix Astragali 12 g • Ren Shen Radix Ginseng 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Dang Gui Radix Angelicae sinensis 6 g • Chen Pi Pericarpium Citri reticulatae 6 g • Sheng Ma Rhizoma Cimicifugae 3 g • Chai Hu Radix Bupleuri 3 g • Lu Jiao Jiao Colla Cornu cervi 6 g • Ai Ye Folium Artemisiae argyi 4.5 g – BU ZHONG YI QI TANG Variation (Chapter 48, Urinary Difficulty after Childbirth, Spleen-Qi deficiency) – Tonifying the Centre and Benefiting Qi Decoction Variation • Huang Qi Radix Astragali 12 g • Ren Shen Radix Ginseng 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Dang Gui Radix Angelicae sinensis 6 g
• Chen Pi Pericarpium Citri reticulatae 6 g • Sheng Ma Rhizoma Cimicifugae 3 g • Chai Hu Radix Bupleuri 3 g • Dong Kui Zi Fructus Malvae 6 g • Tong Cao Medulla Tetrapanacis 3 g • Jie Geng Radix Platycodi 3 g – CANG FU DAO TAN WAN – Atractylodes-Cyperus Conducting Phlegm Pill • Cang Zhu Rhizoma Atractylodis 9 g • Xiang Fu Rhizoma Cyperi 9 g • Zhi Ke Fructus Aurantii 9 g • Fu Ling Poria 6 g • Chen Pi Pericarpium Citri reticulatae 6 g • Dan Nan Xing Rhizoma Arisaematis preparatum 4.5 g • Gan Cao Radix Glycyrrhizae 3 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Shen Qu Massa medicata fermentata 6 g – CANG FU DAO TAN WAN plus FO SHOU SAN Variation (Chapter 16, No Periods, Damp-Phlegm in the Lower Burner) – Atractylodes-Cyperus Conducting Phlegm Pill plus Buddha’s Hand Powder Variation
• Cang Zhu Rhizoma Atractylodis 9 g • Xiang Fu Rhizoma Cyperi 9 g • Zhi Ke Fructus Aurantii 9 g • Fu Ling Poria 6 g • Chen Pi Pericarpium Citri reticulatae 6 g • Dan Nan Xing Rhizoma Arisaematis preparatum 4.5 g • Gan Cao Radix Glycyrrhizae 3 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Shen Qu Massa medicata fermentata 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 4 g – CANG FU DAO TAN WAN Variation (Chapter 60, Abdominal Masses, Retention of food and Phlegm) – Atractylodes-Cyperus Conducting Phlegm Pill Variation • Fu Ling Poria 6 g • Chen Pi Pericarpium Citri reticulatae 6 g • Xiang Fu Rhizoma Cyperi 9 g • Dan Nan Xing Rhizoma Arisaematis preparatum 4.5 g • Zhi Ke Fructus Aurantii 9 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Shen Qu Massa medicata fermentata 6 g
• Ban Xia Rhizoma Pinelliae preparatum 6 g • Gan Cao Radix Glycyrrhizae 3 g – CANG FU DAO TAN WAN Variation (Chapter 65, Endometriosis, DampPhlegm in the Uterus) – Atractylodes-Cyperus Conducting Phlegm Pill Variation • Fu Ling Poria 6 g • Chen Pi Pericarpium Citri reticulatae 6 g • Xiang Fu Rhizoma Cyperi 9 g • Dan Nan Xing Rhizoma Arisaematis preparatum 4.5 g • Zhi Ke Fructus Aurantii 9 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Shen Qu Massa medicata fermentata 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Gan Cao Radix Glycyrrhizae 3 g – CHAI HU SHU GAN TANG – Bupleurum Pacifying the Liver Decoction • Chai Hu Radix Bupleuri 6 g • Bai Shao Radix Paeoniae alba 4.5 g • Zhi Ke Fructus Aurantii 4.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 1.5 g
• Chen Pi Pericarpium Citri reticulatae 6 g • Xiang Fu Rhizoma Cyperi 4.5 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g – CHANG NING TANG – Intestines Tranquillity Decoction • Dang Gui Radix Angelicae sinensis 30 g • Shu Di Huang Radix Rehmanniae preparata 30 g • Ren Shen Radix Ginseng 9 g • Mai Men Dong Radix Ophiopogonis 9 g • E Jiao Colla Corii asini 9 g • Shan Yao Rhizoma Dioscoreae 9 g • Xu Duan Radix Dipsaci 6 g • Rou Gui Cortex Cinnamomi (as a powder) 0.6 g • Gan Cao Radix Glycyrrhizae 3 g – CHEN TONG SAN – Stopping Pain Powder • Dang Gui Radix Angelicae sinensis 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Huang Qi Radix Astragali 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g
• Rou Gui Cortex Cinnamomi 2 g • Du Huo Radix Angelicae pubescentis 6 g • Chuan Niu Xi Radix Cyathulae 6 g • Xie Bai Bulbus Allii macrostemi 4 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices – CHEN TONG SAN Variation (Chapter 23, Body Aches at Period Time, Blood stasis) – Stopping Pain Powder Variation • Dang Gui Radix Angelicae sinensis 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Huang Qi Radix Astragali 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Rou Gui Cortex Cinnamomi 2 g • Du Huo Radix Angelicae pubescentis 6 g • Chuan Niu Xi Radix Cyathulae 6 g • Xie Bai Bulbus Allii macrostemi 4 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Ji Xue Teng Caulis Spatholobi 6 g • Sang Ji Sheng Herba Taxilli 6 g – CHEN XIANG SAN – Aquilaria Powder
• Chen Xiang Lignum Aquilariae resinatum 9 g • Shi Wei Folium Pyrrosiae 6 g • Hua Shi Talcum 6 g • Dong Kui Zi Fructus Malvae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Wang Bu Liu Xing Semen Vaccariae 6 g • Bai Shao Radix Paeoniae alba 6 g • Chen Pi Pericarpium Citri reticulatae 4.5 g • Gan Cao Radix Glycyrrhizae 3 g – CHUAN SHAN JIA SAN – Squama Manitis Powder • Chuan Shan Jia Squama Manitis 9 g • Bie Jia Carapax Trionycis 9 g • Chi Shao Radix Paeoniae rubra 6 g • Da Huang Radix et Rhizoma Rhei 6 g • Gan Qi Resina Toxicodendri 3 g • Gui Zhi Ramulus Cinnamomi 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Yuan Hua Flos Daphnae genkwa 6 g • Dang Gui Radix Angelicae sinensis 6 g
• She Xiang Moschus 1.5 g – CHUN GEN HONG HUA TANG – Ailanthus-Carthamus Decoction • Chun Gen Bai Pi Cortex Ailanthi 9 g • Hong Hua Flos Carthami 6 g • Dang Gui Radix Angelicae sinensis 6 g • Deng Xin Cao Medulla Junci 6 g • Zhu Ye Folium Phyllostachys nigrae 4.5 g • Gan Cao Radix Glycyrrhizae 3 g – CONG RONG TU SI ZI WAN – Cistanche-Cuscuta Pill • Rou Cong Rong Herba Cistanches 9 g • Tu Si Zi Semen Cuscutae 9 g • Fu Pen Zi Fructus Rubi 6 g • Yin Yang Huo Herba Epimedii 4 g • Gou Qi Zi Fructus Lycii 6 g • Dang Gui Radix Angelicae sinensis 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Sang Ji Sheng Herba Taxilli 6 g • Zi He Che Placenta hominis 6 g
• Ai Ye Folium Artemisiae argyi 4 g – CU HUANG TI TANG – Promoting the Corpus Luteum Decoction • Shu Di Huang Radix Rehmanniae preparata 9 g • Gui Ban Plastrum Testudinis 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Xu Duan Radix Dipsaci 6 g • Rou Cong Rong Herba Cistanches 6 g • Mei Gui Hua Flos Rosae rugosae 3 g • Dang Gui Radix Angelicae sinensis 6 g – CUI SHENG YIN – Hastening Labour Decoction • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Da Fu Pi Pericarpium Arecae 4.5 g • Zhi Ke Fructus Aurantii 4.5 g • Bai Zhi Radix Angelicae dahuricae 3 g – CUI SHENG YIN Variation (Chapter 44, Acupuncture and Herbal Treatment in Midwifery, Blood stasis and stagnation of Qi) – Hastening Labour Decoction Variation • Dang Gui Radix Angelicae sinensis 6 g
• Chuan Xiong Rhizoma Chuanxiong 6 g • Da Fu Pi Pericarpium Arecae 4.5 g • Zhi Ke Fructus Aurantii 4.5 g • Bai Zhi Radix Angelicae dahuricae 3 g • Yi Mu Cao Herba Leonuri 6 g – DA BU YIN WAN – Great Tonifying Yin Pill • Zhi Mu Rhizoma Anemarrhenae 120 g • Huang Bo Cortex Phellodendri 120 g • Shu Di Huang Radix Rehmanniae preparata 180 g • Gui Ban Plastrum Testudinis 180 g • Pig’s bone-marrow – DA BU YUAN JIAN – Great Tonifying the Original [Qi] Decoction • Ren Shen Radix Ginseng 3 g • Shan Yao Rhizoma Dioscoreae 6 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Du Zhong Cortex Eucommiae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Shan Zhu Yu Fructus Corni 3 g
• Gou Qi Zi Fructus Lycii 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – DA BU YUAN JIAN Variation (Chapter 63, Prolapse of the Uterus, Kidney-Qi deficient and sinking) – Great Tonifying the Original Qi Pill Variation • Ren Shen Radix Ginseng 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Shan Zhu Yu Fructus Corni 4.5 g • Bai Shao Radix Paeoniae alba 6 g • Bai Zhi Radix Angelicae dahuricae 3 g • Wu Wei Zi Fructus Schisandrae 3 g • Wu Zie Gu Endoconcha Sepiae 9 g • Mu Li Concha Ostreae 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Chai Hu Radix Bupleuri 3 g • Sheng Ma Rhizoma Cimicifugae 3 g • Chuan Lian Zi Fructus Toosendan 3 g • Da Zao Fructus Jujubae 3 dates – DA HUANG BIE CHONG WAN – Rheum-Eupolyphaga Decoction
• Da Huang Radix et Rhizoma Rhei 300 g • Di Bie Chong Eupolyphaga 30 g • Tao Ren Semen Persicae 60 g • Gan Qi Resina Toxicodendri 30 g • Qi Cao Holotrichia 60 g • Shui Zhi Hirudo 60 g • Meng Chong Tabanus 60 g • Huang Qin Radix Scutellariae 60 g • Xing Ren Semen Armeniacae 60 g • Sheng Di Huang Radix Rehmanniae 300 g • Bai Shao Radix Paeoniae alba 120 g • Gan Cao Radix Glycyrrhizae 30 g – DA HUANG MU DAN TANG – Rheum-Moutan Decoction • Da Huang Radix et Rhizoma Rhei 12 g • Mang Xiao Sulfas Natrii 9 g • Mu Dan Pi Cortex Moutan 3 g • Tao Ren Semen Persicae 9 g • Dong Gua Ren Semen Benincasae 15 g – DA HUANG MU DAN TANG Variation (Chapter 51, Fever after Childbirth, Invasion of external Toxins)
– Rheum-Moutan Decoction Variation • Da Huang Radix et Rhizoma Rhei 12 g • Mang Xiao Sulfas Natrii 9 g • Mu Dan Pi Cortex Moutan 9 g • Tao Ren Semen Persicae 9 g • Dong Gua Ren Semen Benincasae 15 g • Bai Jiang Cao Herba Patriniae 6 g • Hong Teng Caulis Sargentodoxae 6 g • Yi Yi Ren Semen Coicis 30 g – DA QI QI TANG – Big Seven Qi Decoction • Qing Pi Pericarpium Citri reticulatae viride 6 g • Chen Pi Pericarpium Citri reticulatae 4.5 g • Xiang Fu Rhizoma Cyperi 6 g • Jie Geng Radix Platycodi 3 g • Huo Xiang Herba Pogostemonis 6 g • Rou Gui Cortex Cinnamomi 3 g • Yi Zhi Ren Fructus Alpiniae oxyphyllae 6 g • San Leng Rhizoma Sparganii 6 g • E Zhu Rhizoma Curcumae 6 g
• Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Da Zao Fructus Jujubae 3 dates – DA TIAO JING WAN – Great Regulating the Period Pill • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Ren Shen Radix Ginseng 6 g • Xiang Fu Rhizoma Cyperi 4.5 g • Wu Yao Radix Linderae 3 g • Rou Gui Cortex Cinnamomi 2 g • Dan Shen Radix Salviae miltiorrhizae 3 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Xu Duan Radix Dipsaci 6 g – DA YING JIAN – Big Nutritive Qi Decoction • Dang Gui Radix Angelicae sinensis 9 g
• Shu Di Huang Radix Rehmanniae preparata 9 g • Gou Qi Zi Fructus Lycii 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Du Zhong Cortex Eucommiae 9 g • Niu Xi Radix Achyranthis bidentatae seu Cyathulae 9 g • Rou Gui Cortex Cinnamomi 6 g – DAN GUI HUO XUE TANG – Salvia-Angelica Invigorating Blood Decoction • Dan Shen Radix Salviae miltiorrhizae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chi Shao Radix Paeoniae rubra 6 g • Hong Hua Flos Carthami 3 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Tao Ren Semen Persicae 4.5 g • Gan Cao Radix Glycyrrhizae 3 g – DAN SHEN YIN – Salvia Decoction • Dan Shen Radix Salviae miltiorrhizae 30 g • Tan Xiang Lignum Santali albi 5 g • Sha Ren Fructus Amomi 5 g
– DAN ZHI XIAO YAO SAN – Moutan-Gardenia Free and Easy Wanderer Powder • Dang Gui Radix Angelicae sinensis 3 g • Bai Shao Radix Paeoniae alba 3 g • Fu Ling Poria 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 3 g • Chai Hu Radix Bupleuri 3 g • Bo He Herba Menthae haplocalycis 3 g • Mu Dan Pi Cortex Moutan 1.5 g • Shan Zhi Zi Fructus Gardeniae 1.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 1.5 g – DAN ZHI XIAO YAO SAN Variation (Chapter 18, Pre-Menstrual Syndrome, Liver-Heat) – Moutan-Gardenia Free and Easy Wanderer Powder Variation • Dang Gui Radix Angelicae sinensis 3 g • Bai Shao Radix Paeoniae alba 3 g • Fu Ling Poria 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 3 g • Chai Hu Radix Bupleuri 3 g • Bo He Herba Menthae haplocalycis 3 g • Mu Dan Pi Cortex Moutan 1.5 g
• Shan Zhi Zi Fructus Gardeniae 1.5 g • Qing Pi Pericarpium Citri reticulatae viride 4.5 g • Xiang Fu Rhizoma Cyperi 6 g • Suan Zao Ren Semen Ziziphi spinosae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 1.5 g – DAN ZHI XIAO YAO SAN Variation (Chapter 24, Fever at Period Time, Blood-Heat) – Moutan-Gardenia Free and Easy Wanderer Powder Variation • Dang Gui Radix Angelicae sinensis 3 g • Bai Shao Radix Paeoniae alba 3 g • Fu Ling Poria 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 3 g • Chai Hu Radix Bupleuri 3 g • Mu Dan Pi Cortex Moutan 1.5 g • Shan Zhi Zi Fructus Gardeniae 1.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 1.5 g • Xiang Fu Rhizoma Cyperi 3 g • Huang Qin Radix Scutellariae 3 g • Gou Teng Ramulus Uncariae cum Uncis 3 g – DANG GUI BU XUE TANG – Angelica Tonifying Blood Decoction
• Huang Qi Radix Astragali 30 g • Dang Gui Radix Angelicae sinensis 6 g – DANG GUI DI HUANG YIN – Angelica sinensis-Rehmannia Decoction • Shu Di Huang Radix Rehmanniae preparata 10 g • Shan Yao Rhizoma Dioscoreae 6 g • Shan Zhu Yu Fructus Corni 4 g • Dang Gui Radix Angelicae sinensis 6 g • Du Zhong Cortex Eucommiae 6 g • Huai Niu Xi Radix Achyranthis bidentatae 6 g • Gan Cao Radix Glycyrrhizae 3 g – DAN GUI HUO XUE TANG – Salvia-Angelica Invigorating Blood Decoction • Dan Shen Radix Salviae miltiorrhizae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chi Shao Radix Paeoniae rubra 6 g • Hong Hua Flos Carthami 3 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Tao Ren Semen Persicae 4.5 g • Gan Cao Radix Glycyrrhizae 3 g
– DANG GUI JIAN ZHONG TANG – Angelica Strengthening the Centre Decoction • Dang Gui Radix Angelicae sinensis 9 g • Yi Tang Maltosum 30 g • Bai Shao Radix Paeoniae alba 18 g • Gui Zhi Ramulus Cinnamomi 9 g • Sheng Jiang Rhizoma Zingiberis recens 10 g • Zhi Gan Cao Radix Glycyrrhizae preparata 6 g • Da Zao Fructus jujubae 12 dates – DANG GUI LONG HUI WAN – Angelica-Gentiana-Aloe Pill • Dang Gui Radix Angelicae sinensis 30 g • Long Dan Cao Radix Gentianae 15 g • Lu Hui Herba Aloes 15 g • Shan Zhi Zi Fructus Gardeniae 30 g • Huang Lian Rhizoma Coptidis 15 g • Huang Bo Cortex Phellodendri 30 g • Huang Qin Radix Scutellariae 30 g • Da Huang Radix et Rhizoma Rhei 15 g • Mu Xiang Radix Aucklandiae 4.5 g
• She Xiang Moschus 1.5 g – DANG GUI SHAO YAO SAN – Angelica-Paeonia Powder • Dang Gui Radix Angelicae sinensis 3 g • Bai Shao Radix Paeoniae alba 15 g • Fu Ling Poria 4 g • Bai Zhu Rhizoma Atractylodis macrocephalae 4 g • Ze Xie Rhizoma Alismatis 8 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – DANG GUI SHENG JIANG YANG ROU TANG – Angelica-Zingiber-Mutton Decoction • Dang Gui Radix Angelicae sinensis 9 g • Sheng Jiang Rhizoma Zingiberis recens 15 g • Yang Rou Ovis aries (mutton, goat or lamb) 48 g – DANG GUI SI NI TANG – Angelica Four Rebellious Decoction • Dang Gui Radix Angelicae sinensis 12 g • Bai Shao Radix Paeoniae alba 9 g • Gui Zhi Ramulus Cinnamomi 9 g
• Xi Xin Herba Asari 1.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Da Zao Fructus jujubae 8 pieces • Mu Tong Caulis Akebiae 3 g – DANG GUI YIN ZI – Angelica Decoction • Dang Gui Radix Angelicae sinensis 4.5 g • Bai Shao Radix Paeoniae alba 4.5 g • Sheng Di Huang Radix Rehmanniae 4.5 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Fang Feng Radix Saposhnikoviae 4.5 g • Jing Jie Herba Schizonepetae 4.5 g • Huang Qi Radix Astragali 3 g • Gan Cao Radix Glycyrrhizae 3 g • Shou Wu Radix Polygoni multiflori preparata 3 g • Bai Ji Li Fructus Tribuli 3 g – DANG GUI YIN ZI Variation (Chapter 27, Skin Eruptions at Period Time, Wind-Heat with Blood deficiency) – Angelica Decoction Variation • Dang Gui Radix Angelicae sinensis 4.5 g • Bai Shao Radix Paeoniae alba 4.5 g
• Sheng Di Huang Radix Rehmanniae 4.5 g • Fang Feng Radix Saposhnikoviae 4.5 g • Jing Jie Herba Schizonepetae 4.5 g • Gan Cao Radix Glycyrrhizae 3 g • Shou Wu Radix Polygoni multiflori preparata 3 g • Bai Ji Li Fructus Tribuli 3 g – DAO CHI SAN – Eliminating Redness Powder • Sheng Di Huang Radix Rehmanniae 15 g • Mu Tong Caulis Akebiae 3 g • Sheng Gan Cao Radix Glycyrrhizae 6 g • Zhu Ye Folium Phyllostachys nigrae 3 g – DAO CHI SAN Variation (Chapter 18, Pre-Menstrual Syndrome, Heart-Heat) – Eliminating Redness Powder Variation • Sheng Di Huang Radix Rehmanniae 15 g • Sheng Gan Cao Radix Glycyrrhizae 6 g • Zhu Ye Folium Phyllostachys nigrae 3 g • Huang Lian Rhizoma Coptidis 3 g • Huang Qin Radix Scutellariae 3 g • Suan Zao Ren Semen ziziphi spinosae 6 g
• Deng Xin Cao Medulla Junci 6 g • Lian Zi Xin Semen Nelumbinis 6 g – DAO CHI SAN Variation (Chapter 26, Mouth Ulcers at Period Time, HeartFire) – Eliminating Redness Powder Variation • Sheng Di Huang Radix Rehmanniae 15 g • Mu Tong Caulis Akebiae 3 g • Sheng Gan Cao Radix Glycyrrhizae 6 g • Zhu Ye Folium Phyllostachys nigrae 3 g • Huang Lian Rhizoma Coptidis 4.5 g – DAO GONG TANG – Conducting and Attacking Decoction • Dang Shen Radix Codonopsis 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – DAO GONG TANG Variation (Chapter 46, Abdominal Pain After Childbirth, Retention of food) – Conducting and Attacking Decoction Variation • Dang Shen Radix Codonopsis 6 g
• Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Shan Zha Fructus Crataegi 6 g • Zhi Shi Fructus Aurantii immaturus 6 g – DAO JING TANG – Reversing the Menses Decoction • Dan Shen Radix Salviae miltiorrhizae 10 g • Dang Gui Radix Angelicae sinensis 10 g • Shan Zhi Zi Fructus Gardeniae 10 g • Chi Shao Radix Paeoniae rubra 10 g • Zhu Ru Caulis Bambusae in taeniam 10 g • Chuan Niu Xi Radix Cyathulae 10 g • Ze Lan Herba Lycopi 10 g • Xiang Fu Rhizoma Cyperi 10 g • Bai Mao Hua Flos Imperatae 6 g • Chong Wei Zi Fructus Leonuri 15 g – DAO TAN ZHONG ZI TANG – Conducting Phlegm and Planting Seeds Decoction
• Dan Nan Xing Rhizoma Arisaematis preparatum 9 g • Fu Ling Poria 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Chen Pi Pericarpium Citri reticulatae 6 g • Ban Xia Rhizoma Pinelliae preparatum 12 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Huang Qi Radix Astragali 12 g • Yin Yang Huo Herba Epimedii 6 g • Ba Ji Tian Radix Morindae officinalis 9 g • Ji Xue Teng Caulis Spatholobi 9 g • Xiang Fu Rhizoma Cyperi 6 g – DAO ZHI TONG JING TANG – Conducting Stagnation and Penetrating the Menses Decoction • Mu Xiang Radix Aucklandiae 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Sang Bai Pi Cortex Mori 4.5 g • Chen Pi Pericarpium Citri reticulatae 3 g • Fu Ling Poria 6 g – DAO ZHI TONG JING TANG plus SI WU TANG Variation (Chapter 21, Oedema during Periods, Stagnation of Qi)
– Conducting Stagnation and Penetrating the Menses Decoction plus Four Substances Decoction Variation • Mu Xiang Radix Aucklandiae 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Sang Bai Pi Cortex Mori 4.5 g • Chen Pi Pericarpium Citri reticulatae 3 g • Fu Ling Poria 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chi Shao Radix Paeoniae rubra 4.5 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g – DI GU PI YIN (from Secret Text of Extraordinarily-Effective Beneficial Formulae from across the Seas, Qi Xiao Hai Shang Liang Fang Mi Ben) – Cortex Lycii Decoction • Di Gu Pi Cortex Lycii 60 g • Chai Hu Radix Bupleuri 60 g • Zhi Mu Rhizoma Anemarrhenae 7.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 7.5 g • Bie Jia Carapax Trionycis 7.5 g • Huang Qin Radix Scutellariae 7.5 g • Ren Shen Radix Ginseng 7.5 g • Fu Ling Poria 15 g
– DI GU PI YIN (from the Golden Mirror of Medicine, Yi Zong Jin Jian) – Cortex Lycii Decoction • Dang Gui Radix Angelicae sinensis 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Bai Shao Radix Paeoniae alba 3 g • Chuan Xiong Rhizoma Chuanxiong 1.5 g • Mu Dan Pi Cortex Moutan 6 g • Di Gu Pi Cortex Lycii 6 g – DI SHEN ZI YIN FANG – Rehmannia-Glehnia Nourishing Yin Formula • Sheng Di Huang Radix Rehmanniae 9 g • Bei Sha Shen Radix Glehniae 6 g • Gou Qi Zi Fructus Lycii 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Chuan Lian Zi Fructus Toosendan 3 g • Sang Ji Sheng Herba Taxilli 6 g • Bai Shao Radix Paeoniae alba 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Shi Jue Ming Concha Haliotidis 15 g – DI TAN TANG
– Scouring Phlegm Decoction • Ban Xia Rhizoma Pinelliae preparatum 6.6 g • Ju Hong Exocarpium Citri reticulatae rubrum 6 g • Fu Ling Poria 6 g • Zhi Shi Fructus Aurantii immaturus 6 g • Zhu Ru Caulis Bambusae in taeniam 2.1 g • Dan Nan Xing Rhizoma Arisaematis preparatum 6.6 g • Shi Chang Pu Rhizoma Acori tatarinowii 3 g • Ren Shen Radix Ginseng 3 g • Gan Cao Radix Glycyrrhizae 1.5 g – DI YU HUANG BO FANG – Sanguisorba-Phellodendron Formula • Chi Xiao Dou Semen Phaseoli 12 g • Sheng Di Huang Radix Rehmanniae 6 g • Di Yu Radix Sanguisorbae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Huai Jiao Fructus Sophorae japonicae 6 g • Qin Jiao Radix Gentianae macrophyllae 6 g • Huang Bo Cortex Phellodendri 6 g • Cang Zhu Rhizoma Atractylodis 6 g
• Fang Feng Radix Saposhnikoviae 6 g • Tao Ren Semen Persicae 6 g • Bai Zhi Radix Angelicae dahuricae 3 g – DING JING TANG – Settling the Menses Decoction • Tu Si Zi Semen Cuscutae 9 g • Bai Shao Radix Paeoniae alba 9 g • Dang Gui Radix Angelicae sinensis 9 g • Shu Di Huang Radix Rehmanniae preparata 4.5 g • Shan Yao Rhizoma Dioscoreae 4.5 g • Fu Ling Poria 3 g • Jing Jie Herba Schizonepetae (char-fried) 2 g • Chai Hu Radix Bupleuri 1.5 g – DING JING TANG Variation (Chapter 9, Late Periods, Liver-Qi stagnation) – Settling the Menses Decoction Variation • Bai Shao Radix Paeoniae alba 9 g • Dang Gui Radix Angelicae sinensis 9 g • Tu Si Zi Semen Cuscutae 9 g • Shu Di Huang Radix Rehmanniae preparata 4.5 g • Yin Yang Huo Herba Epimedii 3 g
• Chai Hu Radix Bupleuri 1.5 g • (Cu) Xiang Fu Rhizoma Cyperi (fried in vinegar) 4.5 g • Shan Yao Rhizoma Dioscoreae 4.5 g • Fu Ling Poria 3 g • Jing Jie Herba Schizonepetae (char-fried) 2 g – DONG KUI ZI SAN – Fructus Malvae Powder • Dong Kui Zi Fructus Malvae 15 g • Shan Zhi Zi Fructus Gardeniae 15 g • Hua Shi Talcum 15 g • Mu Tong Caulis Akebiae 15 g – DONG KUI ZI SAN Variation (Chapter 41, Retention of Urine in Pregnancy, Damp-Heat in the Bladder) – Fructus Malvae Powder Variation • Dong Kui Zi Fructus Malvae 15 g • Shan Zhi Zi Fructus Gardeniae 15 g • Hua Shi Talcum 15 g • Mu Tong Caulis Akebiae 15 g • Fu Ling Poria 6 g – DU HUO JI SHENG TANG – Angelica pubescens-Loranthus Decoction
• Du Huo Radix Angelicae pubescentis 9 g • Xi Xin Herba Asari 3 g • Fang Feng Radix Saposhnikoviae 6 g • Qin Jiao Radix Gentianae macrophyllae 6 g • Sang Ji Sheng Herba Taxilli 6 g • Du Zhong Cortex Eucommiae 6 g • Niu Xi Radix Achyranthis bidentatae seu Cyathulae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Bai Shao Radix Paeoniae alba 6 g • Ren Shen Radix Ginseng 6 g • Fu Ling Poria 6 g • Rou Gui Cortex Cinnamomi 6 g • Gan Cao Radix Glycyrrhizae 6 g – DU SHEN TANG – Solitary Ginseng Decoction • Ren Shen Radix Ginseng 15–30 g • Da Zao Fructus Jujubae 5 dates – DUO MING SAN
– Seizing Life Powder • Mo Yao Myrrha 6 g • Xue Jie Resina Daemonoropis 6 g – DUO MING WAN – Seizing Life Pill • Mu Dan Pi Cortex Moutan 9 g • Tao Ren Semen Persicae 9 g • Fu Ling Poria 6 g • Chi Shao Radix Paeoniae rubra 9 g • Gui Zhi Ramulus Cinnamomi 3 g • Pu Huang Pollen Typhae 6 g – E JIAO YANG XUE TANG – Colla Corii asini Nourishing Blood Decoction • E Jiao Colla Corii asini 9 g • Sheng Di Huang Radix Rehmanniae 6 g • Bei Sha Shen Radix Glehniae 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Han Lian Cao Herba Ecliptae 4.5 g • Sang Ji Sheng Herba Taxilli 6 g
– E ZHU SAN – Curcuma Powder • E Zhu Rhizoma Curcumae 9 g • Gui Zhi Ramulus Cinnamomi 6 g • Dang Gui Radix Angelicae sinensis 9 g • Chi Shao Radix Paeoniae rubra 6 g • Bing Lang Semen Arecae 6 g • Zhi Ke Fructus Aurantii 6 g • Mu Xiang Radix Aucklandiae 3 g • Kun Bu Thallus Eckloniae 9 g • Hu Po Succinum 6 g • Tao Ren Semen Persicae 6 g • Bie Jia Carapax Trionycis 12 g • Da Huang Radix et Rhizoma Rhei 6 g – EMPIRICAL PRESCRIPTIONS – See the end of this Appendix – ER CHEN TANG – Two Old Decoction • Ban Xia Rhizoma Pinelliae preparatum 15 g • Chen Pi Pericarpium Citri reticulatae 15 g
• Fu Ling Poria 9 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Sheng Jiang Rhizoma Zingiberis recens 3 g • Wu Mei Fructus Mume 1 prune – ER MIAO SAN – Two Wonderful Powder • Cang Zhu Rhizoma Atractylodis 15 g • Huang Bo Cortex Phellodendri 12 g – ER MIAO SAN Variation (Chapter 14, Painful Periods, Damp-Heat) – Two Wonderful Powder Variation • Cang Zhu Rhizoma Atractylodis 15 g • Huang Bo Cortex Phellodendri 12 g • Bai Jiang Cao Herba Patriniae 6 g • Yan Hu Suo Rhizoma Corydalis 6 g – ER MIAO SAN Variation (Chapter 65, Endometriosis, Dampness) – Two Wonderful Powder Variation • Cang Zhu Rhizoma Atractylodis 15 g • Huang Bo Cortex Phellodendri 12 g • Bai Jiang Cao Herba Patriniae 6 g • Yan Hu Suo Rhizoma Corydalis 6 g
– ER XIAN TANG – Two Immortals Decoction • Xian Mao Rhizoma Curculiginis 6 g • Yin Yang Huo Herba Epimedii 9 g • Ba Ji Tian Radix Morindae officinalis 9 g • Huang Bo Cortex Phellodendri 4.5 g • Zhi Mu Rhizoma Anemarrhenae 4.5 g • Dang Gui Radix Angelicae sinensis 9 g – ER XIAN TANG plus XIAO YAO SAN Variation (Chapter 59, Breast Lumps, Directing and Penetrating Vessel Disharmony) – Two Immortals Decoction plus Free and Easy Wanderer Powder Variation • Xian Mao Rhizoma Curculiginis 6 g • Yin Yang Huo Herba Epimedii 9 g • Ba Ji Tian Radix Morindae 9 g • Huang Bo Cortex Phellodendri 4.5 g • Zhi Mu Rhizoma Anemarrhenae 4.5 g • Dang Gui Radix Angelicae sinensis 9 g • Bo He Herba Menthae haplocalycis 3 g • Chai Hu Radix Bupleuri 9 g • Bai Shao Radix Paeoniae alba 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g
• Fu Ling Poria 15 g • Gan Cao Radix Glycyrrhizae 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Gua Lou Fructus Trichosanthis 6 g • Hai Zao Sargassum 6 g • Huang Yao Zi Rhizoma Dioscoreae bulbiferae 4 g • Wang Bu Liu Xing Semen Vaccariae 4 g – ER ZHI WAN – Two Solstices Pill • Nu Zhen Zi Fructus Ligustri lucidi 12 g • Han Lian Cao Herba Ecliptae 9 g – FANG JI HUANG QI TANG – Stephania-Astragalus Decoction • Huang Qi Radix Astragali 9 g • Han Fang Ji Radix Stephaniae tetandrae 6 g • Bai Zhu Radix Atractylodis macrocephalae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sheng Jiang Rhizoma Zingiberis recens 3 g • Da Zao Fructus Jujubae 3 dates – FANG JI HUANG QI TANG Variation (Chapter 57, Infertility, Appendix: Male Sterility, Damp-Phlegm)
– Stephania-Astragalus Decoction Variation • Huang Qi Radix Astragali 9 g • Han Fang Ji Radix Stephaniae tetandrae 6 g • Bai Zhu Radix Atractylodis macrocephalae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sheng Jiang Rhizoma Zingiberis recens 3 g • Da Zao Fructus Jujubae 3 dates • Dan Shen Radix Salviae miltiorrhizae 6 g • Yin Chen Hao Herba Artemisiae scopariae 4.5 g • Ze Xie Rhizoma Alismatis 6 g • Fu Ling Poria 6 g • Yin Yang Huo Herba Epimedi 6 g • Gou Qi Zi Fructus Lycii 6 g • He Shou Wu Radix Polygoni multiflori preparata 6 g – FO SHOU SAN – Buddha’s Hand Powder • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 4 g – FU FANG HUANG QI JIAN – Revised Astragalus Decoction
• Huang Qi Radix Astragali 30 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Rou Gui Cortex Cinnamomi 3 g • Chuan Niu Xi Radix Cyathulae 6 g • Tao Ren Semen Persicae 6 g • Hong Hua Flos Carthami 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Mang Xiao Sulfas Natrii 6 g
– FU GENG YIN – Woman’s Menopause Decoction • Sheng Di Huang Radix Rehmanniae 6 g • Zhi Cao Radix Lithospermi 4.5 g • Yin Yang Huo Herba Epimedii 6 g • Sang Ji Sheng Herba Taxilli 6 g • Dang Gui Radix Angelicae sinensis 6 g • Gou Teng Ramulus Uncariae cum Uncis 6 g • Xiang Fu Rhizoma Cyperi 4.5 g • Mai Ya Fructus Hordei germinatus 6 g – FU KE ZHU XIAN DAN – Gynaecological Helping the Immortals Pill • Fu Ling Poria 15 g • Chen Pi Pericarpium Citri reticulatae 15 g • Bai Zhu Rhizoma Atractylodis macrocephalae 10 g • Bai Shao Radix Paeoniae alba 10 g • Shan Yao Rhizoma Dioscoreae 10 g • Tu Si Zi Semen Cuscutae 10 g • Du Zhong Cortex Eucommiae 15 g • Gan Cao Radix Glycyrrhizae 3 g
– FU LING DAO SHUI TANG – Poria Conducting Water Decoction • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Zhu Ling Polyporus 6 g • Ze Xie Rhizoma Alismatis 6 g • Mu Xiang Radix Aucklandiae 3 g • Bing Lang Semen Arecae 4.5 g • Da Fu Pi Pericarpium Arecae 3 g • Sha Ren Fructus Amomi 3 g • Sang Bai Pi Cortex Mori 4.5 g • Zi Su Ye Folium Perillae 3 g • Chen Pi Pericarpium Citri reticulatae 3 g • Mu Gua Fructus Chaenomelis 3 g – FU SHEN SAN – Poria Powder • Ren Shen Radix Ginseng 6 g • Huang Qi Radix Astragali 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Bai Shao Radix Paeoniae alba 6 g
• Dang Gui Radix Angelicae sinensis 6 g • Huai Niu Xi Radix Achyranthis bidentatae 6 g • Rou Gui Cortex Cinnamomi 1.5 g • Fu Shen Sclerotium Poriae pararadicis 9 g • Hu Po Succinum (as a powder) 1.5 g • Long Chi Fossilia Dentis mastodi 15 g – FU YUAN HUO XUE TANG – Restoring the Source and Invigorating Blood Decoction • Dang Gui Radix Angelicae sinensis 9 g • Tao Ren Semen Persicae 9 g • Hong Hua Flos Carthami 6 g • Chuan Shan Jia Squama Manitis 6 g • Da Huang Radix et Rhizoma Rhei (wine-treated) 30 g • Tian Hua Fen Radix Trichosanthis 9 g • Chai Hu Radix Bupleuri 15 g • Gan Cao Radix Glycyrrhizae 6 g – FU ZHENG ZHI BENG TANG – Supporting the Upright Qi and Stopping Flooding Decoction • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 9 g
• Huang Qi Radix Astragali 9 g • Dang Shen Radix Codonopsis 6 g • Xian He Cao Herba Agrimoniae 6 g • Ce Bai Ye Cacumen Platycladi 6 g – GAN JIANG LING ZHU TANG – Glycyrrhiza-Zingiberis-Poria-Atractylodes Decoction • Gan Cao Radix Glycyrrhizae 6 g • Gan Jiang Rhizoma Zingiberis 12 g • Fu Ling Poria 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g – GAN LU XIAO DU YIN – Sweet Dew Eliminating Toxin Decoction • Lian Qiao Fructus Forsythiae 12 g • Huang Qin Radix Scutellariae 12 g • Bo He Herba Menthae haplocalycis 6 g • She Gan Rhizoma Belamcandae 9 g • Chuan Bei Mu Bulbus Fritillariae cirrhosae 6 g • Hua Shi Talcum 18 g • Mu Tong Caulis Akebiae 9 g • Yin Chen Hao Herba Artemisiae scopariae 24 g
• Huo Xiang Herba Pogostemonis 9 g • Shi Chang Pu Rhizoma Acori tatarinowii 4 g • Bai Dou Kou Fructus Amomi rotundus 10 g – GAN MAI DA ZAO TANG – Glycyrrhiza-Triticum–Jujuba Decoction • Gan Cao Radix Glycyrrhizae 9 g • Fu Xiao Mai Fructus Tritici levis 9 g • Da Zao Fructus jujubae 10 dates – GE XIA ZHU YU TANG – Eliminating Stasis below the Diaphragm Decoction • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Chi Shao Radix Paeoniae rubra 6 g • Hong Hua Flos Carthami 9 g • Tao Ren Semen Persicae 9 g • Wu Ling Zhi Faeces Trogopterori 9 g • Yan Hu Suo Rhizoma Corydalis 3 g • Xiang Fu Rhizoma Cyperi 3 g • Zhi Ke Fructus Aurantii 5 g • Wu Yao Radix Linderae 6 g
• Mu Dan Pi Cortex Moutan 6 g • Gan Cao Radix Glycyrrhizae 9 g – GENG NIAN AN – Peaceful Menopause • Shu Di Huang Radix Rehmanniae preparata 9 g • Ze Xie Rhizoma Alismatis 6 g • Fu Ling Poria 6 g • Mu Dan Pi Cortex Moutan 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Shan Zhu Yu Fructus Corni 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Shou Wu Radix Polygoni multiflori preparata 6 g • Xian Mao Rhizoma Curculiginis 6 g – GENG NIAN FANG – Menopause Formula • Sheng Di Huang Radix Rehmanniae 9 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Han Lian Cao Herba Ecliptae 4.5 g • Suan Zao Ren Semen Zizyphi spinosae 4.5 g • Long Chi Fossilia Dentis mastodi 12 g
• Gou Teng Ramulus Uncariae cum Uncis 6 g • Lian Xin Plumula Nelumbinis 4.5 g • Fu Ling Poria 6 g • He Huan Pi Cortex Albiziae 6 g • Zhi Cao Radix Lithospermi 4.5 g – GENG NIAN FANG (Two formulae) – Menopause Formulae – Formula I • Sheng Di Huang Radix Rehmanniae 9 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Han Lian Cao Herba Ecliptae 6 g • Suan Zao Ren Semen Zizyphi spinosae 6 g • Long Chi Fossilia Dentis mastodi 12 g • Gou Teng Ramulus Uncariae cum Uncis 6 g • Lian Xin Plumula Nelumbinis 6 g • Fu Ling Poria 6 g • He Huan Pi Cortex Albiziae 6 g • Zhi Cao Radix Lithospermi 4.5 g – Formula II • Yin Yang Huo Herba Epimedii 6 g
• Xian Mao Rhizoma Curculiginis 6 g • Huang Qi Radix Astragali 6 g • Dang Shen Radix Codonopsis 6 g • Suan Zao Ren Semen Zizyphi spinosae 4.5 g • Fang Ji Radix Stephaniae tetandrae 4.5 g • Fu Ling Poria 6 g • Lian Zi Xin Plumula Nelumbinis 6 g • Xu Duan Radix Dipsaci 6 g • He Huan Pi Cortex Albiziae 6 g – GENG NIAN LE – Happy Menopause • Chai Hu Radix Bupleuri 6 g • Dang Shen Radix Codonopsis 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Huang Qin Radix Scutellariae 4.5 g • Fu Xiao Mai Fructus Tritici levis 6 g • Da Zao Fructus jujubae 6 dates • Shan Zhi Zi Fructus Gardeniae 4.5 g • Zhen Zhu Mu Concha Margaritiferae usta 12 g
• Yin Yang Huo Herba Epimedii 6 g – GONG WAI YUN NO. I FORMULA – Ectopic Pregnancy Formula • Chi Shao Radix Paeoniae rubra 9 g • Dan Shen Radix Salviae miltiorrhizae 12 g • Tao Ren Semen Persicae 6 g – GONG WAI YUN NO. I FORMULA Variation (Chapter 30, Abdominal Pain During Pregnancy, Appendix: ectopic pregnancy, Blood stasis and Qi deficiency) – Ectopic Pregnancy Formula No. I Variation • Chi Shao Radix Paeoniae rubra 9 g • Dan Shen Radix Salviae miltiorrhizae 12 g • Tao Ren Semen Persicae 6 g • Dang Shen Radix Codonopsis 9 g • Huang Qi Radix Astragali 9 g – GONG WAI YUN NO. II FORMULA – Ectopic Pregnancy Formula No. II • Chi Shao Radix Paeoniae rubra 15 g • Dan Shen Radix Salviae miltiorrhizae 15 g • Tao Ren Semen Persicae 9 g • San Leng Rhizoma Sparganii 6 g • E Zhu Rhizoma Curcumae 6 g
– GONG ZHENG TANG – Attacking Upright Decoction • E Zhu Rhizoma Curcumae 9 g • San Leng Rhizoma Sparganii 6 g • Dang Gui Radix Angelicae sinensis 9 g • Tao Ren Semen Persicae 6 g • Chuan Shan Jia Squama Manitis 12 g • Wang Bu Liu Xing Semen Vaccariae 6 g • Chuan Niu Xi Radix Cyathulae 6 g • Xiang Fu Rhizoma Cyperi 6 g • Xu Duan Radix Dipsaci 6 g • Xia Ku Cao Spica Prunellae 6 g • Kun Bu Thallus Eckloniae 9 g • Yi Yi Ren Semen Coicis 12 g – GU BEN ZHI BENG TANG – Consolidating the Root and Stopping Flooding Decoction • Huang Qi Radix Astragali 15 g • Ren Shen Radix Ginseng 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 18 g • Shu Di Huang Radix Rehmanniae preparata 9 g
• Dang Gui Radix Angelicae sinensis 6 g • Pao Jiang Rhizoma Zingiberis recens (fried) 6 g – GU BEN ZHI BENG TANG Variation (Chapter 15, Bleeding between Periods, Spleen- and Kidney-Yang deficiency) – Consolidating the Root and Stopping Flooding Decoction Variation • Huang Qi Radix Astragali 15 g • Ren Shen Radix Ginseng 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 18 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Dang Gui Radix Angelicae sinensis 6 g • Pao Jiang Rhizoma Zingiberis recens (fried) 6 g • Du Zhong Cortex Eucommiae 6 g • Xu Duan Radix Dipsaci 6 g – GU BEN ZHI BENG TANG Variation (Chapter 43, Habitual Miscarriage, Spleen-Qi deficiency) – Consolidating the Root and Stopping Flooding Decoction Variation • Huang Qi Radix Astragali 15 g • Ren Shen Radix Ginseng 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 18 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Pao Jiang Rhizoma Zingiberis recens (fried) 6 g
• Sheng Ma Rhizoma Cimicifugae 3 g • Shan Yao Rhizoma Dioscoreae 6 g • Da Zao Fructus Jujubae 3 dates • Wu Zie Gu Endoconcha Sepiae 9 g – GU CHONG TANG – Consolidating the Penetrating Vessel Decoction • Bai Zhu Rhizoma Atractylodis macrocephalae 15 g • Huang Qi Radix Astragali 9 g • Long Gu Fossilia Ossis mastodi 12 g • Mu Li Concha Ostreae 12 g • Shan Zhu Yu Fructus Corni 12 g • Bai Shao Radix Paeoniae alba 6 g • Wu Zie Gu Endoconcha Sepiae 6 g • Qian Cao Gen Radix Rubiae 4.5 g • Zong Lu Zi Fructus Trachycarpi 4.5 g • Wu Wei Zi Fructus Schisandrae 1.5 g – GU YIN JIAN – Consolidating the Yin Decoction • Ren Shen Radix Ginseng 3 g • Shu Di Huang Radix Rehmanniae preparata 9 g
• Shan Yao Rhizoma Dioscoreae 6 g • Shan Zhu Yu Fructus Corni 4.5 g • Yuan Zhi Radix Polygalae 2.1 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Wu Wei Zi Fructus Schisandrae 3 g • Tu Si Zi Semen Cuscutae 6 g – GUA LOU SAN – Trichosanthes Powder • Gua Lou Fructus Trichosanthis 1 gourd • Gan Cao Radix Glycyrrhizae 1.5 g • Dang Gui Radix Angelicae sinensis 9 g • Ru Xiang Olibanum (fried with Deng Xin Cao Medulla Junci) 1.5 g • Mo Yao Myrrha (fried with Deng Xin Cao Medulla Junci) 1.5 g • Jin Yin Hua Flos Lonicerae 9 g • Bai Zhi Radix Angelicae dahuricae 3 g • Qing Pi Pericarpium Citri reticulatae viride 1.5 g – GUA LOU XIAO YAO SAN – Trichosanthes Free and Easy Wanderer Powder • Gua Lou Fructus Trichosanthis 6 g • Fu Ling Poria 6 g
• Yu Jin Radix Curcumae 6 g • Bai Shao Radix Paeoniae alba 6 g • Chai Hu Radix Bupleuri 6 g • Dang Gui Radix Angelicae sinensis 6 g • Xiang Fu Rhizoma Cyperi 6 g • Gan Cao Radix Glycyrrhizae 3 g • Bo He Herba Menthae haplocalycis 3 g • Lu Jiao Cornu Cervi 6 g – GUI PI TANG – Tonifying the Spleen Decoction • Ren Shen Radix Ginseng 6 g • Huang Qi Radix Astragali 15 g • Bai Zhu Rhizoma Atractylodis macrocephalae 12 g • Dang Gui Radix Angelicae sinensis 6 g • Fu Shen Sclerotium Poriae pararadicis 9 g • Suan Zao Ren Semen Zizyphi spinosae 9 g • Long Yan Rou Arillus longan 12 g • Yuan Zhi Radix Polygalae 9 g • Mu Xiang Radix Aucklandiae 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 4 g
• Sheng Jiang Rhizoma Zingiberis recens 3 slices • Hong Zao Fructus jujubae 5 dates – GUI PI TANG Variation (Chapter 34, Anxiety during Pregnancy, Heart-Blood deficiency) – Tonifying the Spleen Decoction Variation • Ren Shen Radix Ginseng 6 g • Huang Qi Radix Astragali 15 g • Bai Zhu Rhizoma Atractylodis macrocephalae 12 g • Dang Gui Radix Angelicae sinensis 6 g • Fu Shen Sclerotium Poriae pararadicis 9 g • Suan Zao Ren Semen Ziziphi spinosae 9 g • Long Yan Rou Arillus Longan 12 g • Yuan Zhi Radix Polygalae 9 g • Bai Zi Ren Semen Platycladi 9 g • Zhi Gan Cao Radix Glycyrrhizae preparata 4 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Hong Zao Fructus Jujubae 5 dates – GUI PI TANG Variation (Chapter 45, Post-Natal Depression, Heart-Blood deficiency) – Tonifying the Spleen Decoction Variation • Ren Shen Radix Ginseng 6 g
• Huang Qi Radix Astragali 15 g • Bai Zhu Rhizoma Atractylodis macrocephalae 12 g • Dang Gui Radix Angelicae sinensis 6 g • Fu Shen Sclerotium Poriae pararadicis 9 g • Suan Zao Ren Semen Ziziphi spinosae 9 g • Long Yan Rou Arillus Longan 12 g • Yuan Zhi Radix Polygalae 9 g • Mu Xiang Radix Aucklandiae 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 4 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Hong Zao Fructus Jujubae 5 dates • Long Chi Fossilia Dentis Mastodi 12 g – GUI RONG BU CHONG TANG – Plastrum Testudinis-Colla Cornu Cervi Tonifying the Penetrating Vessel Decoction • Dang Shen Radix Codonopsis 6 g • Huang Qi Radix Astragali 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Lu Jiao Jiao Colla Cornu Cervi 6 g • Ai Ye Folium Artemisiae argyi 4.5 g • Gui Ban Plastrum Testudinis 12 g
• Bai Shao Radix Paeoniae alba 6 g • Bao Jiang Rhizoma Zingiberis recens (fried) 6 g • Wu Zie Gu Endoconcha Sepiae 6 g – GUI SHAO DI HUANG TANG – Angelica-Paeonia-Rehmannia Decoction • Shu Di Huang Radix Rehmanniae preparata 9 g • Shan Yao Rhizoma Dioscoreae 6 g • Shan Zhu Yu Fructus Corni 6 g • Mu Dan Pi Cortex Moutan 6 g • Ze Xie Rhizoma Alismatis 6 g • Fu Ling Poria 6 g • Bai Shao Radix Paeoniae alba 6 g • Dang Gui Radix Angelicae sinensis 6 g – GUI SHAO DI HUANG TANG Variation (Chapter 18, Pre-Menstrual Syndrome, Liver-Blood deficiency) – Angelica-Paeonia-Rehmannia Decoction Variation • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 8 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Shan Yao Rhizoma Dioscoreae 6 g
• Shan Zhu Yu Fructus Corni 4 g • Ze Xie Rhizoma Alismatis 4 g • Mu Dan Pi Cortex Moutan 4 g • Fu Ling Poria 8 g • Qing Pi Pericarpium Citri reticulatae viride 4.5 g • Chai Hu Radix Bupleuri 6 g • He Huan Pi Cortex Albiziae 9 g – GUI SHEN WAN – Restoring the Kidneys Pill • Tu Si Zi Semen Cuscutae 6 g • Du Zhong Cortex Eucommiae 4 g • Gou Qi Zi Fructus Lycii 6 g • Shan Zhu Yu Fructus Corni 4 g • Dang Gui Radix Angelicae sinensis 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Fu Ling Poria 6 g – GUI ZHI CHAI HU TANG – Ramulus Cinnamomi-Bupleurum Decoction • Gui Zhi Ramulus Cinnamomi 6 g
• Bai Shao Radix Paeoniae alba 6 g • Sheng Jiang Rhizoma Zingiberis recens 2 slices • Da Zao Fructus jujubae 5 dates • Chai Hu Radix Bupleuri 6 g • Huang Qin Radix Scutellariae 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Dang Shen Radix Codonopsis 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – GUI ZHI FU LING WAN – Ramulus Cinnamomi-Poria Pill • Gui Zhi Ramulus Cinnamomi 9 g • Fu Ling Poria 9 g • Chi Shao Radix Paeoniae rubra 9 g • Mu Dan Pi Cortex Moutan 9 g • Tao Ren Semen Persicae 9 g – GUI ZHI FU LING WAN Variation (Chapter 60, Abdominal Masses, Ovarian cysts) – Ramulus Cinnamomi-Poria Pill Variation • Gui Zhi Ramulus Cinnamomi 15 g • Fu Ling Poria 15 g • Chi Shao Radix Paeoniae rubra 15 g
• Mu Dan Pi Cortex Moutan 15 g • Tao Ren Semen Persicae 15 g • Huang Yao Zi Rhizoma Dioscoreae bulbiferae 30 g • Ji Nei Jin Endothelium Corneum gigeriae galli 15 g • Shui Zhi Hirudo (as a powder) 15 g • Li Zhi He Semen Litchi 15 g • Wu Yao Radix Linderae 15 g – GUI ZHI FU LING WAN Variation (Chapter 67, Myoma, Blood stasis from Qi stagnation) – Ramulus Cinnamomi-Poria Pill Variation – Root formula plus: • Xiang Fu Rhizoma Cyperi 9 g • E Zhu Rhizoma Curcumae 6 g • San Leng Rhizoma Sparganii 6 g • Yi Yi Ren Semen Coicis 12 g • Hai Zao Sargassum 6 g – GUI ZHI FU LING WAN Variation (Chapter 67, Myoma, Blood stasis from Cold) – Ramulus Cinnamomi-Poria Pill Variation – Root formula (but increase Gui Zhi) plus: • E Zhu Rhizoma Curcumae 6 g
• San Leng Rhizoma Sparganii 6 g • Wu Zhu Yu Fructus Evodiae 3 g • Xiao Hui Xiang Fructus Foeniculi 6 g • Yi Yi Ren Semen Coicis 12 g • Hai Zao Sargassum 6 g – GUI ZHI FU LING WAN Variation (Chapter 67, Myoma, Blood stasis with Phlegm) – Ramulus Cinnamomi-Poria Pill Variation – Root formula plus: • Dang Gui Radix Angelicae sinensis 9 g • E Zhu Rhizoma Curcumae 6 g • San Leng Rhizoma Sparganii 6 g • Yi Yi Ren Semen Coicis 12 g • Hai Zao Sargassum 6 g • Zhe Bei Mu Bulbus Fritillariae thunbergii 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Dan Nan Xing Rhizoma Arisaematis preparatum 6 g – GUI ZHI FU LING WAN Variation (Chapter 67, Myoma, Blood stasis with Qi and Blood deficiency) – Ramulus Cinnamomi-Poria Pill Variation • Gui Zhi Ramulus Cinnamomi 9 g
• Fu Ling Poria 9 g • Chi Shao Radix Paeoniae rubra 9 g • Mu Dan Pi Cortex Moutan 9 g • Tao Ren Semen Persicae 9 g • Dang Gui Radix Angelicae sinensis 9 g • E Zhu Rhizoma Curcumae 6 g • San Leng Rhizoma Sparganii 6 g • Yi Yi Ren Semen Coicis 12 g • Hai Zao Sargassum 6 g • Ren Shen Radix Ginseng 6 g • Tu Si Zi Semen Cuscutae 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g – GUI ZHI FU LING WAN Variation (Chapter 67, Myoma, Blood stasis with Kidney-Yang deficiency) – Ramulus Cinnamomi-Poria Pill Variation • Gui Zhi Ramulus Cinnamomi 9 g • Fu Ling Poria 9 g • Chi Shao Radix Paeoniae rubra 9 g • Mu Dan Pi Cortex Moutan 9 g • Tao Ren Semen Persicae 9 g
• Dang Gui Radix Angelicae sinensis 9 g • E Zhu Rhizoma Curcumae 6 g • San Leng Rhizoma Sparganii 6 g • Yi Yi Ren Semen Coicis 12 g • Hai Zao Sargassum 6 g • Ren Shen Radix Ginseng 6 g • Tu Si Zi Semen Cuscutae 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Xu Duan Radix Dipsaci 9 g • Du Zhong Cortex Eucommiae 6 g – GUO QI YIN – Beyond Phase Decoction • Shu Di Huang Radix Rehmanniae preparata 12 g • Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Tao Ren Semen Persicae 6 g • Hong Hua Flos Carthami 3 g • Xiang Fu Rhizoma Cyperi 6 g
• E Zhu Rhizoma Curcumae 3 g • Rou Gui Cortex Cinnamomi 1.5 g • Mu Xiang Radix Aucklandiae 3 g • Mu Tong Caulis Akebiae 2 g • Gan Cao Radix Glycyrrhizae 3 g – HE XUE ZHI YANG TANG – Harmonizing Blood and Stopping Itching Decoction • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Shou Wu Radix Polygoni multiflori preparata 6 g • Bai Xian Pi Cortex Dictamni 6 g • Di Fu Zi Fructus Kochiae 6 g • Bai Ji Li Fructus Tribuli 4.5 g – HU PO SAN – Succinum Powder • Hu Po Succinum 6 g • San Leng Rhizoma Sparganii 6 g • E Zhu Rhizoma Curcumae 6 g • Chi Shao Yao Radix Paeoniae rubra 6 g
• Dang Gui Radix Angelicae sinensis 6 g • Liu Ji Nu Herba Artemisiae anomalae 6 g • Mu Dan Pi Cortex Moutan 6 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Rou Gui Cortex Cinnamomi 2 g • Wu Yao Radix Linderae 6 g • Yan Hu Suo Rhizoma Corydalis 6 g – HUA GAN JIAN – Transforming the Liver Decoction • Qing Pi Pericarpium Citri reticulatae viride 6 g • Chen Pi Pericarpium Citri reticulatae 6 g • Bai Shao Radix Paeoniae alba 6 g • Mu Dan Pi Cortex Moutan 4.5 g • Shan Zhi Zi Fructus Gardeniae 4.5 g • Ze Xie Rhizoma Alismatis 4.5 g • Chuan Bei Mu Bulbus Fritillariae cirrhosae 6 g – HUA JI WAN – Resolving Blood Masses Pill • San Leng Rhizoma Sparganii 6 g • E Zhu Rhizoma Curcumae 6 g
• Wu Ling Zhi Faeces Trogopterori 6 g • Su Mu Lignum Sappan 4.5 g • Xiang Fu Rhizoma Cyperi 6 g • Bing Lang Semen Arecae 6 g • Xiong Huang Realgar 1.5 g • Wa Leng Zi Concha Arcae 15 g • A Wei Herba Ferulae assafoetidae 6 g • Hai Fu Shi Pumex 15 g – HUA MAI SAN – Rescuing the Pulse Powder • Da Huang Radix et Rhizoma Rhei 10.5 g • Bai Zhi Radix Angelicae dahuricae 1.5 g • Ru Xiang Olibanum 1.5 g • Mo Yao Myrrha 1.5 g • Chuan Shan Jia Squama Manitis (fried with Hai Ge Ke Concha Meretricis seu Cyclinae) 1.5 g • Ren Shen Radix Ginseng 6 g • Mu Xiang Radix Aucklandiae 1.5 g – HUA SHUI ZHONG ZI TANG – Transforming Water and Planting a Seed Decoction • Ba Ji Tian Radix Morindae officinalis 15 g
• Bai Zhu Rhizoma Atractylodis macrocephalae 15 g • Fu Ling Poria 9 g • Ren Shen Radix Ginseng 9 g • Tu Si Zi Semen Cuscutae 12 g • Qian Shi Semen Euryales 12 g • Che Qian Zi Semen Plantaginis 6 g • Rou Gui Cortex Cinnamomi 3 g – HUA YU DING TONG TANG – Eliminating Stasis and Stopping Pain Decoction • Dang Gui Radix Angelicae sinensis 9 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Chuan Niu Xi Radix Cyathulae 6 g • Chi Shao Radix Paeoniae rubra 6 g • Xue Jie Resina Daemonoropis 4.5 g • Mo Yao Myrrha 6 g • Xiang Fu Rhizoma Cyperi 4.5 g • Su Mu Lignum Sappan 4.5 g • Yan Hu Suo Rhizoma Corydalis 6 g • Wu Ling Zhi Faeces Trogopterori 4.5 g
• Pu Huang Pollen Typhae 4.5 g – HUA YU LIAO ZHI TANG – Eliminating Stasis and Treating Haemorrhoids Decoction • Huai Hua Flos Sophorae immaturus 9 g • Di Yu Radix Sanguisorbae 6 g • Ku Shen Radix Sophorae flavescentis 9 g • Mo Yao Myrrha 6 g • Chi Shao Radix Paeoniae rubra 6 g • Mu Dan Pi Cortex Moutan 9 g • Yan Hu Suo Rhizoma Corydalis 6 g • Tao Ren Semen Persicae 6 g • Hong Hua Flos Carthami 4 g • Ji Xue Teng Caulis Spatholobi 6 g – HUANG LIAN E JIAO TANG – Coptis-Colla Corii asini Decoction • Huang Lian Rhizoma Coptidis 3 g • Huang Qin Radix Scutellariae 9 g • Bai Shao Radix Paeoniae alba 9 g • Ji Zi Huang Egg yolk 2 yolks • E Jiao Colla Corii asini 9 g
– HUANG LIAN JIE DU TANG – Coptis Expelling Toxin Decoction • Huang Lian Rhizoma Coptidis 9 g • Huang Qin Radix Scutellariae 6 g • Huang Bo Cortex Phellodendri 6 g • Shan Zhi Zi Fructus Gardeniae 6 g – HUANG QI DANG GUI SAN – Astragalus-Angelica Powder • Huang Qi Radix Astragali 9 g • Ren Shen Radix Ginseng 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Gan Cao Radix Glycyrrhizae 3 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Da Zao Fructus Jujubae 3 dates – HUANG QI GUI ZHI WU WU TANG – Astragalus-Ramulus Cinnamomi Five Substances Decoction • Huang Qi Radix Astragali 9 g • Bai Shao Radix Paeoniae alba 9 g
• Gui Zhi Ramulus Cinnamomi 9 g • Sheng Jiang Rhizoma Zingiberis recens 18 g • Da Zao Fructus jujubae 12 dates – HUANG QI GUI ZHI WU WU TANG Variation (Chapter 52, Joint Pain after Childbirth, Blood deficiency) – Astragalus-Ramulus Cinnamomi Five Substances Decoction Variation • Huang Qi Radix Astragali 9 g • Bai Shao Radix Paeoniae alba 9 g • Gui Zhi Ramulus Cinnamomi 9 g • Sheng Jiang Rhizoma Zingiberis recens 18 g • Da Zao Fructus Jujubae 12 dates • Qin Jiao Radix Gentianae macrophyllae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Ji Xue Teng Caulis Spatholobi 6 g – HUANG QI JIAN ZHONG TANG – Astragalus Strengthening the Centre Decoction • Huang Qi Radix Astragali 9 g • Bai Shao Radix Paeoniae alba 18 g • Gui Zhi Ramulus Cinnamomi 9 g • Zhi Gan Cao Radix Glycyrrhizae preparata 6 g • Sheng Jiang Rhizoma Zingiberis recens 10 g
• Da Zao Fructus jujubae 12 dates • Yi Tang Maltosum 30 g – HUANG QI TANG – Astragalus Decoction • Huang Qi Radix Astragali 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fang Feng Radix Saposhnikoviae 3 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Mu Li Concha Ostreae 9 g • Fu Ling Poria 6 g • Mai Men Dong Radix Ophiopogonis 4.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 2 g • Da Zao Fructus jujubae 3 dates – HUI MAI SAN – Rescuing the Pulse Powder • Da Huang Radix et Rhizoma Rhei 10.5 g • Bai Zhi Radix Angelicae dahuricae 1.5 g • Ru Xiang Olibanum 1.5 g • Mo Yao Myrrha 1.5 g • Chuan Shan Jia Squama Manitis (fried with Hai Ge Ke Concha Meretricis seu Cyclinae) 1.5 g
• Ren Shen Radix Ginseng 6 g • Mu Xiang Radix Aucklandiae 1.5 g – HUO PO XIA LING TANG – Agastache-Magnolia-Pinellia-Poria Decoction • Huo Xiang Herba Pogostemonis 6 g • Bai Dou Kou Fructus Amomi rotundus 2 g • Hou Po Cortex Magnoliae officinalis 3 g • Fu Ling Poria 9 g • Zhu Ling Polyporus 4.5 g • Yi Yi Ren Semen Coicis 12 g • Ze Xie Rhizoma Alismatis 4.5 g • Ban Xia Rhizoma Pinelliae preparatum 4.5 g • Dan Dou Chi Semen Sojae preparatum 9 g • Xing Ren Semen Armeniacae 9 g – JI CHUAN JIAN – Benefiting the River Decoction • Dang Gui Radix Angelicae sinensis 9 g • Niu Xi Radix Achyranthis bidentatae seu Cyathulae 6 g • Rou Cong Rong Herba Cistanches 6 g • Ze Xie Rhizoma Alismatis 4.5 g
• Zhi Ke Fructus Aurantii 3 g • Sheng Ma Rhizoma Cimicifugae 1.5 g – JI SHENG SHEN QI WAN – Kidney-Qi Pill from Formulae to Aid the Living • Shu Di Huang Radix Rehmanniae preparata 15 g • Shan Zhu Yu Fructus Corni 30 g • Shan Yao Rhizoma Dioscoreae 30 g • Ze Xie Rhizoma Alismatis 30 g • Fu Ling Poria 30 g • Mu Dan Pi Cortex Moutan 30 g • Rou Gui Cortex Cinnamomi 15 g • Fu Zi Radix Aconiti lateralis preparata 15 g • Chuan Niu Xi Radix Cyathulae 15 g • Che Qian Zi Semen Plantaginis 30 g – JIA JIAN BU ZHONG YI QI TANG – Modified Tonifying the Centre and Benefiting Qi Decoction • Ren Shen Radix Ginseng 15 g • Huang Qi Radix Astragali 9 g • Chai Hu Radix Bupleuri 3 g • Gan Cao Radix Glycyrrhizae 1.5 g
• Dang Gui Radix Angelicae sinensis 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 15 g • Fu Ling Poria 30 g • Sheng Ma Rhizoma Cimicifugae 1.5 g • Chen Pi Pericarpium Citri reticulatae 1.5 g – JIA JIAN SI WU TANG – Modified Four Substances Decoction • Shu Di Huang Radix Rehmanniae preparata 30 g • Bai Shao Radix Paeoniae alba 9 g • Dang Gui Radix Angelicae sinensis 15 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 15 g • Jing Jie Herba Schizonepetae 9 g • Shan Zhu Yu Fructus Corni 9 g • Xu Duan Radix Dipsaci 3 g • Gan Cao Radix Glycyrrhizae 3 g – JIA JIAN XIAO YAO SAN by Fu Qing Zhu (Chapter 61, Excessive Vaginal Discharge) – Modified Free and Easy Wanderer Powder • Fu Ling Poria 15 g • Bai Shao Radix Paeoniae alba 15 g
• Gan Cao Radix Glycyrrhizae 15 g • Chai Hu Radix Bupleuri 3 g • Yin Chen Hao Herba Artemisiae scopariae 9 g • Chen Pi Pericarpium Citri reticulatae 3 g • Shan Zhi Zi Fructus Gardeniae 9 g – JIA WEI LIU JUN ZI TANG – Augmented Six Gentlemen Decoction • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 4.5 g • Fu Ling Poria 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Chen Pi Pericarpium Citri reticulatae 3 g • Ban Xia Rhizoma Pinelliae preparatum 4.5 g • Pi Pa Ye Folium Eriobotryae 4.5 g • Huo Xiang Herba Pogostemonis 3 g • Xuan Fu Hua Flos Inulae 3 g • Zhi Ke Fructus Aurantii 4.5 g • Sha Ren Fructus Amomi 3 g – JIA WEI WU LIN SAN – Augmented Five ‘Lin’ Powder
• Fu Ling Poria 6 g • Dang Gui Radix Angelicae sinensis 4.5 g • Gan Cao Radix Glycyrrhizae 6 g • Chi Shao Radix Paeoniae rubra 4.5 g • Shan Zhi Zi Fructus Gardeniae 4.5 g • Sheng Di Huang Radix Rehmanniae 6 g • Ze Xie Rhizoma Alismatis 6 g • Che Qian Zi Semen Plantaginis 6 g • Hua Shi Talcum 6 g • Mu Tong Caulis Akebiae 3 g – JIA WEI XIAO YAO SAN – Augmented Free and Easy Wanderer Powder • Dang Gui Radix Angelicae sinensis 3 g • Bai Shao Radix Paeoniae alba 3 g • Fu Ling Poria 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 3 g • Chai Hu Radix Bupleuri 3 g • Bo He Herba Menthae haplocalycis 3 g • Mu Dan Pi Cortex Moutan 1.5 g • Shan Zhi Zi Fructus Gardeniae 1.5 g
• Zhi Gan Cao Radix Glycyrrhizae preparata 1.5 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices – JIA WEI XIAO YAO SAN – Variation of Free and Easy Wanderer Powder • Chai Hu Radix Bupleuri 9 g • Qing Pi Pericarpium Citri reticulatae viride 6 g • Chen Pi Pericarpium Citri reticulatae 6 g • Yu Jin Radix Curcumae 9 g • Xiang Fu Rhizoma Cyperi 9 g • Ju He Semen Citri reticulatae 15 g • Ban Xia Rhizoma Pinelliae preparatum 9 g • Gua Lou Fructus Trichosanthis 15 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 12 g – JIA WEI YANG HE TANG – Variation of Yang-Harmonizing Decoction • Gan Jiang Rhizoma Zingiberis 1.5 g • Rou Gui Cortex Cinnamomi 3 g • Ma Huang Herba Ephedrae 1.5 g • Bai Jie Zi Semen Sinapis 9 g
• Lu Jiao Jiao Colla Cornu Cervi 9 g • Shu Di Huang Radix Rehmanniae preparata 30 g • Xiang Fu Rhizoma Cyperi 9 g • Qing Pi Pericarpium Citri reticulatae viride 15 g • Chen Pi Pericarpium Citri reticulatae 15 g • Yu Jin Radix Curcumae 9 g – JIAN GU TANG – Strengthening and Consolidating Decoction • Ren Shen Radix Ginseng 9 g • Fu Ling Poria 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Ba Ji Tian Radix Morindae officinalis 15 g • Yi Yi Ren Semen Coicis 9 g – JIAN PI SHU YU TANG – Strengthening the Spleen and Pacifying Stagnation Decoction • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Yi Yi Ren Semen Coicis 9 g • Xiang Fu Rhizoma Cyperi 6 g
• Chuan Lian Zi Fructus Toosendan 3 g • He Huan Pi Cortex Albiziae 6 g • Tong Cao Medulla Tetrapanacis 3 g – JIAO AI TANG – Colla Corii Asini-Artemisia Decoction • E Jiao Colla Corii asini 6 g • Ai Ye Folium Artemisiae argyi 9 g • Sheng Di Huang Radix Rehmanniae 18 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Bai Shao Radix Paeoniae alba 12 g • Zhi Gan Cao Radix Glycyrrhizae preparata 6 g – JIAO AI TANG Variation (Chapter 30, Abdominal Pain during Pregnancy, Blood deficiency) – Colla Corii Asini-Artemisia Decoction Variation • Sheng Di Huang Radix Rehmanniae 6 g • Dang Gui Radix Angelicae sinensis 4 g • Bai Shao Radix Paeoniae alba 6 g • E Jiao Colla Corii asini 9 g • Gou Qi Zi Fructus Lycii 6 g • Ai Ye Folium Artemisiae argyi 4 g
• Mu Xiang Radix Aucklandiae 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – JIE DU HUO XUE TANG – Expelling Toxin Invigorating Blood Decoction • Lian Qiao Fructus Forsythiae 6 g • Ge Gen Radix Puerariae 6 g • Chai Hu Radix Bupleuri 4.5 g • Gan Cao Radix Glycyrrhizae 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Chi Shao Radix Paeoniae rubra 4.5 g • Dang Gui Radix Angelicae sinensis 6 g • Hong Hua Flos Carthami 3 g • Tao Ren Semen Persicae 4.5 g • Zhi Ke Fructus Aurantii 6 g • Bai Shao Radix Paeoniae alba 6 g – JIE DU HUO XUE TANG Variation (Chapter 51, Fever after Childbirth, Invasion of external Toxins) – Expelling Toxin Invigorating Blood Decoction Variation • Lian Qiao Fructus Forsythiae 6 g • Ge Gen Radix Puerariae 6 g • Chai Hu Radix Bupleuri 4.5 g
• Gan Cao Radix Glycyrrhizae 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Chi Shao Radix Paeoniae rubra 4.5 g • Dang Gui Radix Angelicae sinensis 6 g • Hong Hua Flos Carthami 3 g • Tao Ren Semen Persicae 4.5 g • Zhi Ke Fructus Aurantii 6 g • Bai Shao Radix Paeoniae alba 6 g • Jin Yin Hua Flos Lonicerae 6 g – JIE DU SI WU TANG – Expelling Toxin Four Substances Decoction • Huang Lian Rhizoma Coptidis 3 g • Huang Qin Radix Scutellariae 4 g • Huang Bo Cortex Phellodendri 6 g • Shan Zhi Zi Fructus Gardeniae 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g – JIE DU SI WU TANG Variation (Chapter 11, Heavy Periods, Blood-Heat)
– Expelling Toxin Four Substances Decoction Variation • Huang Lian Rhizoma Coptidis 3 g • Huang Qin Radix Scutellariae 4 g • Huang Bo Cortex Phellodendri 6 g • Shan Zhi Zi Fructus Gardeniae 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Bai Jiang Cao Herba Patriniae 6 g • Mu Dan Pi Cortex Moutan 6 g – JIE DU SI WU TANG Variation (Chapter 13, Long Periods, Blood-Heat) – Expelling Toxin Four Substances Decoction Variation • Huang Lian Rhizoma Coptidis 3 g • Huang Qin Radix Scutellariae 4 g • Huang Bo Cortex Phellodendri 6 g • Shan Zhi Zi Fructus Gardeniae 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g
• Chuan Xiong Rhizoma Chuanxiong 4.5 g • Bai Jiang Cao Herba Patriniae 6 g • Mu Dan Pi Cortex Moutan 6 g – JIN GUI SHEN QI WAN – Golden Chest Kidney-Qi Pill • Fu Zi Radix Aconiti lateralis preparata 3 g • Gui Zhi Ramulus Cinnamomi 3 g • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Ze Xie Rhizoma Alismatis 9 g • Mu Dan Pi Cortex Moutan 9 g • Fu Ling Poria 9 g – JIN GUI SHEN QI WAN Variation (Chapter 41, Retention of Urine in Pregnancy, Kidney-Qi deficient and sinking) – Golden Chest Kidney-Qi Pill Variation • Fu Zi Radix Aconiti lateralis preparata 3 g • Gui Zhi Ramulus Cinnamomi 3 g • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g
• Ze Xie Rhizoma Alismatis 9 g • Mu Dan Pi Cortex Moutan 9 g • Fu Ling Poria 9 g • Ba Ji Tian Radix Morindae 6 g • Tu Si Zi Semen Cuscutae 6 g – JIN LING ZI SAN – Toosendan Powder • Jin Ling Zi (also called Chuan Lian Zi) Fructus Toosendan 30 g • Yan Hu Suo Rhizoma Corydalis 30 g – JING FANG SI WU TANG – Schizonepeta-Ledebouriella Four Substances Decoction • Jing Jie Herba Schizonepetae 4.5 g • Fang Feng Radix Saposhnikoviae 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Bai Shao Radix Paeoniae alba 6 g • Zi Su Ye Folium Perillae 3 g – JING QIN SI WU TANG – Schizonepeta-Scutellaria Four Substances Decoction
• Shu Di Huang Radix Rehmanniae preparata 12 g • Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Jing Jie Herba Schizonepetae (charred) 6 g • Huang Qin Radix Scutellariae 6 g – JU HE WAN – Semen Citri reticulatae Pill • Ju He Semen Citri reticulatae 6 g • Li Zhi He Semen Litchi 6 g • Xiao Hui Xiang Fructus Foeniculi 4.5 g – JU PI ZHU RU TANG – Tangerine Peel-Bambusa Decoction • Ju Pi Pericarpium Citri reticulatae 10 g • Zhu Ru Caulis Bambusae in taeniam 12 g • Sheng Jiang Rhizoma Zingiberis recens 12 g • Dang Shen Radix Codonopsis 12 g • Gan Cao Radix Glycyrrhizae 6 g • Da Zao Fructus jujubae 5 pieces – JU YUAN JIAN
– Raising the Original [Qi] Decoction • Ren Shen Radix Ginseng 9 g • Huang Qi Radix Astragali 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sheng Ma Rhizoma Cimicifugae 1.5 g – JU YUAN JIAN Variation (Chapter 8, Early Periods, Spleen-Qi deficiency) – Raising the Original [Qi] Decoction Variation • Ren Shen Radix Ginseng 9 g • Huang Qi Radix Astragali 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sheng Ma Rhizoma Cimicifugae 1.5 g • E Jiao Colla Corii asini 9 g • Hai Piao Xiao Endoconcha Sepiae 6 g – KAI YU ZHENG YUAN SAN – Opening Stagnation Upright Original [Qi] Powder • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Qing Pi Pericarpium Citri reticulatae viride 3 g
• Xiang Fu Rhizoma Cyperi 6 g • Shan Zha Fructus Crataegi 6 g • Hai Fen Notharcus leachii freeri 6 g • Jie Geng Radix Platycodi 3 g • Fu Ling Poria 6 g • Sha Ren Fructus Amomi 3 g • Yan Hu Suo Rhizoma Corydalis 6 g • Shen Qu Massa medicata fermentata 6 g • Mai Ya Fructus Hordei germinatus 6 g – KAI YU ZHONG YU TANG – Opening Stagnation and Growing Jade Decoction • Dang Gui Radix Angelicae sinensis 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Bai Shao Radix Paeoniae alba 6 g • Fu Ling Poria 6 g • Mu Dan Pi Cortex Moutan 4.5 g • Xiang Fu Rhizoma Cyperi 9 g • Tian Hua Fen Radix Trichosanthis 6 g – KUN BAO TANG – Female Treasure Decoction
• Sheng Di Huang Radix Rehmanniae 9 g • Bai Shao Radix Paeoniae alba 9 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Ju Hua Flos Chrysanthemi 6 g • Huang Qin Radix Scutellariae 4.5 g • Suan Zao Ren Semen Zizyphi spinosae 6 g • Long Chi Fossilia Dentis mastodi 12 g – LI HUO TANG – Drain Fire Decoction • Da Huang Radix et Rhizoma Rhei 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 15 g • Fu Ling Poria 9 g • Che Qian Zi Semen Plantaginis 9 g • Wang Bu Liu Xing Semen Vaccariae 9 g • Huang Lian Rhizoma Coptidis 9 g • Shan Zhi Zi Fructus Gardeniae 9 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Shi Gao Gypsum fibrosum 15 g • Liu Ji Nu Herba Artemisiae anomalae 9 g – LI QI SAN YU TANG
– Regulating Qi and Eliminating Stasis Decoction • Ren Shen Radix Ginseng 30 g • Huang Qi Radix Astragali 30 g • Dang Gui Radix Angelicae sinensis 15 g • Fu Ling Poria 9 g • Hong Hua Flos Carthami 3 g • Mu Dan Pi Cortex Moutan 9 g • Jiang Tan Rhizoma Zingiberis recens (charred) 15 g – LI QI XIE HUO TANG – Freeing Qi and Clearing Fire Decoction • Ren Shen Radix Ginseng 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 30 g • Gan Cao Radix Glycyrrhizae 3 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 15 g • Qian Shi Semen Euryales 9 g • Huang Qin Radix Scutellariae 6 g – LI YU TANG – Carp Decoction
• Carp Cyprinus carpio one fish (about 1–2 pounds) • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Dang Gui Radix Angelicae sinensis 4 g • Bai Shao Radix Paeoniae alba 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices – LI ZHONG WAN – Regulating the Centre Pill • Ren Shen Radix Ginseng 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Gan Jiang Rhizoma Zingiberis 5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 6 g – LI ZHONG WAN Variation (Chapter 29, Morning Sickness, Stomach-Qi deficiency with Empty-Cold) – Regulating the Centre Pill Variation • Ren Shen Radix Ginseng 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Gan Jiang Rhizoma Zingiberis 5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 6 g • Sha Ren Fructus Amomi 3 g – LIANG DI TANG
– Two ‘Di’ Decoction • Sheng Di Huang Radix Rehmanniae 18 g • Di Gu Pi Cortex Lycii 9 g • Xuan Shen Radix Scrophulariae 12 g • Mai Men Dong Radix Ophiopogonis 9 g • Bai Shao Radix Paeoniae alba 12 g • E Jiao Colla Corii asini 9 g – LIANG GE SAN – Cooling the Diaphragm Powder • Da Huang Radix et Rhizoma Rhei 600 g • Mang Xiao Sulfas Natrii 600 g • Gan Cao Radix Glycyrrhizae 600 g • Huang Qin Radix Scutellariae 300 g • Shan Zhi Zi Fructus Gardeniae 300 g • Lian Qiao Fructus Forsythiae 1200 g • Bo He Herba Menthae haplocalycis 300 g • Zhu Ye Folium Phyllostachys nigrae (to make a tea into which the powder is dissolved) 3 g – LIANG SHOU TANG – Two Receiving Decoction • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g
• Ren Shen Radix Ginseng 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Shan Zhu Yu Fructus Corni 4 g • Qian Shi Semen Euryales 4 g • Bian Dou Semen Lablab album 4 g • Ba Ji Tian Radix Morindae officinalis 6 g • Du Zhong Cortex Eucommiae 6 g • Bai Guo Semen Ginkgo 4 g – LIANG XUE CHU SHI TANG – Cooling Blood and Expelling Dampness Decoction • Sheng Di Huang Radix Rehmanniae 9 g • Mu Dan Pi Cortex Moutan 9 g • Chi Shao Radix Paeoniae rubra 6 g • Fu Ling Poria 6 g • Chi Xiao Dou Semen Phaseoli 6 g • Yi Yi Ren Semen Coicis 18 g • Bai Xian Pi Cortex Dictami 9 g • Xi Xian Cao Herba Siegesbeckiae 6 g
• Di Fu Zi Fructus Kochiae 6 g • Ku Shen Radix Sophorae flavescentis X g – LING GUI ZHU GAN TANG – Poria-Ramulus Cinnamomi-Atractylodes-Glycyrrhiza Decoction • Fu Ling Poria 12 g • Gui Zhi Ramulus Cinnamomi 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – LING GUI ZHU GAN TANG Variation (Chapter 21, Oedema during Periods, Spleen- and Kidney-Yang deficiency) – Poria-Ramulus Cinnamomi-Atractylodes-Glycyrrhiza Decoction Variation • Fu Ling Poria 12 g • Gui Zhi Ramulus Cinnamomi 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Bu Gu Zhi Fructus Psoraleae 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Ba Ji Tian Radix Morindae 6 g – LING JIAO GOU TENG TANG – Cornu Antelopis-Uncaria Decoction • Ling Yang Jiao Cornu Saigae tataricae 4.5 g
• Gou Teng Ramulus Uncariae cum Uncis 9 g • Sang Ye Folium Mori 6 g • Ju Hua Flos Chrysanthemi 9 g • Bai Shao Radix Paeoniae alba 9 g • Sheng Di Huang Radix Rehmanniae 15 g • Fu Shen Sclerotium Poriae pararadicis 9 g • Chuan Bei Mu Bulbus Fritillariae cirrhosae 12 g • Zhu Ru Caulis Bambusae in taeniam 15 g • Gan Cao Radix Glycyrrhizae 2.5 g – LIU JUN ZI TANG – Six Gentlemen Decoction • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 4.5 g • Fu Ling Poria 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Chen Pi Pericarpium Citri reticulatae 3 g • Ban Xia Rhizoma Pinelliae preparatum 4.5 g – LIU MO TANG – Six Ground-Herbs Decoction • Mu Xiang Radix Aucklandiae 6 g
• Wu Yao Radix Linderae 6 g • Chen Xiang Lignum Aquilariae resinatum 4.5 g • Da Huang Radix et Rhizoma Rhei 6 g • Bing Lang Semen Arecae 6 g • Zhi Shi Fructus Aurantii immaturus 6 g – LIU MO TANG Variation (Chapter 42, Constipation during Pregnancy, Liver-Qi stagnation) – Six Ground-Herbs Decoction Variation • Mu Xiang Radix Aucklandiae 6 g • Wu Yao Radix Linderae 6 g • Chen Xiang Lignum Aquilariae resinatum 3 g • Bing Lang Semen Arecae 6 g • Zhi Ke Fructus Aurantii 6 g – LIU WEI DI HUANG WAN – Six-Ingredient Rehmannia Pill • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Ze Xie Rhizoma Alismatis 9 g • Mu Dan Pi Cortex Moutan 9 g • Fu Ling Poria 9 g
– LIU WEI DI HUANG WAN Variation (Chapter 38, Aphonia during Pregnancy, Kidney-Yin deficiency) – Six-Ingredient Rehmannia Pill Variation • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Ze Xie Rhizoma Alismatis 9 g • Mu Dan Pi Cortex Moutan 9 g • Fu Ling Poria 9 g • Bei Sha Shen Radix Glehniae 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Tian Men Dong Radix Asparagi 6 g • Lian Zi Xin Semen Nelumbinis 6 g – LONG DAN XIE GAN TANG – Gentiana Draining the Liver Decoction • Long Dan Cao Radix Gentianae 6 g • Huang Qin Radix Scutellariae 9 g • Shan Zhi Zi Fructus Gardeniae 9 g • Ze Xie Rhizoma Alismatis 9 g • Mu Tong Caulis Akebiae 9 g • Che Qian Zi Semen Plantaginis 9 g
• Sheng Di Huang Radix Rehmanniae 12 g • Dang Gui Radix Angelicae sinensis 9 g • Chai Hu Radix Bupleuri 9 g • Gan Cao Radix Glycyrrhizae 3 g – LONG DAN XIE GAN TANG Variation (Chapter 20, Headaches during Periods, Liver-Fire) – Gentiana Draining the Liver Decoction Variation • Long Dan Cao Radix Gentianae 6 g • Huang Qin Radix Scutellariae 9 g • Shan Zhi Zi Fructus Gardeniae 9 g • Ze Xie Rhizoma Alismatis 9 g • Mu Tong Caulis Akebiae 9 g • Che Qian Zi Semen Plantaginis 9 g • Sheng Di Huang Radix Rehmanniae 12 g • Dang Gui Radix Angelicae sinensis 9 g • Chai Hu Radix Bupleuri 9 g • Gan Cao Radix Glycyrrhizae 3 g • Gou Teng Ramulus Uncariae cum Uncis 6 g • Bai Ji Li Fructus Tribuli 3 g – LOU JU CI GU TANG – Trichosanthes-Chrysanthemum- Shancigu Decoction
• Gua Lou Pi Pericarpium Trichosanthis 6 g • Ju Hua Flos Chrysanthemi 6 g • Shan Ci Gu Pseudobulbus Cremastrae 6 g • Xia Ku Cao Spica Prunellae 6 g • Jin Yin Hua Flos Lonicerae 6 g • Lian Qiao Fructus Forsythiae 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Ru Xiang Olibanum 6 g • Mo Yao Myrrha 6 g • Shan Dou Gen Radix Sophorae tonkinensis 6 g – LU PU TANG – Cornu Cervi-Taraxacum Decoction • Lu Jiao Cornu Cervi 24–45 g • Pu Gong Ying Herba Taraxaci 30 g • Shan Ci Gu Pseudobulbus Cremastrae 10 g – MAI MEN DONG TANG – Ophiopogon Decoction • Mai Men Dong Radix Ophiopogonis 60g • Ban Xia Rhizoma Pinelliae preparatum 9g • Ren Shen Radix Ginseng 6g
• Zhi Gan Cao Radix Glycyrrhizae preparata 4g • Geng Mi Semen Oryzae sativae 6g • Da Zao Fructus jujubae 3 dates – MIE DI ZHI YANG TANG – Killing Trichomonas and Stopping Itching Decoction • Bi Xie Rhizoma Dioscoreae hypoglaucae 12 g • Yi Yi Ren Semen Coicis 30 g • Huang Bo Cortex Phellodendri 15 g • Fu Ling Poria 9 g • Mu Dan Pi Cortex Moutan 9 g • Ze Xie Rhizoma Alismatis 9 g • Hua Shi Talcum 15 g • Zhi Mu Rhizoma Anemarrhenae 9 g • He Shi Fructus Carpesii abrotanoidis 9 g • Cang Zhu Rhizoma Atractylodis 15 g – MU XIANG LIU QI YIN – Aucklandia Flowing Qi Decoction • Mu Xiang Radix Aucklandiae 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Chen Pi Pericarpium Citri reticulatae 3 g
• Hou Po Cortex Magnoliae officinalis 4.5 g • Qing Pi Pericarpium Citri reticulatae viride 3 g • Gan Cao Radix Glycyrrhizae 3 g • Xiang Fu Rhizoma Cyperi 6 g • Zi Su Ye Folium Perillae 3 g • Ren Shen Radix Ginseng 6 g • Fu Ling Poria 6 g • Mu Gua Fructus Chaenomelis 3 g • Shi Chang Pu Rhizoma Acori tatarinowii 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 4.5 g • Bai Zhi Radix Angelicae dahuricae 3 g • Mai Men Dong Radix Ophiopogonis 6 g • Cao Guo Fructus Tsaoko 3 g • Rou Gui Cortex Cinnamomi 1.5 g • E Zhu Rhizoma Curcumae 3 g • Da Fu Pi Pericarpium Arecae 3 g • Ding Xiang Flos Caryophylli 3 g • Bing Lang Semen Arecae 3 g • Huo Xiang Herba Pogostemonis 3 g • Mu Tong Caulis Akebiae 1.5 g
– NAN CHANG FANG – Difficult Labour Formula • Huang Qi Radix Astragali 15 g • Dang Gui Radix Angelicae sinensis 9 g • Fu Shen Sclerotium Poriae pararadicis 6 g • Dang Shen Radix Codonopsis 9 g • Gui Ban Plastrum Testudinis (toasted with vinegar) 12 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Bai Shao Radix Paeoniae alba (fried with wine) 6 g • Gou Qi Zi Fructus Lycii 9 g – NEI BU WAN – Inner Tonification Pill • Lu Rong Cornu Cervi pantotrichum 3 g • Tu Si Zi Semen Cuscutae 6 g • Rou Cong Rong Herba Cistanches 6 g • Sha Yuan Zi Semen Astragali complanati 6 g • Huang Qi Radix Astragali 6 g • Sang Piao Xiao Ootheca Mantidis 6 g • Rou Gui Cortex Cinnamomi 2 g • Fu Zi Radix Aconiti lateralis preparata 2 g
• Bai Ji Li Fructus Tribuli 3 g • Zi Wan Radix Asteris 3 g – NEI XIAO LUO LI WAN – Inner Dissolving Scrofula Pill • Xia Ku Cao Spica Prunellae 240 g • Xuan Shen Radix Scrophulariae 150 g • Qing Yan Salt 150 g • Hai Zao Sargassum 30 g • Zhe Bei Mu Bulbus Fritillariae thunbergii 30 g • Bo He Herba Menthae haplocalycis 30 g • Tian Hua Fen Radix Trichosanthis 30 g • Hai Ge Ke Concha Meretricis seu Cyclinae 30 g • Bai Lian Radix Ampelopsis 30 g • Lian Qiao Fructus Forsythiae 30 g • Da Huang Radix et Rhizoma Rhei 30 g • Gan Cao Radix Glycyrrhizae 30 g • Sheng Di Huang Radix Rehmanniae 30 g • Jie Geng Radix Platycodi 30 g • Zhi Ke Fructus Aurantii 30 g • Dang Gui Radix Angelicae sinensis 30 g
• Mang Xiao Sulfas Natrii 30 g – NEI YI FANG – Endometriosis Formula • Dang Gui Radix Angelicae sinensis 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Chi Shao Radix Paeoniae rubra 6 g • Xiang Fu Rhizoma Cyperi 6 g • Xue Jie Resina Daemonoropis 3 g • Chuan Niu Xi Radix Cyathulae 6 g • Gui Zhi Ramulus Cinnamomi 3 g • Zao Jiao Ci Spina Gleditsiae 4.5 g • E Zhu Rhizoma Curcumae 6 g • Hai Zao Sargassum 6 g – PAI LUAN TANG – Ovulation Decoction • Chai Hu Radix Bupleuri 6 g • Chi Shao Radix Paeoniae rubra 6 g • Bai Shao Radix Paeoniae alba 6 g • Ze Lan Herba Lycopi 4.5 g • Liu Ji Nu Herba Artemisiae anomalae 6 g
• Ji Xue Teng Caulis Spatholobi 6 g • Shou Wu Radix Polygoni multiflori preparata 6 g • Pu Huang Pollen Typhae 4.5 g • Xu Duan Radix Dipsaci 6 g • Chuan Niu Xi Radix Cyathulae 4.5 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Han Lian Cao Herba Ecliptae 6 g • E Jiao Colla Corii asini 6 g – PEN QIANG JIE DU TANG – Pelvic Eliminating Toxins Decoction • Hong Teng Caulis Sargentodoxae 9 g • Bai Jiang Cao Herba Patriniae 6 g • Pu Gong Ying Herba Taraxaci 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Chi Shao Radix Paeoniae rubra 6 g • Yi Yi Ren Semen Coicis 9 g • Tu Fu Ling Rhizoma Smilacis glabrae 6 g • Mu Dan Pi Cortex Moutan 6 g • Chuan Lian Zi Fructus Toosendan 3 g • Gan Cao Radix Glycyrrhizae 3 g
– PEN QIANG LING – Pelvis Efficacious [Formula] • Dang Gui Radix Angelicae sinensis 9 g • Chi Shao Radix Paeoniae rubra 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Yan Hu Suo Rhizoma Corydalis 6 g • San Leng Rhizoma Sparganii 4.5 g • Xiang Fu Rhizoma Cyperi 4.5 g • Wu Yao Radix Linderae 4.5 g • Hong Teng Caulis Sargentodoxae 6 g • Bai Jiang Cao Herba Patriniae 6 g • Gan Cao Radix Glycyrrhizae 3 g – PING GAN KAI YU ZHI XUE TANG – Balancing the Liver Opening Stagnation and Stopping Bleeding Decoction • Bai Shao Radix Paeoniae alba 30 g • Bai Zhu Rhizoma Atractylodis macrocephalae 30 g • Dang Gui Radix Angelicae sinensis 30 g • Mu Dan Pi Cortex Moutan 9 g • San Qi Radix Notoginseng 9 g • Sheng Di Huang Radix Rehmanniae 9 g
• Gan Cao Radix Glycyrrhizae 6 g • Jing Jie Herba Schizonepetae 6 g • Chai Hu Radix Bupleuri 3 g – PING WEI SAN – Balancing the Stomach Powder • Cang Zhu Rhizoma Atractylodis 9 g • Chen Pi Pericarpium Citri reticulatae 6 g • Hou Po Cortex Magnoliae officinalis 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sheng Jiang Rhizoma Zingiberis recens 3 g • Da Zao Fructus jujubae 3 dates – QI GONG WAN – Arousing the Uterus Pill • Ban Xia Rhizoma Pinelliae preparatum 6 g • Cang Zhu Rhizoma Atractylodis 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Fu Ling Poria 6 g • Xiang Fu Rhizoma Cyperi 6 g • Shen Qu Massa medicata fermentata 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g
– QI GONG WAN Variation (Chapter 57, Infertility, Damp-Phlegm in the Uterus) – Arousing the Uterus Pill Variation • Ban Xia Rhizoma Pinelliae preparatum 6 g • Cang Zhu Rhizoma Atractylodis 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Fu Ling Poria 6 g • Xiang Fu Rhizoma Cyperi 6 g • Shen Qu Massa medicata fermentata 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Ze Lan Herba Lycopi 6 g • Lu Lu Tong Fructus Liquidambaris 6 g • Yi Yi Ren Semen Coicis 15 g • Huang Bo Cortex Phellodendri 6 g • Shi Chang Pu Rhizoma Acori tatarinowii 6 g – QI GONG WAN Variation (Chapter 67, Myoma, Blood stasis with Phlegm) – Arousing the Uterus Pill Variation • Ban Xia Rhizoma Pinelliae preparatum 6 g • Cang Zhu Rhizoma Atractylodis 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Fu Ling Poria 6 g
• Xiang Fu Rhizoma Cyperi 6 g • Shen Qu Massa medicata fermentata 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Dang Gui Radix Angelicae sinensis 6 g • Chi Shao Radix Paeoniae rubra 6 g • E Zhu Rhizoma Curcumae 6 g • San Leng Rhizoma Sparganii 6 g • Hai Zao Sargassum 6 g – QI JU DI HUANG WAN – Lycium-Chrysanthemum-Rehmannia Pill • Gou Qi Zi Fructus Lycii 9 g • Ju Hua Flos Chrysanthemi 6 g • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Ze Xie Rhizoma Alismatis 9 g • Mu Dan Pi Cortex Moutan 9 g • Fu Ling Poria 9 g – QI JU DI HUANG WAN Variation (Chapter 20, Headaches during Periods, Liver-Yang rising) – Lycium-Chrysanthemum-Rehmannia Pill Variation
• Gou Qi Zi Fructus Lycii 9 g • Ju Hua Flos Chrysanthemi 6 g • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Ze Xie Rhizoma Alismatis 9 g • Mu Dan Pi Cortex Moutan 9 g • Fu Ling Poria 9 g • Gou Teng Ramulus Uncariae cum Uncis 6 g • Tian Ma Rhizoma Gastrodiae 6 g • Bai Ji Li Fructus Tribuli 3 g
– QI JU DI HUANG WAN Variation (Chapter 28, Dizziness at Period Time, Kidney- and Liver-Yin deficiency with Liver-Yang rising) – Lycium-Chrysanthemum-Rehmannia Pill Variation • Gou Qi Zi Fructus Lycii 9 g • Ju Hua Flos Chrysanthemi 6 g • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Ze Xie Rhizoma Alismatis 9 g • Mu Dan Pi Cortex Moutan 9 g • Fu Ling Poria 9 g • Gou Teng Ramulus Uncariae cum Uncis 6 g • Bai Ji Li Fructus Tribuli 6 g – QI JU DI HUANG WAN Variation (Chapter 35, Dizziness during Pregnancy, Liver-Blood deficiency with Liver-Yang rising) – Lycium-Chrysanthemum-Rehmannia Pill Variation • Gou Qi Zi Fructus Lycii 9 g • Ju Hua Flos Chrysanthemi 6 g • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g
• Fu Ling Poria 6 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 9 g • Shou Wu Radix Polygoni multiflori preparata 6 g • Tian Ma Radix Gastrodiae 6 g • Gou Teng Ramulus Uncariae cum Uncis 6 g – QI ZHEN SAN – Raising the Pillow Powder • Rou Gui Cortex Cinnamomi 3 g • Dang Gui Radix Angelicae sinensis 6 g • Chi Shao Radix Paeoniae rubra 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Mu Dan Pi Cortex Moutan 4.5 g • Pu Huang Pollen Typhae 6 g • Wu Ling Zhi Faeces Trogopterori 6 g • Yan Hu Suo Rhizoma Corydalis 6 g • Mo Yao Myrrha 6 g • Bai Zhi Radix Angelicae dahuricae 3 g – QI ZHI XIANG FU WAN – Seven Prepared Cyperus Pill
• Xiang Fu Rhizoma Cyperi 9 g • Dang Gui Radix Angelicae sinensis 9 g • E Zhu Rhizoma Curcumae 9 g • Mu Dan Pi Cortex Moutan 9 g • Ai Ye Folium Artemisiae argyi 9 g • Wu Yao Radix Linderae 9 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Yan Hu Suo Rhizoma Corydalis 9 g • San Leng Rhizoma Sparganii 9 g • Chai Hu Radix Bupleuri 6 g • Hong Hua Flos Carthami 9 g – QIANG GUI SI WU TANG – Notopterygium-Ramulus Cinnamomi Four Substances Decoction • Shu Di Huang Radix Rehmanniae preparata 12 g • Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Qiang Huo Rhizoma seu Radix Notopterygii 4.5 g • Gui Zhi Ramulus Cinnamomi 4.5 g – QIN JIAO NIU BANG TANG
– Gentiana macrophylla Arctium Decoction • Ma Huang Herba Ephedrae 3 g • Huang Qin Radix Scutellariae 6 g • Gan Cao Radix Glycyrrhizae 3 g • Fang Feng Radix Saposhnikoviae 6 g • Sheng Ma Rhizoma Cimicifugae 3 g • Xuan Shen Radix Scrophulariae 6 g • Qin Jiao Radix Gentianae macrophyllae 6 g • Shui Niu Jiao Cornu Bubali 6 g • Niu Bang Zi Fructus Arctii 6 g – QIN JIAO NIU BANG TANG Variation (Chapter 27, Skin Eruptions at Period Time, Wind-Heat with Blood-Heat) – Gentiana macrophylla Arctium Decoction Variation • Ma Huang Herba Ephedrae 3 g • Fang Feng Radix Saposhnikoviae 6 g • Sheng Ma Rhizoma Cimicifugae 3 g • Niu Bang Zi Fructus Arctii 6 g • Xuan Shen Radix Scrophulariae 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Shui Niu Jiao Cornu Bufali 6 g • Mu Dan Pi Cortex Moutan 6 g
• Qin Jiao Radix Gentianae 6 g • Huang Qin Radix Scutellariae 6 g • Gan Cao Radix Glycyrrhizae 3 g – QIN JIAO SI WU TANG – Gentiana macrophylla Four Substances Decoction • Dang Gui Radix Angelicae sinensis 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Bai Shao Radix Paeoniae alba 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Qin Jiao Radix Gentianae macrophyllae 6 g • Yi Yi Ren Semen Coicis 6 g • Can Sha Faeces Bombycis 6 g • Gan Cao Radix Glycyrrhizae 3 g – QIN LIAN SI WU TANG – Scutellaria-Coptis Four Substances Decoction • Huang Qin Radix Scutellariae 3 g • Huang Lian Rhizoma Coptidis 3 g • Mai Men Dong Radix Ophiopogonis 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Dang Gui Radix Angelicae sinensis 9 g
• Bai Shao Radix Paeoniae alba 9 g • Sheng Di Huang Radix Rehmanniae 9 g – QING DAI SAN – Indigo Powder • Qing Dai Indigo pulverata Levis 60 g • Huang Bo Cortex Phellodendri 60 g • Shi Gao Gypsum fibrosum 120 g • Hua Shi Talcum 120 g – QING GAN BU SHEN TANG – Clearing the Liver and Tonifying the Kidneys Decoction • Mu Dan Pi Cortex Moutan 6 g • Shan Zhi Zi Fructus Gardeniae 6 g • Chai Hu Radix Bupleuri 6 g • Dang Gui Radix Angelicae sinensis 6 g • Qing Pi Pericarpium Citri reticulatae viride 3 g • Sheng Di Huang Radix Rehmanniae 9 g • Huang Jing Rhizoma Polygonati 6 g • Yin Yang Huo Herba Epimedii 4.5 g • Bu Gu Zhi Fructus Psoraleae 4.5 g • Chuan Shan Jia Squama Manitis 4.5 g
• Mai Ya Fructus Hordei germinatus 30 g – QING GAN DA YU TANG – Clearing the Liver and Eliminating Stagnation Decoction • Chai Hu Radix Bupleuri 6 g • Bo He Herba Menthae haplocalycis 3 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Ju Hua Flos Chrysanthemi 6 g • Shan Zhi Zi Fructus Gardeniae 6 g • Mu Dan Pi Cortex Moutan 6 g • Ju Ye Folium Citri rubrum 4 g • Chen Pi Pericarpium Citri reticulatae 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – QING GAN HUA SHI TANG – Clearing the Liver and Resolving Dampness Decoction • Long Dan Cao Radix Gentianae 6 g • Bi Xie Rhizoma Dioscoreae hypoglaucae 6 g • Yi Yi Ren Semen Coicis 15 g • Huang Bo Cortex Phellodendri 6 g • Fu Ling Poria 6 g
• Mu Dan Pi Cortex Moutan 6 g • Ze Xie Rhizoma Alismatis 6 g • Tong Cao Medulla Tetrapanacis 3 g • Cang Er Zi Fructus Xanthii 4.5 g • Bai Ji Li Fructus Tribuli 4.5 g • Cang Zhu Rhizoma Atractylodis 6 g – QING GAN JIE YU TANG – Clearing the Liver and Eliminating Stagnation Decoction • Bai Shao Radix Paeoniae alba 4.5 g • Dang Gui Radix Angelicae sinensis 3 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Shan Zhi Zi Fructus Gardeniae 1.5 g • Mu Dan Pi Cortex Moutan 1.5 g • Chai Hu Radix Bupleuri 2 g – QING GAN JIE YU TANG Variation (Chapter 59, Breast Lumps, Stagnant Liver-Qi turned into Fire) – Clearing the Liver and Eliminating Stagnation Decoction Variation • Bai Shao Radix Paeoniae alba 4.5 g • Dang Gui Radix Angelicae sinensis 3 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Shan Zhi Zi Fructus Gardeniae 1.5 g
• Mu Dan Pi Cortex Moutan 1.5 g • Chai Hu Radix Bupleuri 2 g • Sheng Di Huang Radix Rehmanniae 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Zhe Bei Mu Bulbus Fritillariae thunbergii 6 g • Fu Shen Sclerotium Poriae pararadicis 6 g • Yuan Zhi Radix Polygalae 6 g • Zi Su Ye Folium Perillae 3 g • Mu Tong Caulis Akebiae 2 g • Xiang Fu Rhizoma Cyperi 6 g • Ban Zhi Lian Herba Scutellariae barbatae 4 g • Bai Hua She She Cao Herba Hedyotis diffusae 4 g • Gan Cao Radix Glycyrrhizae 3 g – QING GAN YIN JING TANG – Clearing the Liver and Guiding the Period Decoction • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Gan Cao Radix Glycyrrhizae 3 g
• Shan Zhi Zi Fructus Gardeniae 6 g • Huang Qin Radix Scutellariae 4 g • Chuan Lian Zi Fructus Toosendan 3 g • Qian Cao Gen Radix Rubiae 6 g • Bai Mao Gen Rhizoma Imperatae 6 g • Chuan Niu Xi Radix Cyathulae 3 g • Mu Dan Pi Cortex Moutan 6 g – QING GAN ZHI LIN TANG – Clearing the Liver and Stopping ‘Lin’ Decoction • Dang Gui Radix Angelicae sinensis 30 g • Bai Shao Radix Paeoniae alba 30 g • Hei Xiao Dou Black beans 30 g • Sheng Di Huang Radix Rehmanniae 15 g • E Jiao Colla Corii asini 10 g • Mu Dan Pi Cortex Moutan 10 g • Huang Bo Cortex Phellodendri 10 g • Huai Niu Xi Radix Achyranthis bidentatae 10 g • Xiang Fu Rhizoma Cyperi 3 g • Hong Zao Fructus jujubae 1 date – QING GAN ZHI LIN TANG Variation (Chapter 15, Bleeding Between Periods, Damp-Heat)
– Clearing the Liver and Stopping ‘Lin’ Decoction Variation • Dang Gui Radix Angelicae sinensis 30 g • Bai Shao Radix Paeoniae alba 30 g • Hei Xiao Dou Black beans 30 g • Sheng Di Huang Radix Rehmanniae 15 g • E Jiao Colla Corii asini 10 g • Mu Dan Pi Cortex Moutan 10 g • Huang Bo Cortex Phellodendri 10 g • Huai Niu Xi Radix Achyranthis bidentatae 10 g • Xiang Fu Rhizoma Cyperi 3 g • Hong Zao Fructus jujubae 1 date • Fu Ling Poria 6 g – QING GU SAN – Clearing the Bones Powder • Yin Chai Hu Radix Stellariae 4.5 g • Zhi Mu Rhizoma Anemarrhenae 3 g • Hu Huang Lian Rhizoma Picrorhizae 3 g • Di Gu Pi Cortex Lycii 3 g • Qing Hao Herba Artemisiae annuae 3 g • Qin Jiao Radix Gentianae macrophyllae 3 g
• (Zhi) Bie Jia Carapax Trionycis (toasted) 3 g • Gan Cao Radix Glycyrrhizae 1.5 g – QING HAO BIE JIA TANG – Artemisia-Amyda Decoction • Bie Jia Carapax Trionycis 15 g • Qing Hao Herba Artemisiae annuae 6 g • Sheng Di Huang Radix Rehmanniae 12 g • Zhu Mu Rhizoma Anemarrhenae 6 g • Mu Dan Pi Cortex Moutan 9 g – QING HUN SAN – Clearing the Ethereal Soul Powder • Jing Jie Herba Schizonepetae 15 g • Ren Shen Radix Ginseng 6 g • Chuan Xiong Rhizoma Chuanxiong 15 g • Gan Cao Radix Glycyrrhizae 6 g • Ze Lan Herba Lycopi 6 g – QING JIN JIANG HUO TANG – Clearing Metal and Lowering Fire Decoction • Huang Qin Radix Scutellariae 6 g • Xing Ren Semen Armeniacae 4.5 g
• Chuan Bei Mu Bulbus Fritillariae cirrhosae 6 g • Qian Hu Radix Peucedani 6 g • Gua Lou Fructus Trichosanthis 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Fu Ling Poria 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Shi Gao Gypsum fibrosum 9 g • Jie Geng Radix Platycodi 3 g • Zhi Ke Fructus Aurantii 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices – QING JIN JIANG HUO TANG Variation (Chapter 39, Cough during Pregnancy, Phlegm-Heat in the Lungs) – Clearing Metal and Lowering Fire Decoction Variation • Huang Qin Radix Scutellariae 6 g • Xing Ren Semen Armeniacae 4.5 g • Chuan Bei Mu Bulbus Fritillariae cirrhosae 6 g • Qian Hu Radix Peucedani 6 g • Gua Lou Fructus Trichosanthis 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Fu Ling Poria 6 g
• Ban Xia Rhizoma Pinelliae preparatum 6 g • Shi Gao Gypsum 9 g • Jie Geng Radix Platycodi 3 g • Zhi Ke Fructus Aurantii 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Sang Ye Folium Mori 3 g • Pi Pa Ye Folium Eriobotryae 6 g – QING JING SAN – Clearing the Menses Powder • Mu Dan Pi Cortex Moutan 6 g • Bai Shao Radix Paeoniae alba 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Di Gu Pi Cortex Lycii 15 g • Qing Hao Herba Artemisiae annuae 6 g • Fu Ling Poria 3 g • Huang Bo Cortex Phellodendri 1.5 g – QING JING SAN Variation (Chapter 8, Early Periods, Liver- and Kidney-Yin deficiency with Empty-Heat) – Clearing the Menses Powder Variation
• Mu Dan Pi Cortex Moutan 6 g • Bai Shao Radix Paeoniae alba 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Di Gu Pi Cortex Lycii 15 g • Qing Hao Herba Artemisiae annuae 6 g • Fu Ling Poria 3 g • Huang Bo Cortex Phellodendri 1.5 g • Xuan Shen Radix Scrophulariae 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Zhi Mu Rhizoma Anemarrhenae 6 g – QING JING SAN Variation (Chapter 57, Infertility, Blood-Heat) – Clearing the Menses Powder Variation • Mu Dan Pi Cortex Moutan 6 g • Bai Shao Radix Paeoniae alba 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Di Gu Pi Cortex Lycii 15 g • Qing Hao Herba Artemisiae annuae 6 g • Fu Ling Poria 3 g • Huang Bo Cortex Phellodendri 1.5 g • Huang Qin Radix Scutellariae 4.5 g
• Qu Mai Herba Dianthi 6 g • Che Qian Zi Semen Plantaginis 6 g – QING RE GU JING TANG – Clearing Heat and Consolidating the Menses Decoction • Huang Qin Radix Scutellariae 4.5 g • Shan Zhi Zi Fructus Gardeniae (charred) 6 g • Sheng Di Huang Radix Rehmanniae 9 g • Di Gu Pi Cortex Lycii 6 g • Di Yu Radix Sanguisorbae 6 g • E Jiao Colla Corii asini 6 g • Ou Jie Nodus Nelumbinis rhizomatis 6 g • Zong Lu Zi Fructus Trachycarpi 4.5 g • Gui Ban Plastrum Testudinis (toasted) 12 g • Mu Li Concha Ostreae 12 g • Gan Cao Radix Glycyrrhizae 3 g – QING RE GU JING TANG Variation (Chapter 43, Habitual Miscarriage, BloodHeat) – Clearing Heat and Consolidating the Menses Decoction Variation • Huang Qin Radix Scutellariae 4.5 g • Shan Zhi Zi Fructus Gardeniae (charred) 6 g • Sheng Di Huang Radix Rehmanniae 9 g
• Di Gu Pi Cortex Lycii 6 g • Di Yu Radix Sanguisorbae 6 g • E Jiao Colla Corii asini 6 g • Ou Jie Nodus Nelumbinis rhizomatis 6 g • Zong Lu Zi Fructus Trachycarpi 4.5 g • Gui Ban Plastrum Testudinis (toasted) 12 g • Mu Li Concha Ostreae 12 g • Gan Cao Radix Glycyrrhizae 3 g • Bei Sha Shen Radix Glehniae 6 g – QING RE LI SHI TANG – Clearing Heat and Resolving Dampness Decoction • Bi Xie Rhizoma Dioscoreae hypoglaucae 12 g • Qu Mai Herba Dianthi 12 g • Shan Zhi Zi Fructus Gardeniae (charred) 9 g • Huang Qin Radix Scutellariae 9 g • Huang Lian Rhizoma Coptidis 6 g • Zhi Mu Rhizoma Anemarrhenae 9 g • Mu Dan Pi Cortex Moutan 6 g • Bai Mao Gen Rhizoma Imperatae 6 g – QING RE LI SHI TANG Variation (Chapter 17, Flooding and Trickling, DampHeat in the Uterus)
– Clearing Heat and Resolving Dampness Decoction Variation • Bi Xie Rhizoma Dioscoreae hypoglaucae 12 g • Qu Mai Herba Dianthi 12 g • Shan Zhi Zi Fructus Gardeniae (charred) 9 g • Huang Qin Radix Scutellariae 9 g • Huang Lian Rhizoma Coptidis 6 g • Zhi Mu Rhizoma Anemarrhenae 9 g • Mu Dan Pi Cortex Moutan 6 g • Ou Jie Nodus Nelumbinis rhizomatis 15 g • Xian He Cao Herba Agrimoniae 12 g – QING RE TIAO XUE TANG – Clearing Heat and Regulating Blood Decoction • Mu Dan Pi Cortex Moutan 6 g • Sheng Di Huang Radix Rehmanniae 9 g • Huang Lian Rhizoma Coptidis 4.5 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 9 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Hong Hua Flos Carthami 6 g • Tao Ren Semen Persicae 6 g
• E Zhu Rhizoma Curcumae 6 g • Xiang Fu Rhizoma Cyperi 6 g • Yan Hu Suo Rhizoma Corydalis 6 g – QING RE YANG YIN TANG – Clearing Heat and Nourishing Yin Decoction • Sheng Di Huang Radix Rehmanniae 6 g • Huang Qin Radix Scutellariae 6 g • Di Gu Pi Cortex Lycii 6 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Bai Shao Radix Paeoniae alba 6 g • Du Zhong Cortex Eucommiae 6 g • E Jiao Colla Corii asini 6 g • Xu Duan Radix Dipsaci 6 g • Sang Ji Sheng Herba Taxilli 6 g – QING RE ZHI BENG TANG – Clearing Heat and Arresting Flooding Decoction • Shan Zhi Zi Fructus Gardeniae 9 g • Huang Qin Radix Scutellariae 9 g • Huang Bo Cortex Phellodendri 6 g
• Sheng Di Huang Radix Rehmanniae 24 g • Mu Dan Pi Cortex Moutan 9 g • Di Yu Radix Sanguisorbae 12 g • Ce BAi Ye Cacumen Platycladi 12 g • Chun Gen Bai Pi Cortex Ailanthi 12 g • Gui Ban Plastrum Testudinis 15 g • Bai Shao Radix Paeoniae alba 24 g – QING WEN BAI DU YIN – Clearing Epidemics Expelling Toxin Decoction • Shi Gao Gypsum fibrosum 6 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Gan Cao Radix Glycyrrhizae 3 g • Zhu Ye Folium Phyllostachys nigrae 3 g • Shui Niu Jiao Cornu Bubali 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Mu Dan Pi Cortex Moutan 6 g • Chi Shao Radix Paeoniae rubra 6 g • Xuan Shen Radix Scrophulariae 6 g • Huang Lian Rhizoma Coptidis 6 g • Huang Qin Radix Scutellariae 4.5 g
• Shan Zhi Zi Fructus Gardeniae 6 g • Lian Qiao Fructus Forsythiae 6 g • Jie Geng Radix Platycodi 3 g – QING WEN BAI DU YIN Variation (Chapter 56, Convulsions after Childbirth, Exterior invasion of Toxin) – Clearing Warm Disease and Expelling Toxin Decoction Variation • Shi Gao Gypsum fibrosum 6 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Gan Cao Radix Glycyrrhizae 3 g • Zhu Ye Folium Phyllostachys nigrae 3 g • Shui Niu Jiao Cornu Bufali Cornu 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Mu Dan Pi Cortex Moutan 6 g • Chi Shao Radix Paeoniae rubra 6 g • Xuan Shen Radix Scrophulariae 6 g • Huang Lian Rhizoma Coptidis 6 g • Huang Qin Radix Scutellariae 4.5 g • Shan Zhi Zi Fructus Gardeniae 6 g • Lian Qiao Fructus Forsythiae 6 g • Jie Geng Radix Platycodi 3 g • Tian Ma Rhizoma Gastrodiae 6 g
• Gou Teng Ramulus Uncariae cum Uncis 6 g • Jiang Can Bombyx batryticatus 6 g – QING XIN PING GAN TANG – Clearing the Heart and Balancing the Liver Decoction • Huang Lian Rhizoma Coptidis 3 g • Mai Men Dong Radix Ophiopogonis 9 g • Bai Shao Radix Paeoniae alba 9 g • Bai Wei Radix Cynanchi baiwei 9 g • Dan Shen Radix Salviae miltiorrhizae 9 g • Long Gu Fossilia Ossis Mastodi 15 g • Suan Zao Ren Semen Zizyphi spinosae 9 g – QING XIN PING GAN TANG Variation (Chapter 8, Early Periods, Heart-Fire) – Clearing the Heart and Balancing the Liver Decoction Variation • Huang Lian Rhizoma Coptidis 3 g • Mai Men Dong Radix Ophiopogonis 9 g • Bai Shao Radix Paeoniae alba 9 g • Bai Wei Radix Cynanchi baiwei 9 g • Dan Shen Radix Salviae miltiorrhizae 9 g • Long Gu Fossilia Ossis Mastodi 15 g • Suan Zao Ren Semen Zizyphi spinosae 9 g
• Qian Cao Gen Radix Rubiae 6 g – QING ZHI SI WU TANG – Citrus-Gardenia Four Substances Decoction • Qing Pi Pericarpium Citri reticulatae viride 3 g • Zhi Zi Fructus Gardeniae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Bai Shao Radix Paeoniae alba 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Xiang Fu Rhizoma Cyperi 6 g • Fu Ling Poria 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g – QU YU DING TONG TANG – Eliminating Stasis and Stopping Pain Decoction • Ru Xiang Olibanum 6 g • Mo Yao Myrrha 6 g • Chuan Niu Xi Radix Cyathulae 6 g • Mu Dan Pi Cortex Moutan 6 g • Mu Tong Caulis Akebiae 3 g • Ze Xie Rhizoma Alismatis 6 g
• Bai Zhi Radix Angelicae dahuricae 3 g • Chi Xiao Dou Semen Phaseoli 6 g – QUAN SHENG BAI ZHU SAN – Whole Generating Atractylodes Powder • Bai Zhu Rhizoma Atractylodis macrocephalae 30 g • Fu Ling Pi Cutis Poriae 6 g • Da Fu Pi Pericarpium Arecae 6 g • Sheng Jiang Pi Pericarpium Zingiberis recens (peel) 3 g • Chen Pi Pericarpium Citri reticulatae 3 g – QUAN SHENG BAI ZHU SAN Variation (Chapter 21, Oedema during Periods, Spleen- and Kidney-Yang deficiency) – Whole Generating Atractylodes Powder Variation • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Chen Pi Pericarpium Citri reticulatae 4.5 g • Sheng Jiang Pi Pericarpium Zingiberis recens 3 slices • Da Fu Pi Pericarpium Arecae 6 g • Fu Ling Pi Cutis Poriae 6 g • Gui Zhi Ramulus Cinnamomi 4.5 g – REN SHEN DANG GUI TANG – Ginseng-Angelica Decoction • Ren Shen Radix Ginseng 6 g
• Dang Gui Radix Angelicae sinensis 9 g • Mai Men Dong Radix Ophiopogonis 6 g • Bai Shao Radix Paeoniae alba 9 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Rou Gui Cortex Cinnamomi 1.5 g – REN SHEN MAI DONG SAN – Ginseng-Ophiopogon Powder • Ren Shen Radix Ginseng 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Fu Ling Poria 6 g • Huang Qin Radix Scutellariae 6 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Zhu Ru Caulis Bambusae in taeniam 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – REN SHEN TANG – Ginseng Decoction • Ren Shen Radix Ginseng 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Mai Men Dong Radix Ophiopogonis 6 g
• Bing Lang Semen Arecae 3 g • Da Fu Pi Pericarpium Arecae 3 g • Bai Dou Kou Fructus Amomi rotundus 3 g • Zhi Ke Fructus Aurantii 4.5 g • Mu Dan Pi Cortex Moutan 6 g • Bai Shao Radix Paeoniae alba 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Fang Ji Radix Stephaniae tetandrae 4.5 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Ding Xiang Flos Caryophylli 3 g • Gui Zhi Ramulus Cinnamomi 3 g • Jie Geng Radix Platycodi 3 g • Fu Ling Poria 6 g • Yuan Zhi Radix Polygalae 6 g • Da Huang Radix et Rhizoma Rhei 6 g • Gan Cao Radix Glycyrrhizae 3 g – REN SHEN YANG RONG TANG – Ginseng Nourishing and Flourishing Decoction • Ren Shen Radix Ginseng 9 g
• Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Huang Qi Radix Astragali 9 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 18 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Rou Gui Cortex Cinnamomi 9 g • Wu Wei Zi Fructus Schisandrae 6 g • Yuan Zhi Radix Polygalae 4.5 g • Fu Ling Poria 6 g • Chen Pi Pericarpium Citri reticulatae 9 g • Zhi Gan Cao Radix Glycyrrhizae preparata 6 g – REN SHEN ZI XUE TANG – Ginseng Growing Blood Decoction • Ren Shen Radix Ginseng 9 g • Shan Yao Rhizoma Dioscoreae 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Fu Ling Poria 3 g
– ROU GAN ZHI TONG TANG – Softening the Liver and Stopping Pain Decoction • Dang Gui Radix Angelicae sinensis 6 g • Shou Wu Radix Polygoni multiflori preparata 6 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Wu Mei Fructus Mume 3 g • Lu Lu Tong Fructus Liquidambaris 3 g • Hou Po Cortex Magnoliae officinalis 4.5 g • Gan Cao Radix Glycyrrhizae 3 g – RU HE NEI XIAO TANG – Breast Kernel Inner-Dissolving Decoction • Chai Hu Radix Bupleuri (or Qing Pi Pericarpium Citri reticulatae viride) 6 g • Xiang Fu Rhizoma Cyperi 9 g • Ju He Semen Citri reticulatae 6 g • Yu Jin Radix Curcumae (or San Leng Rhizoma Sparganii) 9 g • Dang Gui Radix Angelicae sinensis 6 g • Chi Shao Radix Paeoniae rubra 15 g • Shan Ci Gu Pseudobulbus Cremastrae 9 g • Xia Ku Cao Spica Prunellae 12 g • Lou Lu Radix Rhapontici 9 g
• Si Gua Luo Retinervus Luffae fructus 5 g • Gan Cao Radix Glycyrrhizae 3 g – RUAN JIAN HUA TAN FANG – Softening Hardness and Resolving Phlegm Formula • Hai Zao Sargassum 9 g • Bie Jia Carapax Trionycis 12 g • Zhe Bei Mu Blubus Fritillariae thunbergii 9 g • Ban Xia Rhizoma Pinelliae preparatum 9 g • Fu Ling Poria 9 g • Chen Pi Pericarpium Citri reticulatae 6 g • Dan Nan Xing Rhizoma Arisaematis preparatum 6 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 6 g – SAN CU TANG – Three Promotions Decoction 1. Promoting Follicular Development • Shu Di Huang Radix Rehmanniae preparata 9 g • Bai Shao Radix Paeoniae alba 6 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Han Lian Cao Herba Ecliptae 6 g
• Tu Si Zi Semen Cuscutae 6 g • Shou Wu Radix Polygoni multiflori preparata 6 g 2. Promoting Ovulation • Dang Gui Radix Angelicae sinensis 9 g • Chi Shao Radix Paeoniae rubra 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Ze Lan Herba Lycopi 4.5 g • Hong Hua Flos Carthami 4.5 g • Chong Wei Zi Semen Leonori 4.5 g • Xiang Fu Rhizoma Cyperi 4.5 g 3. Promoting Luteal Phase • Shu Di Huang Radix Rehmanniae preparata 9 g • Bai Shao Radix Paeoniae alba 6 g • Yin Yang Huo Herba Epimedii 6 g • Fu Zi Radix Aconiti lateralis preparata 3 g • Xu Duan Radix Dipsaci 6 g • Ba Ji Tian Radix Morindae officinalis 6 g – SAN HUANG SAN – Three Yellows Powder • Huang Lian Rhizoma Coptidis 10 g
• Huang Bo Cortex Phellodendri 10 g • Da Huang Radix et Rhizoma Rhei 10 g – SAN JIA FU MAI TANG – Three-Shell Restoring the Pulse Decoction • Zhi Gan Cao Radix Glycyrrhizae preparata 18 g • Sheng Di Huang Radix Rehmanniae 18 g • Bai Shao Radix Paeoniae alba 18 g • Mai Men Dong Radix Ophiopogonis 15 g • Huo Ma Ren Semen Cannabis 9 g • E Jiao Colla Corii asini 9 g • Mu Li Concha Ostreae 15 g • Bie Jia Carapax Trionycis 24 g • Gui Ban Plastrum Testudinis 30 g – SAN MIAO SAN – Three Wonderful Powder • Cang Zhu Rhizoma Atractylodis 15 g • Huang Bo Cortex Phellodendri 12 g • Niu Xi Radix Achyranthis bidentatae seu Cyathulae 6 g – SAN QI HONG TENG TANG – Notoginseng-Sargentodoxa Decoction
– Prescription I • Hong Teng Caulis Sargentodoxae 12 g • Jin Yin Hua Flos Lonicerae 6 g • Yi Yi Ren Semen Coicis 12 g • San Qi Radix Notoginseng 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Tao Ren Semen Persicae 6 g • Xiang Fu Rhizoma Cyperi 6 g • Mai Men Dong Radix Ophiopogonis 6 g – Prescription II • Dang Gui Radix Angelicae sinensis 9 g • Chi Shao Radix Paeoniae rubra 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • E Zhu Rhizoma Curcumae 4.5 g • Wu Ling Zhi Faeces Trogopterori 4.5 g • San Qi Radix Notoginseng 6 g • Shui Zhi Hirudo 3 g • Hong Teng Caulis Sargentodoxae 6 g • Pu Gong Ying Herba Taraxaci 6 g
• Gui Ban Plastrum Testudinis 9 g • Xuan Shen Radix Scrophulariae 6 g – Prescription III • Jin Yin Hua Flos Lonicerae 6 g • Bai Jiang Cao Herba Patriniae 9 g • Da Qing Ye Folium Isatidis 6 g • Xiang Fu Rhizoma Cyperi 4.5 g • Chuan Lian Zi Fructus Toosendan 6 g • Qian Cao Gen Radix Rubiae 4.5 g • Yi Mu Cao Herba Leonuri 6 g • Yan Hu Suo Rhizoma Corydalis 6 g • San Qi Radix Notoginseng 3 g • Ji Xue Teng Caulis Spatholobi 9 g • Jin Ying Zi Fructus Rosae laevigatae 6 g – SAN REN TANG – Three Seeds Decoction • Xing Ren Semen Armeniacae 12 g • Bai Dou Kou Fructus Amomi rotundus 6 g • Yi Yi Ren Semen Coicis 18 g • Hua Shi Talcum 18 g
• Tong Cao Medulla Tetrapanacis 6 g • Zhu Ye Folium Phyllostachys nigrae 6 g • Ban Xia Rhizoma Pinelliae preparatum 10 g • Hou Po Cortex Magnoliae officinalis 6 g – SHA SHEN MAI DONG TANG – Glehnia-Ophiopogon Decoction • Bei Sha Shen Radix Glehniae 9 g • Mai Men Dong Radix Ophiopogonis 9 g • Yu Zhu Rhizoma Polygonati odorati 6 g • Tian Hua Fen Radix Trichosanthis 4.5 g • Sang Ye Folium Mori 4.5 g • Bian Dou Semen Lablab album 4.5 g • Gan Cao Radix Glycyrrhizae 3 g – SHA XIANG SAN – Cinnabaris-Musk Powder • Ren Shen Radix Ginseng 6 g • Huang Qi Radix Astragali 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Fu Ling Poria 6 g • Yuan Zhi Radix Polygalae 6 g
• Zhu Sha Cinnabaris 1.5 g • Fu Shen Sclerotium Poriae pararadicis 6 g • Gan Cao Radix Glycyrrhizae 3 g • Jie Geng Radix Platycodi 3 g • Mu Xiang Radix Aucklandiae 3 g • She Xiang Moschus 1.5 g – SHAO FU ZHU YU TANG – Lower Abdomen Eliminating Stasis Decoction • Xiao Hui Xiang Fructus Foeniculi 6 g • Gan Jiang Rhizoma Zingiberis 2 g • Rou Gui Cortex Cinnamomi 1.5 g • Yan Hu Suo Rhizoma Corydalis 6 g • Mo Yao Myrrha 6 g • Pu Huang Pollen Typhae 6 g • Wu Ling Zhi Faeces Trogopterori 4.5 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Chi Shao Yao Radix Paeoniae rubra 6 g – SHAO FU ZHU YU TANG Variation (Chapter 12, Scanty Periods, Stasis of Blood) – Lower Abdomen Eliminating Stasis Decoction Variation
• Xiao Hui Xiang Fructus Foeniculi 6 g • Gan Jiang Rhizoma Zingiberis 2 g • Rou Gui Cortex Cinnamomi 1.5 g • Yan Hu Suo Rhizoma Corydalis 6 g • Mo Yao Myrrha 6 g • Wu Ling Zhi Faeces Trogopteri 4.5 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Chi Shao Yao Radix Paeoniae rubra 6 g – SHAO FU ZHU YU TANG Variation (Chapter 43, Habitual Miscarriage, Blood stasis) – Lower Abdomen Eliminating Stasis Decoction Variation • Xiao Hui Xiang Fructus Foeniculi 6 g • Gan Jiang Rhizoma Zingiberis 2 g • Rou Gui Cortex Cinnamomi 1.5 g • Yan Hu Suo Rhizoma Corydalis 6 g • Mo Yao Myrrha 6 g • Pu Huang Pollen Typhae 6 g • Wu Ling Zhi Faeces Trogopteri 4.5 g • Dang Gui Radix Angelicae sinensis (only ‘body’) 9 g • Qian Cao Gen Radix Rubiae 6 g
– SHE CHUANG ZI SAN – Cnidium Powder • She Chuang Zi Fructus Cnidii 10 g • Chuan Jiao Pericarpium Zanthoxyli 10 g • Ming Fan Alumen 10 g • Ku Shen Radix Sophorae flavescentis 10 g • Bai Bu Radix Stemonae 10 g – SHE HUA TANG – Cnidium-Zanthoxylum Decoction • She Chuang Zi Fructus Cnidii 30 g • Chuan Jiao Pericarpium Zanthoxyli 9 g • Huang Bo Cortex Phellodendri 9 g • Bai Fan Alumen 9 g • Ku Shen Radix Sophorae flavescentis 15 g – SHEN FU TANG – Ginseng-Aconitum Decoction • Ren Shen Radix Ginseng 12 g • Fu Zi Radix Aconiti lateralis preparata 9 g – SHEN GUI YIN CHAN FANG – Codonopsis-Angelica Labour-Inducing Formula
• Dang Shen Radix Codonopsis 15 g • Dang Gui Radix Angelicae sinensis 15 g • Chuan Xiong Rhizoma Chuanxiong 9 g • Hong Hua Flos Carthami 6 g • Chuan Niu Xi Radix Cyathulae 6 g • Yi Mu Cao Herba Leonuri 6 g • Ji Xue Teng Caulis Spatholobi 6 g – SHEN LING BAI ZHU SAN – Ginseng-Poria-Atractylodes Powder • Ren Shen Radix Ginseng 6 g (or Dang Shen Radix Codonopsis 12 g) • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Fu Ling Poria 12 g • Zhi Gan Cao Radix Glycyrrhizae preparata 6 g • Bian Dou Semen Lablab album 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Lian Zi Semen Nelumbinis 12 g • Sha Ren Fructus Amomi 4.5 g • Yi Yi Ren Semen Coicis 10 g • Jie Geng Radix Platycodi 6 g – SHEN TONG ZHU YU TANG
– Body-Aches Eliminating Stasis Decoction • Qin Jiao Radix Gentianae macrophyllae 3 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Tao Ren Semen Persicae 9 g • Hong Hua Flos Carthami 9 g • Gan Cao Radix Glycyrrhizae 6 g • Qiang Huo Rhizoma seu Radix Notopterygii 3 g • Mo Yao Myrrha 6 g • Dang Gui Radix Angelicae sinensis 9 g • Wu Ling Zhi Faeces Trogopterori 6 g • Xiang Fu Rhizoma Cyperi 3 g • Chuan Niu Xi Radix Cyathulae 9 g • Di Long Pheretima 6 g – SHEN XIAO GUA LOU SAN – Trichosantes Spirit-Effect Powder • Gua Lou Fructus Trichosanthis 1 gourd • Dang Gui Radix Angelicae sinensis 15 g • Gan Cao Radix Glycyrrhizae 15 g • Ru Xiang Olibanum 3 g • Mo Yao Myrrha 7.5 g
– SHENG HUA TANG – Generating and Resolving Decoction • Dang Gui Radix Angelicae sinensis 24 g • Chuan Xiong Rhizoma Chuanxiong 9 g • Tao Ren Semen Persicae 6 g • Pao Jiang Rhizoma Zingiberis recens (fried) 1.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 1.5 g – SHENG HUA TANG Variation (Chapter 31, Threatened Miscarriage, Falls, traumas) – Generating and Transforming Decoction Variation • Dang Gui Radix Angelicae sinensis 24 g • Chuan Xiong Rhizoma Chuanxiong 9 g • Tao Ren Semen Persicae 14 pieces • Gan Jiang Rhizoma Zingiberis 1.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 1.5 g • Hong Hua Flos Carthami 6 g • Chuan Niu Xi Radix Cyathulae 6 g • Che Qian Zi Semen Plantaginis 3 g – SHENG HUA TANG Variation (Chapter 46, Abdominal Pain after Childbirth, Blood stasis) – Generating and Resolving Decoction Variation
• Dang Gui Radix Angelicae sinensis 24 g • Chuan Xiong Rhizoma Chuanxiong 9 g • Tao Ren Semen Persicae 6 g • Pao Jiang Rhizoma Zingiberis recens (fried) 1.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 1.5 g • Yi Mu Cao Herba Leonuri 6 g – SHENG HUA TANG Variation (Chapter 51, Fever after Childbirth, Blood stasis) – Generating and Resolving Decoction Variation • Dang Gui Radix Angelicae sinensis 24 g • Chuan Xiong Rhizoma Chuanxiong 9 g • Tao Ren Semen Persicae 6 g • Pao Jiang Rhizoma Zingiberis recens (fried) 1.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 1.5 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Mu Dan Pi Cortex Moutan 6 g • Yi Mu Cao Herba Leonuri 4.5 g – SHENG MAI SAN – Generating the Pulse Powder • Ren Shen Radix Ginseng 9 g • Mai Men Dong Radix Ophiopogonis 9 g
• Wu Wei Zi Fructus Schisandrae 3 g – SHENG TI GU TUO JIAN – Lifting and Raising and Consolidating Collapse Decoction • Dang Shen Radix Codonopsis 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Huang Qi Radix Astragali 15 g • Huang Jing Rhizoma Polygonati 6 g • Gui Ban Plastrum Testudinis (toasted) 15 g • Ba Ji Tian Radix Morindae officinalis 6 g • Dang Gui Radix Angelicae sinensis 6 g • Zhi Ke Fructus Aurantii 3 g • Sheng Ma Rhizoma Cimicifugae 3 g • Yi Mu Cao Herba Leonuri 3 g • Da Zao Fructus jujubae 3 dates – SHENG TIE LUO YIN – Frusta Ferri Decoction • Sheng Tie Luo Frusta Ferri 60 g • Dan Nan Xing Rhizoma Arisaematis preparatum 9 g • Zhe Bei Mu Bulbus Fritillariae thunbergii 9 g • Xuan Shen Radix Scrophulariae 9 g
• Tian Men Dong Radix Asparagi 9 g • Mai Men Dong Radix Ophiopogonis 9 g • Lian Qiao Fructus Forsythiae 9 g • Dan Shen Radix Salviae miltiorrhizae 12 g • Fu Ling Poria 12 g • Chen Pi Pericarpium Citri reticulatae 6 g • Shi Chang Pu Rhizoma Acori tatarinowii 6 g • Yuan Zhi Radix Polygalae 6 g • Zhu Sha Cinnabaris 1.8 g – SHENG YU TANG – Sage-like Healing Decoction • Ren Shen Radix Ginseng 12 g • Huang Qi Radix Astragali 18 g • Dang Gui Radix Angelicae sinensis 15 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Shu Di Huang Radix Rehmanniae preparata 18 g • Bai Shao Radix Paeoniae alba 12 g – SHENG YU TANG Variation (Chapter 31, Threatened Miscarriage, Kidney deficiency) – Sage-like Healing Decoction Variation • Ren Shen Radix Ginseng 12 g
• Huang Qi Radix Astragali 18 g • Dang Gui Radix Angelicae sinensis 15 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Shu Di Huang Radix Rehmanniae preparata 18 g • Bai Shao Radix Paeoniae alba 12 g • Du Zhong Cortex Eucommiae 6 g • Xu Duan Radix Dipsaci 6 g • Sha Ren Fructus Amomi 3 g – SHI QUAN DA BU TANG – Ten Complete Great Tonification Decoction • Dang Gui Radix Angelicae sinensis 10 g • Chuan Xiong Rhizoma Chuanxiong 5 g • Bai Shao Radix Paeoniae alba 8 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 10 g • Fu Ling Poria 8 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Huang Qi Radix Astragali 8 g • Rou Gui Cortex Cinnamomi 4 g
– SHI QUAN DA BU TANG Variation (Chapter 47, Persistent Lochial Discharge, Qi deficiency) – Ten Complete Great Tonification Decoction Variation • Dang Gui Radix Angelicae sinensis 10 g • Chuan Xiong Rhizoma Chuanxiong 5 g • Bai Shao Radix Paeoniae alba 8 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Ren Shen Radix Ginseng 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 10 g • Fu Ling Poria 8 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Huang Qi Radix Astragali 8 g • Rou Gui Cortex Cinnamomi 4 g • E Jiao Colla Corii asini 6 g • Xu Duan Radix Dipsaci 6 g – SHI QUAN DA BU TANG Variation (Chapter 53, Breast Milk Not Flowing, Acute mastitis) – Ten Complete Great Tonification Decoction Variation • Chuan Xiong Rhizoma Chuanxiong 5 g • Shu Di Huang Radix Rehmanniae preparata 15 g • Ren Shen Radix Ginseng 3 g
• Bai Zhu Rhizoma Atractylodis macrocephalae 10 g • Fu Ling Poria 8 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Huang Qi Radix Astragali 8 g • Jin Yin Hua Flos Lonicerae 9 g – SHI WEI LIU QI YIN – Ten Ingredients Coursing Qi Decoction • Rou Gui Cortex Cinnamomi 2 g • Ren Shen Radix Ginseng 6 g • Huang Qi Radix Astragali 6 g • Bai Zhi Radix Angelicae dahuricae 3 g • Jie Geng Radix Platycodi 3 g • Wu Yao Radix Linderae 6 g • Zhi Ke Fructus Aurantii 6 g • Hou Po Cortex Magnoliae officinalis 4.5 g • Bing Lang Semen Arecae 4.5 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g • E Zhu Rhizoma Curcumae 6 g
• Fang Feng Radix Saphosnikovae 4.5 g • Zi Su Ye Folium Perillae 4.5 g • Mu Tong Caulis Akebiae 3 g • Gan Cao Radix Glycyrrhizae 3 g • Tu Fu Ling Rhizoma Smilacis glabrae 4.5 g • Zhe Bei Mu Bulbus Fritillariae thunbergii 6 g – SHI XIAO SAN – Breaking into a Smile Powder • Pu Huang Pollen Typhae 6 g • Wu Ling Zhi Faeces Trogopterori 6 g – SHI XIAO SAN Variation (Chapter 17, Flooding and Trickling, Complex patterns, Full with Full, Blood stasis and Blood-Heat) – Protecting the Yin Decoction Variation • Pu Huang Pollen Typhae 6 g • Wu Ling Zhi Faeces Trogopteri 6 g • Dang Gui Radix Angelicae sinensis 6 g • Mu Dan Pi Cortex Moutan 6 g • Yi Mu Cao Herba Leonuri 6 g • Ma Bian Cao Herba Verbenae 6 g – SHI XIAO SAN Variation (Chapter 17, Flooding and Trickling, Complex patterns, Empty with Full, Qi deficiency, Kidney-Yang deficiency and stasis of
Blood) – Breaking into a Smile Powder Variation • Pu Huang Pollen Typhae 6 g • Wu Ling Zhi Faeces Trogopteri 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chi Shao Radix Paeoniae rubra 6 g • Yi Mu Cao Herba Leonuri 6 g • Huang Qi Radix Astragali 6 g • Dang Shen Radix Codonopsis 6 g • Xu Duan Radix Dipsaci 6 g • Du Zhong Cortex Eucommiae 6 g • Huang Jing Rhizoma Polygonati 6 g • Lu Rong Cornu Cervi parvum 4.5 g – SHOU TAI WAN – Fetus Longevity Pill • Tu Si Zi Semen Cuscutae 6 g • Sang Ji Sheng Herba Taxilli 6 g • Xu Duan Radix Dipsaci 6 g • E Jiao Colla Corii asini 6 g – SHU GAN JIANG NI TANG
– Pacifying the Liver and Subduing Rebellious Qi Decoction • Sang Ye Folium Mori 3 g • Dai Zhe Shi Haematitum 12 g • Bai Shao Radix Paeoniae alba 9 g • Sheng Di Huang Radix Rehmanniae 6 g • Mu Dan Pi Cortex Moutan 6 g • Xiang Fu Rhizoma Cyperi 3 g • Bai Mao Gen Rhizoma Imperatae 6 g • Huai Niu Xi Radix Achyranthis bidentatae 9 g – SHU GAN TONG RU TANG – Pacifying the Liver and Penetrating the Breast Decoction • Chai Hu Radix Bupleuri 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Mu Tong Caulis Akebiae 3 g • Tong Cao Medulla Tetrapanacis 3 g • Wang Bu Liu Xing Semen Vaccariae 4.5 g • Chuan Shan Jia Squama Manitis 6 g • Jie Geng Radix Platycodi 3 g • Lu Lu Tong Fructus Liquidambaris 4.5 g • Lou Lu Radix Rhapontici 4.5 g
• Dang Gui Radix Angelicae sinensis 6 g – SHU QI HUO LUO TANG – Pacifying Qi and Invigorating the Connecting Channels Decoction • Dan Shen Radix Salviae miltiorrhizae 6 g • Xiang Fu Rhizoma Cyperi 6 g • Chai Hu Radix Bupleuri 6 g • Yu Jin Radix Curcumae 6 g • Ze Lan Herba Lycopi 4.5 g • Wang Bu Liu Xing Semen Vaccariae 4.5 g • Gua Lou Fructus Trichosanthis 6 g • Chuan Shan Jia Squama Manitis 4.5 g – SHUN JING FANG – Orderly Menses Formula • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 12 g • Sheng Di Huang Radix Rehmanniae 12 g • (Hei) Jing Jie Herba Schizonepetae (charred) 9 g • Niu Xi Radix Achyranthis bidentatae seu Cyathulae 6 g • Ban Xia Rhizoma Pinelliae preparatum 9 g • Ou Jie Nodus Nelumbinis rhizomatis 6 g
– SHUN JING FANG Variation (Chapter 25, Epistaxis or Haemoptysis at Period Time, Lung- and Kidney-Yin deficiency) – Ordering the Periods Formula Variation • Dang Gui Radix Angelicae sinensis 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Bei Sha Shen Radix Glehniae 6 g • Bai Shao Radix Paeoniae alba 6 g • Jing Jie Herba Schizonepetae 4 g • Fu Ling Poria 6 g • Mu Dan Pi Cortex Moutan 6 g • Niu Xi Radix Achyranthis bidentatae seu Cyathulae 3 g – SI JUN ZI TANG – Four Gentlemen Decoction • Ren Shen Radix Ginseng 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – SI LING SAN – Four ‘Ling’ Powder • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g
• Ze Xie Rhizoma Alismatis 12 g • Zhu Ling Polyporus 6 g – SI MIAO SAN – Four Wonderful Powder • Cang Zhu Rhizoma Atractylodis 15 g • Huang Bo Cortex Phellodendri 12 g • Chuan Niu Xi Radix Cyathulae 6 g • Yi Yi Ren Semen Coicis 9 g – SI NI SAN – Four Rebellious Powder • Chai Hu Radix Bupleuri 6 g • Bai Shao Radix Paeoniae alba 9 g • Zhi Shi Fructus Aurantii immaturus 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 6 g – SI QI TANG – Four Seven Decoction • Ban Xia Rhizoma Pinelliae preparatum 9 g • Hou Po Cortex Magnoliae officinalis 9 g • Fu Ling Poria 12 g • Zi Su Ye Folium Perillae 6 g
• Sheng Jiang Rhizoma Zingiberis recens 15 g • Da Zao Fructus jujubae 5 dates – SI WU TANG – Four Substances Decoction • Shu Di Huang Radix Rehmanniae preparata 12 g • Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Xiong Rhizoma Chuanxiong 8 g – SI WU TANG and SHI XIAO SAN Variation (Chapter 11, Heavy Periods, Blood stasis) – Four Substances Decoction and Breaking into a Smile Powder Variation • Shu Di Huang Radix Rehmanniae preparata 12 g • Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Pu Huang Pollen Typhae 6 g • Wu Ling Zhi Faeces Trogopteri 6 g • San Qi Radix Notoginseng 6 g • E Jiao Colla Corii asini 6 g – SI WU TANG Variation (Chapter 42, Constipation during Pregnancy, Blood deficiency)
– Four Substances Decoction Variation • Shu Di Huang Radix Rehmanniae preparata 9 g • Dang Gui Radix Angelicae sinensis (‘body’ only, without ‘tail’) 6 g • Bai Shao Radix Paeoniae alba 9 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Rou Cong Rong Herba Cistanches 6 g • Bai Zi Ren Semen Platycladi 6 g • Shou Wu Radix Polygoni multiflori preparata 6 g – SI WU TANG Variation (Chapter 50, Constipation after Childbirth, Blood deficiency) – Four Substances Decoction Variation • Shu Di Huang Radix Rehmanniae preparata 12 g • Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Rou Cong Rong Herba Cistanches 6 g • Bai Zi Ren Semen Platycladi 6 g • Shou Wu Radix Polygoni multiflori preparata 6 g • Huo Ma Ren Semen Cannabis 6 g – SI WU TANG Variation (Chapter 53, Breast Milk Not Flowing, Qi and Blood deficiency)
– Four Substances Decoction Variation • Shu Di Huang Radix Rehmanniae preparata 12 g • Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Tian Hua Fen Radix Trichosanthis 6 g • Wang Bu Liu Xing Semen Vaccariae 4.5 g • Mu Tong Caulis Akebiae 3 g • Zhu Di Pig’s Trotter 1 trotter – SONG BAO TANG – Despatching the Uterus Decoction • Dang Gui Radix Angelicae sinensis 60 g • Chuan Xiong Rhizoma Chuanxiong 15 g • Yi Mu Cao Herba Leonuri 30 g • Ru Xiang Olibanum 30 g • Mo Yao Myrrha 30 g • Jing Jie Herba Schizonepetae (charred) 9 g • She Xiang Moschus 5 li – SU YE HUANG LIAN TANG – Perilla-Coptis Decoction
• Zi Su Ye Folium Perillae 6 g • Huang Lian Rhizoma Coptidis 3 g – SU YE HUANG LIAN TANG Variation (Chapter 29, Morning Sickness, Stagnant Liver-Qi invading the Stomach) – Perilla-Coptis Decoction Variation • Zi Su Ye Folium Perillae 6 g • Huang Lian Rhizoma Coptidis 3 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Zhu Ru Caulis Bambusae in Taeniam 6 g • Bai Shao Radix Paeoniae alba 6 g – TA YANG FANG – Calming Itching Formula • He Shi Fructus Carpesii abrotanoidis 30 g • Ku Shen Radix Sophorae flavescentis 15 g • Wei Ling Xian Radix Clematidis 15 g • Dang Gui (Wei) Radix Angelicae sinensis (tail) 15 g • She Chuang Zi Fructus Cnidii 15 g • Lang Du Radix Euphorbiae fischerianae 15 g – TAI SHAN PAN SHI SAN – Huge Rock from Mount Taishan Powder
• Dang Gui Radix Angelicae sinensis 6 g • Huang Qi Radix Astragali 9 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Xu Duan Radix Dipsaci 6 g • Fu Ling Poria 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Bai Shao Radix Paeoniae alba 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sha Ren Fructus Amomi 3 g – TAI YUAN YIN – Fetus Original Qi Decoction • Ren Shen Radix Ginseng 9 g • Dang Gui Radix Angelicae sinensis 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Bai Shao Radix Paeoniae alba 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Du Zhong Cortex Eucommiae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g
– TAI YUAN YIN Variation (Chapter 31, Threatened Miscarriage, Qi and Blood deficiency) – Fetus Original Qi Decoction Variation • Ren Shen Radix Ginseng 9 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Bai Shao Radix Paeoniae alba 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Du Zhong Cortex Eucommiae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Huang Qi Radix Astragali 6 g • E Jiao Colla Corii asini 6 g – TANG SHI SHU JIE FANG – Dr Tang’s Pacifying [the Liver] and Eliminating Stagnation Formula • Chai Hu Radix Bupleuri 6 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Mu Dan Pi Cortex Moutan 6 g • Shan Zhi Zi Fructus Gardeniae 4.5 g • Xia Ku Cao Spica Prunellae 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g
• Xiang Fu Rhizoma Cyperi 4.5 g • Ba Yue Zha Fructus Akebiae 4.5 g • Mei Gui Hua Flos Rosae rugosae 4.5 g – TAO HE CHENG QI TANG – Persica Conducting Qi Decoction • Tao Ren Semen Persicae 12 g • Da Huang Radix et Rhizoma Rhei 12 g • Gui Zhi Ramulus Cinnamomi 6 g • Mang Xiao Sulfas Natrii 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 6 g – TAO HONG SI WU TANG – Persica-Carthamus Four Substances Decoction • Shu Di Huang Radix Rehmanniae preparata 12 g • Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Tao Ren Semen Persicae 6 g • Hong Hua Flos Carthami 4 g – TAO HONG SI WU TANG Variation (Chapter 14, Painful Periods, Blood stasis) – Persica-Carthamus Four Substances Decoction Variation
• Shu Di Huang Radix Rehmanniae preparata 12 g • Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Tao Ren Semen Persicae 6 g • Hong Hua Flos Carthami 4 g • Yan Hu Suo Rhizoma Corydalis 6 g • Xiang Fu Rhizoma Cyperi 6 g • Chuan Niu Xi Radix Cyathulae 6 g – TAO HONG SI WU TANG Variation (Chapter 16, No Periods, Stagnation of Qi and Blood) – Persica-Carthamus Four Substances Decoction Variation • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Chi Shao Radix Paeoniae rubra 6 g • Tao Ren Semen Persicae 6 g • Hong Hua Flos Carthami 4 g • Ze Lan Herba Lycopi 4 g • Mu Xiang Radix Aucklandiae 3 g • Xiang Fu Rhizoma Cyperi 6 g • Niu Xi Radix Achyranthis bidentatae seu Cyathulae 6 g
– TAO HONG SI WU TANG and SHI XIAO SAN Variation (Chapter 17, Flooding and Trickling, Stasis of Blood) – Persica-Carthamus Four Substances Decoction and Breaking into a Smile Powder Variation • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Shu Di Huang Radix Rehmanniae preparata 12 g • Bai Shao Radix Paeoniae alba 9 g • Tao Ren Semen Persicae 6 g • Hong Hua Flos Carthami 6 g • Pu Huang Pollen Typhae 9 g • Wu Ling Zhi Faeces Trogopteri 9 g • Qian Cao Gen Radix Rubiae 6 g • San Qi Radix Notoginseng 6 g – TAO HONG SI WU TANG Variation (Chapter 24, Fever During Period Time, Blood stasis with Heat) – Persica-Carthamus Four Substances Decoction Variation • Shu Di Huang Radix Rehmanniae preparata 12 g • Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Xiong Rhizoma Chuanxiong 8 g
• Tao Ren Semen Persicae 6 g • Hong Hua Flos Carthami 4 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Bie Jia Carapax Trionycis 9 g – TAO HONG YIN – Persica-Carthamus Decoction • Tao Ren Semen Persicae 6 g • Hong Hua Flos Carthami 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Dang Gui (Wei) Radix Angelicae sinensis (‘tail’ only) 6 g • Wei Ling Xian Radix Clematidis 6 g – TAO REN SAN (From Beneficial Formulae for Women, Fu Ren Liang Fang, 1237, by Chen Zi Ming) – Persica Powder • Tao Ren Semen Persicae 9 g • Shui Zhi Hirudo 6 g • Wu Zie Gu Endoconcha Sepiae 12 g • Yuan Hua Flos Daphni genkwa 9 g • Zhi Ke Fructus Aurantii 9 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Niu Xi Radix Cyathulae 6 g
• Chi Shao Radix Paeoniae rubra 9 g • Nao Sha Sal Ammoniac 3 g • Gui Zhi Ramulus Cinnamomi 6 g • Carp – TAO REN WAN – Persica Pill • Tao Ren Semen Persicae 9 g • Da Huang Radix et Rhizoma Rhei 6 g • Meng Chong Tabanus 3 g • Shui Zhi Hirudo 3 g – TIAN MA GOU TENG YIN – Gastrodia-Uncaria Decoction • Tian Ma Rhizoma Gastrodiae 9 g • Gou Teng Ramulus Uncariae cum Uncis 9 g • Shi Jue Ming Concha Haliotidis 6 g • Sang Ji Sheng Herba Taxilli 9 g • Du Zhong Cortex Eucommiae 9 g • Chuan Niu Xi Radix Cyathulae 9 g • Shan Zhi Zi Fructus Gardeniae 6 g • Huang Qin Radix Scutellariae 9 g
• Yi Mu Cao Herba Leonuri 9 g • Ye Jiao Teng Caulis Polygoni multiflori 9 g • Fu Shen Sclerotium Poriae pararadicis 6 g – TIAN WANG BU XIN DAN – Heavenly Emperor Tonifying the Heart Pill • Sheng Di Huang Radix Rehmanniae 12 g • Xuan Shen Radix Scrophulariae 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Tian Men Dong Radix Asparagi 6 g • Ren Shen Radix Ginseng 6 g • Fu Ling Poria 6 g • Wu Wei Zi Fructus Schisandrae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Bai Zi Ren Semen Platycadi 6 g • Suan Zao Ren Semen Zizyphi spinosae 6 g • Yuan Zhi Radix Polygalae 6 g • Jie Geng Radix Platycodi 3 g – TIAO GAN TANG – Regulating the Liver Decoction
• Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 9 g • Shan Yao Rhizoma Dioscoreae 12 g • E Jiao Colla Corii asini 9 g • Shan Zhu Yu Fructus Corni 6 g • Ba Ji Tian Radix Morindae 9 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – TONG GAN SHENG RU TANG – Penetrating the Liver and Generating Milk Decoction • Bai Shao Radix Paeoniae alba 15 g • Dang Gui Radix Angelicae sinensis 15 g • Bai Zhu Rhizoma Atractylodis macrocephalae 15 g • Shu Di Huang Radix Rehmanniae preparata 1 g • Gan Cao Radix Glycyrrhizae 1 g • Mai Men Dong Radix Ophiopogonis 15 g • Tong Cao Medulla Tetrapanacis 3 g • Chai Hu Radix Bupleuri 3 g • Yuan Zhi Radix Polygalae 3 g – TONG JING HUO LUO TANG – Penetrating the Menses and Invigorating the Connecting Channels Decoction
• Xiang Fu Rhizoma Cyperi 6 g • Qing Pi Pericarpium Citri viride 6 g • Si Gua Luo Retinervus Luffae fructus 6 g • Tong Cao Medulla Tetrapanacis 6 g • Gua Lou Fructus Trichosanthis 6 g • Dang Gui Radix Angelicae sinensis 6 g • Bian Dou Semen Lablab album 6 g • Ju Luo Retinervus Fructi Citri reticulatae 6 g – TONG JING YIN – Painful Menses Decoction • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Lian Zi Fructus Toosendan 4 g • Wu Yao Radix Linderae 6 g • Yan Hu Suo Rhizoma Corydalis 6 g • Chuan Xiong Rhizoma Chuanxiong 4 g • Yi Mu Cao Herba Leonuri 6 g • Xiao Hui Xiang Fructus Foeniculi 6 g • Gan Cao Radix Glycyrrhizae 3 g – TONG PAO YIN
– Penetrating the Bladder Decoction • Huang Qi Radix Astragali 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Tong Cao Medulla Tetrapanacis 3 g • Wu Wei Zi Fructus Schisandrae 3 g • Huai Niu Xi Radix Achyranthis bidentatae 6 g • Fu Ling Poria 6 g • Shan Yao Rhizoma Dioscoreae 6 g – TONG QIAO HUO XUE TANG – Opening the Orifices and Invigorating Blood Decoction • Chi Shao Yao Radix Paeoniae rubra 3 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Tao Ren Semen Persicae 9 g • Hong Hua Flos Carthami 9 g • She Xiang Moschus 0.15 g • Cong Bai Bulbus Allii fistulosi 3 g • Hong Zao Fructus jujubae 7 red dates • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Rice wine – TONG QIAO HUO XUE TANG Variation (Chapter 20, Headaches during Periods, Blood stasis)
– Opening the Orifices and Invigorating Blood Decoction Variation • Chi Shao Yao Radix Paeoniae rubra 3 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Tao Ren Semen Persicae 9 g • Hong Hua Flos Carthami 9 g • She Xiang Moschus 0.15 g • Cong Bai Herba Allii fistulosi 3 g • Hong Zao Fructus Jujubae 7 red dates • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Rice wine • Ge Gen Radix Puerariae 6 g • Chuan Niu Xi Radix Cyathulae 6 g – TONG RU DAN – Penetrating the Breast Special Pill • Ren Shen Radix Ginseng 30 g • Huang Qi Radix Astragali 30 g • Dang Gui Radix Angelicae sinensis 60 g • Mai Men Dong Radix Ophiopogonis 15 g • Mu Tong Caulis Akebiae 1 g • Jie Geng Radix Platycodi 1 g
• Zhu Di Pig’s Trotter 2 trotters – TONG XIE YAO FANG – Painful Diarrhoea Formula • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Bai Shao Radix Paeoniae alba 6 g • Chen Pi Pericarpium Citri reticulatae 4.5 g • Fang Feng Radix Saposhnikoviae 6 g – TONG YOU TANG – Penetrating the Deep Decoction • Sheng Di Huang Radix Rehmanniae 12 g • Shu Di Huang Radix Rehmanniae preparata 12 g • Dang Gui Radix Angelicae sinensis 12 g • Tao Ren Semen Persicae 4.5 g • Hong Hua Flos Carthami 4.5 g • Sheng Ma Rhizoma Cimicifugae 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – TONG YU JIAN – Eliminating Stasis Decoction • Dang Gui Radix Angelicae sinensis 9 g • Shan Zha Fructus Crataegi 6 g
• Xiang Fu Rhizoma Cyperi 6 g • Hong Hua Flos Carthami 6 g • Wu Yao Radix Linderae 3 g • Qing Pi Pericarpium Citri reticulatae viride 4.5 g • Ze Xie Rhizoma Alismatis 4.5 g • Mu Xiang Radix Aucklandiae 0.5 g – TU SI ZI WAN – Cuscuta Pill • Tu Si Zi Semen Cuscutae 60 g • Lu Rong Cornu Cervi pantotrichum 30 g • Rou Cong Rong Herba Cistanches 60 g • Shan Yao Rhizoma Dioscoreae 30 g • Fu Zi Radix Aconiti lateralis preparata 30 g • Wu Yao Radix Linderae 30 g • Wu Wei Zi Fructus Schisandrae 30 g • Sang Piao Xiao Ootheca Mantidis 30 g • Yi Zhi Ren Fructus Alpiniae oxyphyllae 30 g • (Duan) Mu Li Concha Ostreae (calcined) 60 g • Ji Nei Jin Endothelium Corneum gigeriae galli 15 g – TUO LI XIAO DU SAN
– Supporting the Interior and Dissolving Toxin Powder • Huang Qi Radix Astragali 9 g • Dang Shen Radix Codonopsis 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Bai Zhi Radix Angelicae dahuricae 3 g • Bai Shao Radix Paeoniae alba 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Zao Jiao Ci Spina Gleditsiae 4 g • Jin Yin Hua Flos Lonicerae 4 g • Jie Geng Radix Platycodi 3 g – WAN DAI TANG – Ending Vaginal Discharge Decoction • Bai Zhu Rhizoma Atractylodis macrocephalae (fried) 30 g • Shan Yao Rhizoma Dioscoreae (fried) 30 g • Ren Shen Radix Ginseng 6 g • Bai Shao Radix Paeoniae alba (fried) 15 g • Che Qian Zi Semen Plantaginis (fried) 6 g
• Cang Zhu Rhizoma Atractylodis 9 g • Gan Cao Radix Glycyrrhizae 3 g • Chen Pi Pericarpium Citri reticulatae 1.5 g • Jing Jie Herba Schizonepetae (charred) 1.5 g • Chai Hu Radix Bupleuri 1.8 g – WEN BAO YIN – Warming the Uterus Decoction • Bai Zhu Rhizoma Atractylodis macrocephalae 15 g • Ba Ji Tian Radix Morindae officinalis 15 g • Ren Shen Radix Ginseng 9 g • Du Zhong Cortex Eucommiae 9 g • Tu Si Zi Semen Cuscutae 9 g • Shan Yao Rhizoma Dioscoreae 9 g • Qian Shi Semen Euryales 9 g • Rou Gui Cortex Cinnamomi 6 g • Fu Zi Radix Aconiti lateralis preparata 0.8 g • Bu Gu Zhi Fructus Psoraleae 6 g – WEN DAN TANG – Warming the Gall Bladder Decoction • Ban Xia Rhizoma Pinelliae preparatum 6 g
• Fu Ling Poria 5 g • Chen Pi Pericarpium Citri reticulatae 9 g • Zhu Ru Caulis Bambusae in taeniam 6 g • Zhi Shi Fructus Aurantii immaturus 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sheng Jiang Rhizoma Zingiberis recens 5 slices • Da Zao Fructus jujubae 1 date – WEN DAN TANG Variation (Chapter 18, Pre-Menstrual Syndrome, Liver-Qi stagnation with Phlegm) – Warming the Gall Bladder Decoction • Ban Xia Rhizoma Pinelliae preparatum 6 g • Fu Shen Sclerotium Poriae pararadicis 5 g • Chen Pi Pericarpium Citri reticulatae 9 g • Zhu Ru Caulis Bambusae in taeniam 6 g • Zhi Shi Fructus Aurantii immaturus 6 g • Qing Pi Pericarpium Citri reticulatae viride 6 g • Xiang Fu Rhizoma Cyperi 6 g • Yuan Zhi Radix Polygalae 6 g • He Huan Pi Cortex Albiziae 6 g • Mei Gui Hua Flos Rosae rugosae 6 g • Yu Jin Radix Curcumae 6 g
• Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sheng Jiang Rhizoma Zingiberis recens 5 slices • Da Zao Fructus Jujubae 1 date – WEN DAN TANG Variation (Chapter 18, Pre-Menstrual Syndrome, PhlegmFire harassing upwards) – Warming the Gall Bladder Decoction Variation • Ban Xia Rhizoma Pinelliae preparatum 6 g • Fu Ling Poria 5 g • Chen Pi Pericarpium Citri reticulatae 9 g • Zhu Ru Caulis Bambusae in taeniam 6 g • Zhi Shi Fructus Aurantii immaturus 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Sheng Jiang Rhizoma Zingiberis recens 5 slices • Da Zao Fructus Jujubae 1 date • Qing Pi Pericarpium Citri reticulatae viride 6 g • Xiang Fu Rhizoma Cyperi 6 g • He Huan Pi Cortex Albiziae 6 g – WEN JING TANG – Warming the Menses Decoction • Wu Zhu Yu Fructus Evodiae 9 g
• Gui Zhi Ramulus Cinnamomi 9 g • Sheng Jiang Rhizoma Zingiberis recens 6 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Bai Shao Radix Paeoniae alba 9 g • Dang Shen Radix Codonopsis 12 g • Mai Men Dong Radix Ophiopogonis 6 g • E Jiao Colla Corii asini 9 g • Mu Dan Pi Cortex Moutan 4.5 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – WEN QI HUA SHI TANG – Warming the Umbilicus and Resolving Dampness Decoction • Bai Zhu Rhizoma Atractylodis macrocephalae (fried) 31 g • Fu Ling Poria 9 g • Shan Yao Rhizoma Dioscoreae 15 g • Ba Ji Tian Radix Morindae officinalis 15 g • Bian Dou Semen Lablab album 9 g • Bai Guo Semen Ginkgo 10 pieces • Lian Zi Semen Nelumbinis 30 pieces
– WEN SHEN FU YANG TANG – Warming the Kidneys and Supporting Yang Decoction • Ren Shen Radix Ginseng 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Shan Yao Rhizoma Dioscoreae 9 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Shan Zhu Yu Fructus Corni 6 g • Wu Zhu Yu Fructus Evodiae 3 g • Tu Si Zi Semen Cuscutae 6 g • Rou Gui Cortex Cinnamomi 3 g • Fu Zi Radix Aconiti lateralis preparata 3 g • Bu Gu Zhi Fructus Psoraleae 6 g – WEN TU YU LIN TANG – Warming the Earth and Giving Birth to the Unicorn Decoction • Ba Ji Tian Radix Morindae 6 g • Fu Pen Zi Fructus Rubi 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Ren Shen Radix Ginseng 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Shen Qu Massa medicata fermentata 6 g
– WU PI YIN – Five Skin Decoction • Sheng Jiang Pi Pericarpium Zingiberis recens 9 g • Sang Bai Pi Cortex Mori 9 g • Chen Pi Pericarpium Citri reticulatae 9 g • Da Fu Pi Pericarpium Arecae 9 g • Fu Ling Pi Cutis Poriae 9 g – WU WEI XIAO DU YIN – Five-Ingredient Dissolving Toxin Decoction • Jin Yin Hua Flos Lonicerae 9 g • Ju Hua Flos Chrysanthemi 3.6 g • Pu Gong Ying Herba Taraxaci 3.6 g • Zi Hua Di Ding Herba Violae 3.6 g • Zi Bei Tian Kui Herba Begoniae fimbristipulatae 3.6 g – WU WEI XIAO DU YIN Variation (Chapter 61, Excessive Vaginal Discharge, Toxic-Heat) – Five-Ingredient Dissolving Toxin Decoction Variation • Jin Yin Hua Flos Lonicerae 9 g • Ju Hua Flos Chrysanthemi 3.6 g • Pu Gong Ying Herba Taraxaci 3.6 g • Zi Hua Di Ding Herba Violae 3.6 g
• Zi Bei Tian Kui Herba Begoniae fimbristipulatae 3.6 g • Bai Hua She She Cao Herba Hedyotis diffusae 6 g – WU XIANG WAN – Five Aromatic Pill • Wu Ling Zhi Faeces Trogopterori 500 g • Xiang Fu Rhizoma Cyperi 500 g – WU YAO SAN – Lindera Powder • Wu Yao Radix Linderae 6 g • Xiang Fu Rhizoma Cyperi 6 g • Su Zi Fructus Perillae 4.5 g • Chen Pi Pericarpium Citri reticulatae 3 g • Chai Hu Radix Bupleuri 6 g • Mu Dan Pi Cortex Moutan 6 g • Gui Zhi Ramulus Cinnamomi 3 g • Mu Xiang Radix Aucklandiae 3 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Bo He Herba Menthae haplocalycis 3 g • Gan Cao Radix Glycyrrhizae 3 g
– WU YAO TANG – Lindera Decoction • Wu Yao Radix Linderae 6 g • Xiang Fu Rhizoma Cyperi 12 g • Mu Xiang Radix Aucklandiae 3 g • Gan Cao Radix Glycyrrhizae 3 g • Dang Gui Radix Angelicae sinensis 6 g – WU YAO TANG Variation (Chapter 9, Late Periods, Liver-Qi stagnation) – Lindera Decoction Variation • Wu Yao Radix Linderae 9 g • Xiang Fu Rhizoma Cyperi 6 g • Mu Xiang Radix Aucklandiae 3 g • Sha Ren Fructus Amomi 3 g • Yan Hu Suo Rhizoma Corydalis 6 g • Bing Lang Semen Arecae 4.5 g • Gan Cao Radix Glycyrrhizae 3 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g – WU ZI YAN ZONG WAN – Five-Seed Developing Ancestors Pill
• Tu Si Zi Semen Cuscutae 240 g • Wu Wei Zi Fructus Schisandrae 30 g • Gou Qi Zi Fructus Lycii 240 g • Fu Pen Zi Fructus Rubi 120 g • Che Qian Zi Semen Plantaginis 60 g – WU ZI YAN ZONG WAN Variation (Chapter 61, Excessive Vaginal Discharge, Kidney-Yang deficiency) – Five-Seed Developing Ancestors Pill Variation • Tu Si Zi Semen Cuscutae 240 g • Wu Wei Zi Fructus Schisandrae 30 g • Gou Qi Zi Fructus Lycii 240 g • Fu Pen Zi Fructus Rubi 120 g • Che Qian Zi Semen Plantaginis 60 g • Qian Shi Semen Euryales 6 g • Ba Ji Tian Radix Morindae 6 g – XIA RU YONG QUAN SAN – Promoting Lactation Gushing Spring Powder • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Sheng Di Huang Radix Rehmanniae 6 g
• Tian Hua Fen Radix Trichosanthis 6 g • Qing Pi Pericarpium Citri reticulatae viride 4.5 g • Chai Hu Radix Bupleuri 6 g • Jie Geng Radix Platycodi 3 g • Tong Cao Medulla Tetrapanacis 3 g • Lou Lu Radix Rhapontici 4.5 g • Chuan Shan Jia Squama Manitis 4.5 g • Wang Bu Liu Xing Semen Vaccariae 4.5 g • Gan Cao Radix Glycyrrhizae 3 g – XIAN FANG HUO MING YIN – Immortal’s Formula Life-Saving Decoction • Jin Yin Hua Flos Lonicerae 12 g • Bai Zhi Radix Angelicae dahuricae 6 g • Fang Feng Radix Saposhnikoviae 6 g • Dang Gui Radix Angelicae sinensis 9 g • Chen Pi Pericarpium Citri reticulatae 3 g • Gan Cao Radix Glycyrrhizae 6 g • Zhe Bei Mu Bulbus Fritillariae thunbergii 9 g • Tian Hua Fen Radix Trichosanthis 6 g • Ru Xiang Olibanum 6 g
• Mo Yao Myrrha 6 g • Zhen Zhu Mu Concha Margaritiferae usta 9 g • Zao Jiao Ci Spina Gleditsiae 3 g – XIAN QI TANG – Decoction for Early Periods • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Huang Bo Cortex Phellodendri 3 g • Zhi Mu Rhizoma Anemarrhenae 3 g • Huang Qin Radix Scutellariae 2.4 g • Huang Lian Rhizoma Coptidis 2.4 g • Chuan Xiong Rhizoma Chuanxiong 2.4 g • E Jiao Colla Corii asini 2.4 g • Ai Ye Folium Artemisiae argyi 2.1 g • Xiang Fu Rhizoma Cyperi 2.1 g • Gan Cao Radix Glycyrrhizae 2.1 g – XIANG AI XIONG DANG YIN – Cyperus-Artemisia-Ligusticum- Angelica Decoction • Xiang Fu Rhizoma Cyperi 6 g
• Ai Ye Folium Artemisiae argyi 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Dang Gui Radix Angelicae sinensis 9 g • Yan Hu Suo Rhizoma Corydalis 6 g – XIANG BEI YANG RONG TANG – Cyperus-Fritillaria Nourishing and Flourishing Decoction • Xiang Fu Rhizoma Cyperi 6 g • Zhe Bei Mu Bulbus Fritillariae thunbergii 6 g • Ren Shen Radix Ginseng 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Jie Geng Radix Platycodi 3 g • Gan Cao Radix Glycyrrhizae 3 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Da Zao Fructus jujubae 3 dates
• Pu Gong Ying Herba Taraxaci 4.5 g • Ban Zhi Lian Herba Scutellariae barbatae 4.5 g • Bai Hua She She Cao Herba Hedyotis diffusae 4.5 g
– XIANG LENG WAN – Aucklandia-Sparganium Pill • Mu Xiang Radix Aucklandiae 6 g • Zhi Ke Fructus Aurantii 6 g • Chuan Lian Zi Fructus Toosendan 3 g • Qing Pi Pericarpium Citri reticulatae viride 3 g • Ding Xiang Flos Caryophylli 3 g • Xiao Hui Xiang Fructus Foeniculi 3 g • San Leng Rhizoma Sparganii 6 g • E Zhu Rhizoma Curcumae 6 g – XIANG SHA LIU JUN ZI TANG – Aucklandia-Amomum Six Gentlemen Decoction • Ren Shen Radix Ginseng 10 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Fu Ling Poria 9 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Chen Pi Pericarpium Citri reticulatae 4.5 g • Ban Xia Rhizoma Pinelliae preparatum 12 g • Mu Xiang Radix Aucklandiae 6 g • Sha Ren Fructus Amomi 6 g
– XIAO BAN XIA TANG – Small Pinellia Decoction • Ban Xia Rhizoma Pinelliae preparatum 9 g • Sheng Jiang Rhizoma Zingiberis recens 21 g – XIAO CHAI HU TANG – Small Bupleurum Decoction • Chai Hu Radix Bupleuri 12 g • Huang Qin Radix Scutellariae 9 g • Ban Xia Rhizoma Pinelliae preparatum 9 g • Ren Shen Radix Ginseng 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Sheng Jiang Rhizoma Zingiberis recens 9 g • Da Zao Fructus jujubae 4 dates – XIAO DU YIN – Dissolving Toxin Decoction • Qing Pi Pericarpium Citri reticulatae viride 3 g • Chai Hu Radix Bupleuri 6 g • Bai Zhi Radix Angelicae dahuricae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Zhe Bei Mu Bulbus Fritillariae thunbergii 6 g
• Jiang Can Bombyx batryticatus 3 g • Tian Hua Fen Radix Trichosanthis 6 g • Jin Yin Hua Flos Lonicerae 6 g • Gan Cao Radix Glycyrrhizae 3 g – XIAO FENG SAN – Expelling Wind Powder • Jing Jie Herba Schizonepetae 3 g • Fang Feng Radix Saposhnikoviae 3 g • Chan Tui Periostracum Cicadae 3 g • Niu Bang Zi Fructus Arctii 3 g • Ku Shen Radix Sophorae flavescentis 3 g • Mu Tong Caulis Akebiae 1.5 g • Cang Zhu Rhizoma Atractylodis 3 g • Sheng Di Huang Radix Rehmanniae 5 g • Shi Gao Gypsum 10 g • Zhi Mu Rhizoma Anemarrhenae 3 g • Dang Gui Radix Angelicae sinensis 3 g • Hei Zhi Ma Semen Sesami nigrum 3 g • Gan Cao Radix Glycyrrhizae 3 g – XIAO FENG SAN Variation (Chapter 27, Skin Eruptions at Period Time, BloodHeat)
– Expelling Wind Powder Variation • Jing Jie Herba Schizonepetae 3 g • Fang Feng Radix Saposhnikoviae 3 g • Chan Tui Periostracum Cicadae 3 g • Sheng Di Huang Radix Rehmanniae 6 g • Mu Dan Pi Cortex Moutan 9 g • Zhi Cao Radix Lithospermi 6 g • Shi Gao Gypsum 10 g • Zhi Mu Rhizoma Anemarrhenae 3 g • Dang Gui Radix Angelicae sinensis 3 g • Hong Zao Flos Carthami 4.5 g • Gan Cao Radix Glycyrrhizae 3 g – XIAO LIU FANG – Dissolving and Flowing Formula • San Leng Rhizoma Sparganii 6 g • E Zhu Rhizoma Curcumae 6 g • Mu Li Concha Ostreae 12 g • Chai Hu Radix Bupleuri 6 g • Xiang Fu Rhizoma Cyperi 6 g • Qing Pi Pericarpium Citri reticulatae viride 6 g
• Xia Ku Cao Spica Prunellae 6 g • Pu Gong Ying Herba Taraxaci 6 g • Da Huang Radix et Rhizoma Rhei 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Wa Leng Zi Concha Arcae 12 g • E Jiao Colla Corii asini 6 g – XIAO TIAO JING TANG – Small Regulating the Menses Decoction • Bai Shao Radix Paeoniae alba 3 g • Dang Gui Radix Angelicae sinensis 3 g • Mo Yao Myrrha 3 g • Hu Po Succinum 3 g • Rou Gui Cortex Cinnamomi 3 g • Xi Xin Herba Asari 1.5 g • She Xiang Moschus 1.5 g – XIAO XIAN XIONG TANG – Small Sinking [Qi of the] Chest Decoction • Huang Lian Rhizoma Coptidis 6 g • Ban Xia Rhizoma Pinelliae preparatum 12 g • Gua Lou Fructus Trichosanthis 30 g
– XIAO XIAN XIONG TANG Variation (Chapter 39, Cough during Pregnancy, Phlegm-Heat in the Lungs) – Small Sinking [Qi of the] Chest Decoction Variation • Huang Lian Rhizoma Coptidis 6 g • Ban Xia Rhizoma Pinelliae preparatum 12 g • Gua Lou Fructus Trichosanthis 30 g • Chuan Bei Mu Bulbus Fritillariae cirrhosae 6 g – XIAO YAO SAN – Free and Easy Wanderer Powder • Bo He Herba Menthae haplocalycis 3 g • Chai Hu Radix Bupleuri 9 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Fu Ling Poria 15 g • Gan Cao Radix Glycyrrhizae 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices – XIAO YAO SAN Variation (Chapter 14, Painful Periods, Qi stagnation) – Free and Easy Wanderer Powder Variation • Bo He Herba Menthae haplocalycis 3 g • Chai Hu Radix Bupleuri 9 g
• Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Fu Ling Poria 15 g • Gan Cao Radix Glycyrrhizae 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Wu Yao Radix Linderae 6 g • Xiang Fu Rhizoma Cyperi 6 g • Zhi Ke Fructus Aurantii 6 g • Yan Hu Suo Rhizoma Corydalis 6 g – XIAO YAO SAN Variation (Chapter 18, Pre-Menstrual Syndrome, Liver-Blood deficiency) – Free and Easy Wanderer Powder Variation • Bo He Herba Menthae hyplocalycis 3 g • Chai Hu Radix Bupleuri 9 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Fu Ling Poria 15 g • Gan Cao Radix Glycyrrhizae 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices
• Shu Di Huang Radix Rehmanniae preparata 6 g • Gou Qi Zi Fructus Lycii 6 g – XIAO YAO SAN Variation (I) (Chapter 59, Breast Lumps, Stagnation of LiverQi) – Free and Easy Wanderer Powder Variation • Bo He Herba Menthae haplocalycis 3 g • Chai Hu Radix Bupleuri 9 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Fu Ling Poria 15 g • Gan Cao Radix Glycyrrhizae 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Gua Lou Fructus Trichosanthis 6 g • Xia Ku Cao Spica Prunellae 6 g • Hai Zao Sargassum 6 g • Qing Pi Pericarpium Citri reticulatae viride 3 g • Xiang Fu Rhizoma Cyperi 6 g • Huang Yao Zi Rhizoma Dioscoreae bulbiferae 6 g – XIAO YAO SAN Variation (II) (Chapter 59, Breast Lumps, Stagnation of Liver-Qi)
– Free and Easy Wanderer Powder Variation • Chai Hu Radix Bupleuri 6 g • Qing Pi Pericarpium Citri reticulatae viride 3 g • Bai Shao Radix Paeoniae alba 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chi Shao Radix Paeoniae rubra 6 g • Yu Jin Radix Curcumae 6 g • Dan Shen Radix Salviae miltiorrhizae 4.5 g • E Zhu Rhizoma Curcumae 6 g • Chuan Shan Jia Squama Manitis 6 g • Yi Mu Cao Herba Leonuri 6 g • Gua Lou Fructus Trichosanthis 6 g • Hai Zao Sargassum 9 g • Lou Lu Radix Rhapontici 6 g – XIAO YAO SAN Variation (Chapter 59, Breast Lumps, Stagnation of Liver-Qi, Dr Shan Dao Wei, Nanjing) – Free and Easy Wanderer Powder Variation • Chai Hu Radix Bupleuri 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Qing Pi Pericarpium Citri reticulatae viride 3 g • Dang Gui Radix Angelicae sinensis 6 g
• Bai Shao Radix Paeoniae alba 6 g • Yu Jin Radix Curcumae 6 g • Fu Ling Poria 6 g • Xia Ku Cao Spica Prunellae 6 g • Zhe Bei Mu Bulbus Fritillariae thunbergii 6 g • Yu Zhu Rhizoma Polygonati odorati 6 g – XIAO YAO SAN Variation (Chapter 61, Excessive Vaginal Discharge, Liver-Qi stagnation) – Free and Easy Wanderer Powder Variation • Bo He Herba Menthae haplocalycis 3 g • Chai Hu Radix Bupleuri 9 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 12 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g • Fu Ling Poria 15 g • Gan Cao Radix Glycyrrhizae 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Yi Yi Ren Semen Coicis 12 g • Bian Dou Semen Lablab album 6 g • Xiang Fu Rhizoma Cyperi 6 g – XIAO ZHANG SHU YU TANG
– Dissolving Distension and Relaxing Stagnation Decoction • Xiang Fu Rhizoma Cyperi (fried in vinegar) 6 g • Chai Hu Radix Bupleuri 6 g • Qing Pi Pericarpium Citri reticulatae viride 3 g • Ju He Semen Citri reticulatae 3 g • Chuan Lian Zi Fructus Toosendan 3 g • Zhi Ke Fructus Aurantii 6 g • Lu Lu Tong Fructus Liquidambaris 6 g • Mu Gua Fructus Chaenomelis 3 g – XIAO ZHI TANG – Dissolving Haemorrhoids Decoction • Wu Mei Fructus Mume 6 g • Wu Wei Zi Fructus Schisandrae 6 g • Ku Shen Radix Sophorae flavescentis 9 g • She Gan Rhizoma Belamcandae 6 g • Chuan Shan Jia Squama Manitis 6 g • Mu Li Concha Ostreae 12 g • Huo Ma Ren Semen Cannabis 6 g – XIE GAN AN SHEN WAN – Draining the Liver and Calming the Mind Pill
• Long Dan Cao Radix Gentianae 9 g • Shan Zhi Zi Fructus Gardeniae 6 g • Huang Qin Radix Scutellariae 6 g • Bai Ji Li Fructus Tribuli 4 g • Shi Jue Ming Concha Haliotidis 12 g • Ze Xie Rhizoma Alismatis 6 g • Che Qian Zi Semen Plantaginis 6 g • Dang Gui Radix Angelicae sinensis 6 g • Sheng Di Huang Radix Rehmanniae 9 g • Mai Men Dong Radix Ophiopogonis 6 g • Zhen Zhu Mu Concha Margaritiferae usta 12 g • Long Gu Fossilia Ossis mastodi 12 g • Mu Li Concha Ostreae 12 g • Fu Shen Sclerotium Poriae pararadicis 6 g • Yuan Zhi Radix Polygalae 6 g • Bai Zi Ren Semen Platycadi 6 g • Suan Zao Ren Semen Zizyphi spinosae 6 g • Gan Cao Radix Glycyrrhizae 3 g – XIE XIN TANG – Draining the Heart Decoction
• Da Huang Radix et Rhizoma Rhei 6 g • Huang Lian Rhizoma Coptidis 3 g • Huang Qin Radix Scutellariae 3 g – XUAN FU DAI ZHE TANG – Inula-Haematitum Decoction • Xuan Fu Hua Flos Inulae 3 g • Dai Zhe Shi Haematitum 18 g • Ban Xia Rhizoma Pinelliae preparatum 12 g • Ren Shen Radix Ginseng 3.6 g • Gan Cao Radix Glycyrrhizae 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Da Zao Fructus jujubae 2 dates – XUAN YU TONG JING TANG – Dispersing Stagnation and Penetrating the Menses Decoction • Bai Shao Radix Paeoniae alba 15 g • Dang Gui Radix Angelicae sinensis 15 g • Mu Dan Pi Cortex Moutan 15 g • Shan Zhi Zi Fructus Gardeniae 9 g • Huang Qin Radix Scutellariae 3 g • Bai Jie Zi Semen Sinapis 6 g
• Chai Hu Radix Bupleuri 3 g • Xiang Fu Rhizoma Cyperi 3 g • Yu Jin Radix Curcumae 3 g • Gan Cao Radix Glycyrrhizae 3 g – XUE FU ZHU YU TANG – Blood Mansion Eliminating Stasis Decoction • Dang Gui Radix Angelicae sinensis 9 g • Sheng Di Huang Radix Rehmanniae 9 g • Chi Shao Radix Paeoniae rubra 6 g • Chuan Xiong Rhizoma Chuanxiong 5 g • Tao Ren Semen Persicae 12 g • Hong Hua Flos Carthami 9 g • Chai Hu Radix Bupleuri 3 g • Zhi Ke Fructus Aurantii 6 g • Niu Xi Radix Achyranthis bidentatae seu Cyathulae 9 g • Jie Geng Radix Platycodi 5 g • Gan Cao Radix Glycyrrhizae 3 g – XUE FU ZHU YU TANG Variation (Chapter 24, Fever at Period Time, Blood stasis with Heat) – Blood Mansion Eliminating Stasis Decoction Variation • Dang Gui Radix Angelicae sinensis 9 g
• Sheng Di Huang Radix Rehmanniae 9 g • Chi Shao Radix Paeoniae rubra 6 g • Chuan Xiong Rhizoma Chuanxiong 5 g • Tao Ren Semen Persicae 12 g • Hong Hua Flos Carthami 9 g • Chai Hu Radix Bupleuri 3 g • Zhi Ke Fructus Aurantii 6 g • Niu Xi Radix Achyranthis bidentatae seu Cyathulae 9 g • Jie Geng Radix Platycodi 5 g • Gan Cao Radix Glycyrrhizae 3 g • Mu Dan Pi Cortex Moutan 6 g – YANG JING ZHONG YU TANG – Nourishing the Essence and Planting Jade Decoction • Shu Di Huang Radix Rehmanniae preparata 15 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 9 g • Shan Zhu Yu Fructus Corni 9 g – YANG JING ZHONG YU TANG Variation (Chapter 57, Infertility, Kidney-Yin deficiency) – Nourishing the Essence and Growing Jade Decoction Variation • Dang Gui Radix Angelicae sinensis 9 g
• Bai Shao Radix Paeoniae alba 9 g • Shu Di Huang Radix Rehmannia preparata 15 g • Shan Zhu Yu Fructus Corni 9 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Han Lian Cao Herba Ecliptae 6 g – YANG RONG TANG – Nourishing and Flourishing Decoction • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Bai Shao Radix Paeoniae alba 6 g • Sheng Di Huang Radix Rehmanniae 4 g • Mai Men Dong Radix Ophiopogonis 6 g • Yuan Zhi Radix Polygalae 6 g • Shi Chang Pu Rhizoma Acori tatarinowii 4 g • Chen Pi Pericarpium Citri reticulatae 3 g • Wu Yao Radix Linderae 3 g • Fu Ling Poria 6 g • Zhi Shi Fructus Aurantii immaturus 3 g • Huang Lian Rhizoma Coptidis 1.5 g • Fang Feng Radix Saposhnikoviae 3 g
• Qiang Huo Rhizoma seu Radix Notopterygii 3 g • Qin Jiao Radix Gentianae macrophyllae 3 g • Ban Xia Rhizoma Pinelliae 4 g • Dan Nan Xing Rhizoma Arisaematis preparatum 3 g • Gan Cao Radix Glycyrrhizae 3 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Zhu Ru Caulis Bambusae in taeniam 3 g – YANG RONG ZHUANG SHEN TANG – Nourishing and Flourishing Strengthening the Kidneys Decoction • Sang Ji Sheng Herba Taxilli 6 g • Dang Gui Radix Angelicae sinensis 6 g • Xu Duan Radix Dipsaci 6 g • Du Zhong Cortex Eucommiae 6 g • Du Huo Radix Angelicae pubescentis 6 g • Fang Feng Radix Saposhnikoviae 4.5 g • Rou Gui Cortex Cinnamomi 2 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices – YANG XIN TANG – Nourishing the Heart Decoction • Huang Qi Radix Astragali 15 g
• Fu Ling Poria 6 g • Fu Shen Sclerotium Poriae pararadicis 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 4 g • Rou Gui Cortex Cinnamomi 3 g • Bai Zi Ren Semen Platycadi 9 g • We Wei Zi Fructus Schisandrae 6 g • Ren Shen Radix Ginseng 9 g • Gan Cao Radix Glycyrrhizae 3 g – YANG XUE DING FENG TANG – Nourishing Blood and Subduing Wind Decoction • Sheng Di Huang Radix Rehmanniae 6 g • Dang Gui Radix Angelicae sinensis 9 g • Chi Shao Radix Paeoniae rubra 4 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Tian Men Dong Radix Asparagi 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Jiang Can Bombyx batryticatus 3 g • Shou Wu Radix Polygoni multiflori preparata 9 g
• Shan Zhi Zi Fructus Gardeniae 3 g • Mu Dan Pi Cortex Moutan 6 g – YANG XUE RUN FU YIN – Nourishing Blood and Moistening the Skin Decoction • Dang Gui Radix Angelicae sinensis 9 g • Dan Shen Radix Salviae miltiorrhizae 4 g • Sheng Di Huang Radix Rehmanniae 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Xuan Shen Radix Scrophulariae 6 g • Shou Wu Radix Polygoni multiflori preparata 9 g • Ji Xue Teng Caulis Spatholobi 6 g • Tian Mai Dong Radix Asparagi 6 g • Hei Zhi Ma Semen Sesami nigrum 6 g • Chan Tui Periostracum Cicadae 3 g – YANG XUE XI FENG FANG – Nourishing Blood and Extinguishing Wind Formula • Ling Yang Jiao Cornu Saigae tataricae 6 g • Gou Teng Ramulus Uncariae cum Uncis 6 g • Jiang Can Bombyx batryticatus 4.5 g • Di Long Pheretima 4.5 g
• Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Sheng Di Huang Radix Rehmanniae 6 g • Bai Shao Radix Paeoniae alba 9 g – YI GAN HE WEI YIN – Restraining the Liver and Harmonizing the Stomach Decoction • Zi Su Ye Folium Perillae 3 g • Huang Lian Rhizoma Coptidis 2 g • Zhu Ru Caulis Bambusae in taeniam 10 g • Chen Pi Pericarpium Citri reticulatae 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g – YI GUAN JIAN – One Linking Decoction • Bei Sha Shen Radix Glehniae 10 g • Mai Men Dong Radix Ophiopogonis 10 g • Dang Gui Radix Angelicae sinensis 10 g • Sheng Di Huang Radix Rehmanniae 30 g • Gou Qi Zi Fructus Lycii 12 g • Chuan Lian Zi Fructus Toosendan 5 g – YI GUAN JIAN Variation (Chapter 18, Pre-Menstrual Syndrome, Liver- and Kidney-Yin deficiency)
– One Linking Decoction Variation • Bei Sha Shen Radix Glehniae 10 g • Mai Men Dong Radix Ophiopogonis 10 g • Dang Gui Radix Angelicae sinensis 10 g • Sheng Di Huang Radix Rehmanniae 30 g • Gou Qi Zi Fructus Lycii 12 g • Chuan Lian Zi Fructus Toosendan 5 g • Mei Gui Hua Flos Rosae rugosae 6 g • Fo Shou Fructus Citri sarcodactylis 6 g – YI GUAN JIAN Variation (Chapter 51, Fever after Childbirth, Blood deficiency) – One Linking Decoction Variation • Bei Sha Shen Radix Glehniae 10 g • Mai Men Dong Radix Ophiopogonis 10 g • Dang Gui Radix Angelicae sinensis 10 g • Sheng Di Huang Radix Rehmanniae 30 g • Gou Qi Zi Fructus Lycii 12 g • Chuan Lian Zi Fructus Toosendan 5 g • Gui Ban Plastrum Testudinis 9 g • Qing Hao Herba Artemisiae annuae 3 g – YI HUANG TANG
– Change Yellow Decoction • Shan Yao Rhizoma Dioscoreae (fried) 30 g • Qian Shi Semen Euryales (fried) 30 g • Huang Bo Cortex Phellodendri (fried with salt water) 6 g • Che Qian Zi Semen Plantaginis (fried with wine) 3 g • Bai Guo Semen Ginkgo 10 pieces – YI MU XIONG GUI TANG – Leonorus-Ligusticum-Angelica Decoction • Dang Gui Radix Angelicae sinensis 15 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Yi Mu Cao Herba Leonuri 6 g • Hou Po Cortex Magnoliae officinalis 4.5 g • Hong Hua Flos Carthami 4.5 g • Tao Ren Semen Persicae 6 g • Huai Niu Xi Radix Achyranthis bidentatae 6 g – YI PI WEN SHEN TANG – Benefiting the Spleen and Warming the Kidneys Decoction • Ren Shen Radix Ginseng 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 9 g
• Shan Yao Rhizoma Dioscoreae 9 g • Ba Ji Tian Radix Morindae officinalis 9 g • Tu Si Zi Semen Cuscutae 9 g • Dang Gui Radix Angelicae sinensis 9 g • Gan Cao Radix Glycyrrhizae 6 g – YI QI DAO NI TANG – Benefiting Qi and Conducting Turbidity Decoction • Dang Shen Radix Codonopsis 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Bian Dou Semen Lablab album 6 g • Fu Ling Poria 6 g • Sheng Ma Rhizoma Cimicifugae 3 g • Jie Geng Radix Platycodi 3 g • Wu Yao Radix Linderae 4.5 g • Gui Zhi Ramulus Cinnamomi 3 g • Tong Cao Medulla Tetrapanacis 2 g – YI QI GU CHONG TANG – Benefiting Qi and Consolidating the Penetrating Vessel Decoction • Huang Qi Radix Astragali 15 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g
• Dang Shen Radix Codonopsis 9 g • Ai Ye Folium Artemisiae argyi 4.5 g • Xian He Cao Herba Agrimoniae 6 g • Jing Jie Herba Schizonepetae (charred) 6 g • Dang Gui Radix Angelicae sinensis 6 g • Xu Duan Radix Dipsaci 6 g • Sheng Ma Rhizoma Cimicifugae 3 g • Gan Cao Radix Glycyrrhizae 3 g – YI QI LI SHUI TANG – Benefiting Qi and Transforming Water Decoction • Huang Qi Radix Astragali 9 g • Sheng Ma Rhizoma Cimicifugae 3 g • Tong Cao Medulla Tetrapanacis 3 g • Gui Zhi Ramulus Cinnamomi 4.5 g • Dang Shen Radix Codonopsis 6 g • Che Qian Cao Herba Plantaginis 3 g • Yi Mu Cao Herba Leonuri 4.5 g • Dang Gui Radix Angelicae sinensis 6 g • Wu Yao Radix Linderae 4.5 g • Ze Xie Rhizoma Alismatis 6 g
• Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Gu Ya Fructus Setariae germinatus 4.5 g – YI QI YANG XUE TANG – Benefiting Qi and Nourishing Blood Decoction • Ren Shen Radix Ginseng 6 g • Huang Qi Radix Astragali 6 g • Sheng Ma Rhizoma Cimicifugae 3 g • Shan Yao Rhizoma Dioscoreae 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Du Zhong Cortex Eucommiae 6 g • Xu Duan Radix Dipsaci 6 g • Sang Ji Sheng Herba Taxilli 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Dang Gui Radix Angelicae sinensis 4.5 g • Ai Ye Folium Artemisiae argyi 4.5 g • Gan Cao Radix Glycyrrhizae 3 g – YI SHEN FU YANG TANG – Benefiting the Kidneys and Supporting the Yang Decoction • Ren Shen Radix Ginseng 9 g • Shu Di Huang Radix Rehmanniae preparata 9 g
• Shan Yao Rhizoma Dioscoreae 9 g • Shan Zhu Yu Fructus Corni 9 g • Tu Si Zi Semen Cuscutae 9 g • Yuan Zhi Radix Polygalae 9 g • Wu Wei Zi Fructus Schisandrae 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 6 g • Fu Zi Radix Aconiti lateralis preparata 3 g • Rou Gui Cortex Cinnamomi 3 g • Bu Gu Zhi Fructus Psoraleae 6 g – YI SHEN TONG JING TANG – Benefiting the Kidneys and Penetrating the Menses Decoction • Shan Yao Rhizoma Dioscoreae 12 g • Ba Ji Tian Radix Morindae officinalis 9 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 6 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Xiang Fu Rhizoma Cyperi 6 g • Chai Hu Radix Bupleuri 4.5 g • Yu Jin Radix Curcumae 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g
– YI YIN JIAN – One Yin Decoction • Sheng Di Huang Radix Rehmanniae 6 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Bai Shao Radix Paeoniae alba 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Gan Cao Radix Glycyrrhizae 3 g • Huai Niu Xi Radix Achyranthis bidentatae 4.5 g • Dan Shen Radix Salviae miltiorrhizae 6 g – YI YIN JIAN Variation (Chapter 9, Late Periods, Blood deficiency) – One Yin Decoction Variation • Sheng Di Huang Radix Rehmanniae 6 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Bai Shao Radix Paeoniae alba 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Gan Cao Radix Glycyrrhizae 3 g • Huai Niu Xi Radix Achyranthis bidentatae 4.5 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Di Gu Pi Cortex Lycii 6 g
– YI YIN JIAN Variation (Chapter 16, No Periods, Liver- and Kidney-Yin deficiency) – One Yin Decoction Variation • Sheng Di Huang Radix Rehmanniae 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Bai Shao Radix Paeoniae alba 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Di Gu Pi Cortex Lycii 6 g • Huang Jing Rhizoma Polygonati 6 g • Dan Shen Radix Salviae miltiorrhizae 4 g • Zhi Ke Fructus Aurantii 3 g – YIN DAO 1 HAO PIAN – Vaginal No. 1 Suppository • Bai Tou Weng Radix Pulsatillae • Tou Gu Cao Caulis Impatientis – YIN QIAO SAN – Lonicera-Forsythia Powder • Jin Yin Hua Flos Lonicerae 9 g • Lian Qiao Fructus Forsythiae 9 g • Jie Geng Radix Platycodi 6 g
• Niu Bang Zi Fructus Arctii 9 g • Bo He Herba Menthae haplocalycis 6 g • Jing Jie Herba Schizonepetae 5 g • Zhu Ye Folium Phyllostachys nigrae 4 g • Dan Dou Chi Semen Sojae preparatum 5 g • Gan Cao Radix Glycyrrhizae 5 g – YIN QIAO SAN Variation (Chapter 51, Fever after Childbirth, Invasion of external Wind) – Lonicera-Forsythia Powder Variation • Jin Yin Hua Flos Lonicerae 9 g • Lian Qiao Fructus Forsythiae 9 g • Jie Geng Radix Platycodi 6 g • Niu Bang Zi Fructus Arctii 9 g • Bo He Herba Menthae haplocalycis 6 g • Jing Jie Herba Schizonepetae 5 g • Zhu Ye Folium Phyllostachys nigrae 4 g • Dan Dou Chi Semen Sojae preparatum 5 g • Gan Cao Radix Glycyrrhizae 5 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g – YONG QUAN SAN
– Gushing Spring Powder • Ding Xiang Flos Caryophylli 3 g • Wang Bu Liu Xing Semen Vaccariae 4.5 g • Tian Hua Fen Radix Trichosanthis 6 g • Lou Lu Radix Rhapontici 4.5 g • Jiang Can Bombyx batryticatus 3 g • Zhu Di Pig’s Trotter 1 trotter – YOU GUI WAN – Restoring the Right [Kidney] Pill • Fu Zi Radix Aconiti lateralis preparata 3 g • Rou Gui Cortex Cinnamomi 3 g • Du Zhong Cortex Eucommiae 6 g • Shan Zhu Yu Fructus Corni 4.5 g • Tu Si Zi Semen Cuscutae 6 g • Lu Jiao Jiao Colla Cornu Cervi 6 g • Shu Di Huang Radix Rehmanniae preparata 12 g • Shan Yao Rhizoma Dioscoreae 6 g • Gou Qi Zi Fructus Lycii 6 g • Dang Gui Radix Angelicae sinensis 4.5 g – YOU GUI WAN Variation (Chapter 43, Habitual Miscarriage, Kidney-Yang
deficiency) – Restoring the Right [Kidney] Pill Variation • Fu Zi Radix Aconiti lateralis preparata 3 g • Du Zhong Cortex Eucommiae 6 g • Shan Zhu Yu Fructus Corni 4.5 g • Tu Si Zi Semen Cuscutae 6 g • Lu Jiao Jiao Colla Corni Cervi 6 g • Shu Di Huang Radix Rehmanniae preparata 12 g • Shan Yao Rhizoma Dioscoreae 6 g • Gou Qi Zi Fructus Lycii 6 g • Huang Qi Radix Astragali 6 g • Fu Pen Zi Fructus Rubi 4 g • Chi Shi Zhi Halloysitum rubrum 6 g – YOU GUI YIN – Restoring the Right [Kidney] Decoction • Shu Di Huang Radix Rehmanniae preparata 15 g • Shan Zhu Yu Fructus Corni 3 g • Shan Yao Rhizoma Dioscoreae 6 g • Du Zhong Cortex Eucommiae 6 g • Rou Gui Cortex Cinnamomi 3 g
• Fu Zi Radix Aconiti lateralis preparata 3 g • Gou Qi Zi Fructus Lycii 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – YU LIN ZHU – Fertility Pearl • Ren Shen Radix Ginseng 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Bai Shao Radix Paeoniae alba 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Dang Gui Radix Angelicae sinensis 9 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Tu Si Zi Semen Cuscutae 6 g • Du Zhong Cortex Eucommiae 6 g • Lu Jiao Shuang Cornu Cervi degelatinatum 6 g • Chuan Jiao Pericarpium Zanthoxyli 2 g – YU LIN ZHU Variation (Chapter 57, Infertility, Kidney-Yang deficiency with various combinations) – Fertility Pearl Variation • Ren Shen Radix Ginseng 9 g
• Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Bai Shao Radix Paeoniae alba 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Dang Gui Radix Angelicae sinensis 9 g • Shu Di Huang Radix Rehmannia preparata 9 g • Tu Si Zi Semen Cuscutae 6 g • Du Zhong Cortex Eucommiae 6 g • Lu Jiao Shuang Cornu Cervi degelatinatum 6 g • Chuan Jiao Pericarpium Zanthoxyli 2 g • Zi He Che Placenta hominis 6 g • Dan Shen Radix Salviae miltiorrhizae 4.5 g • Xiang Fu Rhizoma Cyperi 6 g – YU NU JIAN – Jade Woman Decoction • Shi Gao Gypsum fibrosum 30 g • Zhi Mu Rhizoma Anemarrhenae 4.5 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Mai Men Dong Radix Ophiopogonis 6 g
• Niu Xi Radix Achyranthis bidentatae seu Cyathulae 4.5 g – YU PING FENG SAN – Jade Wind-Screen Powder • Huang Qi Radix Astragali 30 g • Bai Zhu Rhizoma Atractylodis macrocephalae 60 g • Fang Feng Radix Saposhnikoviae 30 g – YU PING FENG SAN Variation (Chapter 49, Sweating after Childbirth, Qi deficiency) – Jade Wind-Screen Powder Variation • Huang Qi Radix Astragali 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 12 g • Fang Feng Radix Saposhnikoviae 6 g • Dang Shen Radix Codonopsis 6 g • Fu Xiao Mai Semen Tritici levis 6 g • Mu Li Concha Ostreae 12 g • Da Zao Fructus Jujubae 3 dates – YU SHEN HUA YU TANG – Generating the Kidneys and Transforming Stasis Decoction • Ba Ji Tian Radix Morindae officinalis 6 g • Yin Yang Huo Herba Epimedii 6 g • Xu Duan Radix Dipsaci 6 g
• Tu Si Zi Semen Cuscutae 6 g • Dang Shen Radix Codonopsis 6 g • Dang Gui Radix Angelicae sinensis 6 g • Mu Dan Pi Cortex Moutan 6 g • Tao Ren Semen Persicae 4.5 g • Hong Hua Flos Carthami 3 g • Pu Huang Pollen Typhae 3 g • Chi Shao Radix Paeoniae rubra 4.5 g • Xiang Fu Rhizoma Cyperi 4.5 g – YU SHEN JIAN PI AN TAI TANG – Generating the Kidneys, Strengthening the Spleen and Calming the Fetus Decoction • Tu Si Zi Semen Cuscutae 9 g • Du Zhong Cortex Eucommiae 6 g • Xu Duan Radix Dipsaci 9 g • Sang Ji Sheng Herba Taxilli 6 g • Dang Shen Radix Codonopsis 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Su Geng Caulis Perillae 3 g
• Zhu Ma Gen Radix Boehmeriae 4.5 g – YU SHI WEN BU FANG – Master Yu’s Warming and Tonifying Formula • Shu Di Huang Radix Rehmanniae preparata 9 g • Huang Jing Rhizoma Polygonati 9 g • Xian Ling Pi Herba Epimedii 6 g • Bu Gu Zhi Fructus Psoraleae 6 g • Chuan Shan Jia Squama Manitis 6 g • Zao Jiao Ci Spina Gleditsiae 6 g • Yi Yi Ren Semen Coicis 9 g • Zhe Bei Mu Bulbus Fritillariae thunbergii 6 g – YU TAI JIAN ZI TANG – Giving Birth to the Fetus and Strengthening the Baby Decoction • Tu Si Zi Semen Cuscutae 6 g • Dang Shen Radix Codonopsis 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g
• Shu Di Huang Radix Rehmanniae preparata 6 g • Bai Shao Radix Paeoniae alba 6 g – YU YIN TANG – Generating Yin Decoction • Shu Di Huang Radix Rehmanniae preparata 6 g • Shan Zhu Yu Fructus Corni 6 g • Xu Duan Radix Dipsaci 6 g • Sang Ji Sheng Herba Taxilli 6 g • Du Zhong Cortex Eucommiae 6 g • Mu Li Concha Ostreae 9 g • Long Gu Fossilia Ossis mastodi 9 g • Bai Shao Radix Paeoniae alba 6 g • E Jiao Colla Corii asini 6 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Di Gu Pi Cortex Lycii 6 g • Gui Ban Plastrum Testudinis 9 g – YU YIN TANG Variation (Chapter 31, Threatened Miscarriage, Kidney deficiency) – Generating Yin Decoction Variation • Shu Di Huang Radix Rehmanniae preparata 6 g • Shan Zhu Yu Fructus Corni 6 g
• Xu Duan Radix Dipsaci 6 g • Sang Ji Sheng Herba Taxilli 6 g • Du Zhong Cortex Eucommiae 6 g • Mu Li Concha Ostreae 9 g • Long Gu Fossilia Ossis mastodi 9 g • Bai Shao Radix Paeoniae alba 6 g • E Jiao Colla Corii asini 6 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Di Gu Pi Cortex Lycii 6 g • Gui Ban Plastrum Testudinis 9 g – YU YIN ZHI BENG TANG – Generating Yin and Stopping Flooding Decoction • Sheng Di Huang Radix Rehmanniae 9 g • Shan Yao Rhizoma Dioscoreae 6 g • Bai Shao Radix Paeoniae alba 6 g • Xu Duan Radix Dipsaci 6 g • E Jiao Colla Corii asini 8 g • Du Zhong Cortex Eucommiae 4.5 g • Shan Zhu Yu Fructus Corni 4.5 g • Sang Ji Sheng Herba Taxilli 6 g
• Hai Piao Xiao Endoconcha Sepiae 9 g • Gui Ban Plastrum Testudinis 9 g • Mu Li Concha Ostreae 9 g • Di Yu Radix Sanguisorbae 6 g • Pu Huang Pollen Typhae 4.5 g – YUAN TU GU TAI TANG – Helping the Earth and Consolidating the Fetus Decoction • Ren Shen Radix Ginseng 15 g • Bai Zhu Rhizoma Atractylodis macrocephalae 15 g • Shan Yao Rhizoma Dioscoreae 15 g • Rou Gui Cortex Cinnamomi 6 g • Fu Zi Radix Aconiti lateralis preparata 1.5 g • Xu Duan Radix Dipsaci 9 g • Du Zhong Cortex Eucommiae 9 g • Shan Zhu Yu Fructus Corni 15 g • Gou Qi Zi Fructus Lycii 9 g • Tu Si Zi Semen Cuscutae 9 g • Sha Ren Fructus Amomi 3 pieces • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – YUE JU WAN
– Gardenia-Chuanxiong Pill • Cang Zhu Rhizoma Atractylodis 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Xiang Fu Rhizoma Cyperi 6 g • Shan Zhi Zi Fructus Gardeniae 6 g • Shen Qu Massa medicata fermentata 6 g – YUE JU WAN Variation (Chapter 59, Breast Lumps, Prevention, Qi stagnation from emotional problems) – Gardenia-Chuanxiong Pill Variation • Cang Zhu Rhizoma Atractylodis 6 g • Xiang Fu Rhizoma Cyperi 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Shan Zhi Zi Fructus Gardeniae 6 g • Shen Qu Massa medicata fermentata 6 g • Qing Pi Pericarpium Citri reticulatae viride 3 g • Yu Jin Radix Curcumae 6 g • He Huan Pi Cortex Albiziae 6 g – YUE JU WAN Variation (Chapter 59, Breast Lumps, Prevention, Blood stasis from emotional problems) – Gardenia-Chuanxiong Pill Variation • Cang Zhu Rhizoma Atractylodis 6 g
• Chuan Xiong Rhizoma Chuanxiong 9 g • Xiang Fu Rhizoma Cyperi 6 g • Shan Zhi Zi Fructus Gardeniae 6 g • Shen Qu Massa medicata fermentata 6 g • Qing Pi Pericarpium Citri reticulatae viride 3 g • Yu Jin Radix Curcumae 6 g • Mo Yao Myrrha 6 g • Chuan Shan Jia Squama Manitis 6 g • He Huan Pi Cortex Albiziae 6 g – YUN NAN BAI YAO – Yunnan White Medicine • San Qi Radix Notoginseng • Other ingredients not disclosed – ZAN YU DAN – Aiding Fertility Pill • Fu Zi Radix Aconiti lateralis preparata 60 g • Rou Gui Cortex Cinnamomi 60 g • Rou Cong Rong Herba Cistanches 120 g • Ba Ji Tian Radix Morindae officinalis 120 g • Yin Yang Huo Herba Epimedii 120 g
• She Chuang Zi Fructus Cnidii 60 g • Jiu Zi Semen Allii tuberosi 120 g • Xian Mao Rhizoma Curculiginis 120 g • Shan Zhu Yu Fructus Corni 120 g • Du Zhong Cortex Eucommiae 120 g • Shu Di Huang Radix Rehmanniae preparata 240 g • Dang Gui Radix Angelicae sinensis 180 g • Gou Qi Zi Fructus Lycii 180 g • Bai Zhu Rhizoma Atractylodis macrocephalae 240 g – ZE LAN TANG – Lycopus Decoction • Ze Lan Herba Lycopi 3 g • Dang Gui Radix Angelicae sinensis 3 g • Bai Shao Radix Paeoniae alba 3 g • Gan Cao Radix Glycyrrhizae 1.5 g – ZENG YE TANG – Increasing Fluids Decoction • Xuan Shen Radix Scrophulariae 18 g • Mai Men Dong Radix Ophiopogonis 12 g • Sheng Di Huang Radix Rehmanniae 12 g
– ZHEN GAN XI FENG TANG – Pacifying the Liver and Subduing Wind Decoction • Huai Niu Xi Radix Achyranthis bidentatae 15 g • Dai Zhe Shi Haematitum 15 g • Long Gu Fossilia Ossis mastodi 12 g • Mu Li Concha Ostreae 12 g • Gui Ban Plastrum Testudinis 12 g • Xuan Shen Radix Scrophulariae 12 g • Tian Men Dong Radix Asparagi 12 g • Bai Shao Radix Paeoniae alba 12 g • Yin Chen Hao Herba Artemisiae scopariae 6 g • Chuan Lian Zi Fructus Toosendan 6 g • Mai Ya Fructus Hordei germinatus 6 g • Gan Cao Radix Glycyrrhizae 6 g – ZHEN WU TANG – True Warrior Decoction • Fu Zi Radix Aconiti lateralis preparata 9 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Fu Ling Poria 9 g • Bai Shao Radix Paeoniae alba 9 g
• Sheng Jiang Rhizoma Zingiberis recens 9 g – ZHI BO DI HUANG WAN – Anemarrhena-Phellodendron-Rehmannia Pill • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Ze Xie Rhizoma Alismatis 9 g • Fu Ling Poria 9 g • Mu Dan Pi Cortex Moutan 9 g • Zhi Mu Rhizoma Anemarrhenae 9 g • Huang Bo Cortex Phellodendri 9 g – ZHI BO DI HUANG WAN (also called BA WEI DI HUANG WAN) Variation (Chapter 40, Urinary Syndrome during Pregnancy, Kidney-Yin deficiency with Empty-Heat) – Anemarrhena-Phellodendron-Rehmannia Pill Variation • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Ze Xie Rhizoma Alismatis 9 g • Fu Ling Poria 9 g • Mu Dan Pi Cortex Moutan 9 g
• Zhi Mu Rhizoma Anemarrhenae 9 g • Huang Bo Cortex Phellodendri 9 g • Bian Xu Herba Polygoni avicularis 6 g – ZHI BO DI HUANG WAN Variation (Chapter 61, Excessive Vaginal Discharge, Kidney-Yin deficiency) – Anemarrhena-Phellodendron-Rehmannia Pill Variation • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Ze Xie Rhizoma Alismatis 9 g • Fu Ling Poria 9 g • Mu Dan Pi Cortex Moutan 9 g • Zhi Mu Rhizoma Anemarrhenae 9 g • Huang Bo Cortex Phellodendri 9 g • Qian Shi Semen Euryales 6 g • Jin Ying Zi Fructus Rosae laevigatae 6 g – ZHI BO DI HUANG WAN Variation (Chapter 62, Vaginal Itching, Liver- and Kidney-Yin deficiency) – Anemarrhena-Phellodendron-Rehmannia Pill Variation • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g
• Shan Yao Rhizoma Dioscoreae 12 g • Ze Xie Rhizoma Alismatis 9 g • Fu Ling Poria 9 g • Mu Dan Pi Cortex Moutan 9 g • Zhi Mu Rhizoma Anemarrhenae 9 g • Huang Bo Cortex Phellodendri 9 g • Bai Xian Pi Cortex Dictami 6 g • Ku Shen Radix Sophorae flavescentis 6 g – ZHI BO SI WU TANG – Anemarrhena-Phellodendron Four Substances Decoction • Shu Di Huang Radix Rehmanniae preparata 12 g • Dang Gui Radix Angelicae sinensis 10 g • Bai Shao Radix Paeoniae alba 12 g • Chuan Xiong Rhizoma Chuanxiong 8 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Huang Bo Cortex Phellodendri 6 g – ZHI DAI WAN – Stopping Vaginal Discharge Pill • Zhu Ling Polyporus 6 g • Fu Ling Poria 6 g
• Che Qian Zi Semen Plantaginis 4.5 g • Ze Xie Rhizoma Alismatis 6 g • Yin Chen Hao Herba Artemisiae scopariae 4.5 g • Chi Shao Radix Paeoniae rubra 4.5 g • Mu Dan Pi Cortex Moutan 6 g • Huang Bo Cortex Phellodendri 6 g • Shan Zhi Zi Fructus Gardeniae 3 g • Niu Xi Radix Achyranthis bidentatae seu Cyathulae 6 g – ZHI HAN SAN – Stopping Sweating Powder • Ren Shen Radix Ginseng 6 g • Dang Gui Radix Angelicae sinensis 6 g • Shu Di Huang Radix Rehmanniae preparata 4.5 g • Ma Huang Gen Radix Ephedrae 1.5 g • Huang Lian Rhizoma Coptidis 1.5 g • Fu Xiao Mai Fructus Tritici levis 1 handful • Da Zao Fructus jujubae 1 date – ZHI JIE ER CHEN TANG – Aurantium-Platycodon Two Old Decoction • Ban Xia Rhizoma Pinelliae preparatum 15 g
• Chen Pi Pericarpium Citri reticulatae 15 g • Fu Ling Poria 9 g • Zhi Gan Cao Radix Glycyrrhizae preparata 5 g • Sheng Jiang Rhizoma Zingiberis recens 3 g • Wu Mei Fructus Mume 1 prune • Zhi Ke Fructus Aurantii 6 g • Jie Geng Radix Platycodi 3 g – ZHI LING WAN – Haemorrhoids Miraculous Pill • Chuan Shan Jia Squama Manitis 6 g • Chi Shao Radix Paeoniae rubra 6 g • Bai Zhi Radix Angelicae dahuricae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Fang Feng Radix Saposhnikoviae 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Wu Wei Zi Fructus Schisandrae 6 g • Sheng Di Huang Radix Rehmanniae 3 g • Mu Dan Pi Cortex Moutan 6 g • Huai Hua Flos Sophorae immaturus 3 g • Di Yu Radix Sanguisorbae 3 g
• Da Huang Radix et Rhizoma Rhei 1.5 g – ZHI MEI JING YIN SAI JI – Anti-fungal Vaginal Cleansing Formula • Wu Mei Fructus Mume 30 g • Da Suan Bulbus Allii sativi 15 g • Shi Liu Pi Pericarpium Granati 15 g • Bing Lang Semen Arecae 12 g • Chuan Jiao Pericarpium Zanthoxyli 3 g – ZHI MEI XI JI – Treating Fungus [infection] Wash Formula • Ku Shen Radix Sophorae flavescentis 30 g • She Chuang Zi Fructus Cnidii 15 g • Xun Gu Feng Radix Aristolochiae mollissimae 15 g • Tu Fu Ling Rhizoma Smilacis glabrae 30 g • Huang Bo Cortex Phellodendri 15 g • Ku Fan Alumen 9 g • Xiong Huang Realgar 9 g – ZHI MU SAN – Anemarrhena Powder • Zhi Mu Rhizoma Anemarrhenae 15 g
• Mai Men Dong Radix Ophiopogonis 15 g • Gan Cao Radix Glycyrrhizae 15 g • Fu Ling Poria 20 g • Huang Qin Radix Scutellariae 20 g • Huang Qi Radix Astragali 20 g – ZHI MU SAN Variation (Chapter 34, Anxiety during Pregnancy, Empty-Heat from Yin deficiency) – Anemarrhena Powder Variation • Zhi Mu Rhizoma Anemarrhenae 15 g • Mai Men Dong Radix Ophiopogonis 15 g • Gan Cao Radix Glycyrrhizae 15 g • Fu Ling Poria 20 g • Huang Qin Radix Scutellariae 20 g • Huang Qi Radix Astragali 20 g • Bei Sha Shen Radix Glehniae 6 g • Lian Zi Xin Semen Nelumbinis 6 g – ZHONG YAO REN GONG TIAO QI ZU FANG – Chinese Herbal Formula to Artificially Regulate the Menstrual Cycle 1. During the follicular phase – Kidney-Yang deficiency • Yin Yang Huo Herba Epimedii 6 g
• Xian Mao Rhizoma Curculiginis 4.5 g • Dang Gui Radix Angelicae sinensis 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Tu Si Zi Semen Cuscutae 6 g • Ba Ji Tian Radix Morindae officinalis 6 g • Rou Cong Rong Herba Cistanches 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g – Kidney-Yin deficiency • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Han Lian Cao Herba Ecliptae 6 g • Dan Shen Radix Salviae miltiorrhizae 4.5 g • Shan Yao Rhizoma Dioscoreae 6 g • Tu Si Zi Semen Cuscutae 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Rou Cong Rong Herba Cistanches 4.5 g • Shou Wu Radix Polygoni multiflori preparata 6 g 2. Ovulation phase – Kidney-Yang deficiency • Dang Gui Radix Angelicae sinensis 9 g • Dan Shen Radix Salviae miltiorrhizae 6 g
• Chong Wei Zi Semen Leonori 4.5 g • Tao Ren Semen Persicae 4.5 g • Hong Hua Flos Carthami 3 g • Ji Xue Teng Caulis Spatholobi 6 g • Xu Duan Radix Dipsaci 6 g • Xiang Fu Rhizoma Cyperi 4.5 g • Gui Zhi Ramulus Cinnamomi 3 g – Kidney-Yin deficiency • Dan Shen Radix Salviae miltiorrhizae 6 g • Chi Shao Radix Paeoniae rubra 6 g • Ze Lan Herba Lycopi 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Gou Qi Zi Fructus Lycii 6 g • Tao Ren Semen Persicae 4.5 g • Hong Hua Flos Carthami 3 g • Yi Yi Ren Semen Coicis 9 g • Xiang Fu Rhizoma Cyperi 4.5 g 3. Luteal phase – Kidney-Yang deficiency • E Jiao Colla Corii asini 6 g
• Gui Ban Jiao Colla Plastri testudinis 9 g • Dang Gui Radix Angelicae sinensis 9 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Shou Wu Radix Polygoni multiflori preparata 6 g • Tu Si Zi Semen Cuscutae 6 g • Xu Duan Radix Dipsaci 6 g • Xiang Fu Rhizoma Cyperi 4.5 g • Gui Zhi Ramulus Cinnamomi 3 g – Kidney-Yin deficiency • Dan Shen Radix Salviae miltiorrhizae 6 g • Gui Ban Plastrum Testudinis 9 g • Gou Qi Zi Fructus Lycii 6 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Han Lian Cao Herba Ecliptae 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Shou Wu Radix Polygoni multiflori preparata 6 g • Rou Cong Rong Herba Cistanches 6 g • Tu Si Zi Semen Cuscutae 6 g – 4. Menstrual phase – Kidney-Yang deficiency
• Dang Gui Radix Angelicae sinensis 9 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Chi Shao Radix Paeoniae rubra 6 g • Ze Lan Herba Lycopi 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Xiang Fu Rhizoma Cyperi 4.5 g • Chong Wei Zi Semen Leonori 4.5 g – Kidney-Yin deficiency • Dan Shen Radix Salviae miltiorrhizae 6 g • Chi Shao Radix Paeoniae rubra 6 g • Ze Lan Herba Lycopi 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Fu Ling Poria 6 g • Chong Wei Zi Semen Leonori 4.5 g • Dang Gui Radix Angelicae sinensis 6 g • Xiang Fu Rhizoma Cyperi 6 g – ZHU LI TANG – Succus Bambusae Decoction • Zhu Li Succus Bambusae 9 ml
• Mai Men Dong Radix Ophiopogonis 6 g • Huang Qin Radix Scutellariae 6 g • Fu Ling Poria 6 g • Fang Feng Radix Saposhnikoviae 4 g – ZHU YU ZHI XUE TANG – Eliminating Stasis and Stopping Bleeding Decoction • Sheng Di Huang Radix Rehmanniae 30 g • Da Huang Radix et Rhizoma Rhei 9 g • Chi Shao Radix Paeoniae rubra 9 g • Mu Dan Pi Cortex Moutan 3 g • Dang Gui (Wei) Radix Angelicae sinensis (‘tail’) 15 g • Zhi Ke Fructus Aurantii (toasted) 15 g • Gui Ban Plastrum Testudinis (toasted with vinegar) 9 g • Tao Ren Semen Persicae 10 pieces – ZHU YUN TANG – Aiding Pregnancy Decoction • Mu Xiang Radix Aucklandiae 6 g • Chai Hu Radix Bupleuri 3 g • Xiang Fu Rhizoma Cyperi 6 g • Dang Gui Radix Angelicae sinensis 6 g
• Bai Shao Radix Paeoniae alba 6 g • Zi He Che Placenta hominis 6 g • Yi Mu Cao Herba Leonuri 4.5 g • Qiang Huo Rhizoma seu Radix Notopterygii 6 g – ZHU YUN YU LIN FANG – Aiding Pregnancy and Giving Birth to Unicorn Formula – Formula I (for 7 days after the period) • Shu Di Huang Radix Rehmanniae preparata 12 g • Gui Ban Plastrum Testudinis 9 g • Yin Yang Huo Herba Epimedii 12 g • Shi Nan Ye Folia Photiniae serrulatae 9 g • Huang Jing Rhizoma Polygonati 12 g • Ding Xiang Flos Caryophylli 2.5 g • Gui Zhi Ramulus Cinnamomi 2.5 g • Fu Ling Poria 12 g • Chuan Niu Xi Radix Cyathulae 9 g – Formula II (for 8 days during ovulation) • Shu Di Huang Radix Rehmanniae preparata 12 g • Shi Nan Ye Folia Photiniae serrulatae 9 g • Yin Yang Huo Herba Epimedii 9 g
• Gou Ji Rhizoma Cibotii 12 g • Rou Cong Rong Herba Cistanches 9 g • Xian Mao Rhizoma Curculiginis 9 g • Hu Lu Ba Semen Trigonellae 9 g • Nu Zhen Zi Fructus Ligustri lucidi 9 g • Lu Jiao Shuang Cornu Cervi degelatinatum 9 g • Zi Shi Ying Fluoritum 12 g • Fu Ling Poria 12 g – ZI SHEN TANG – Nourishing the Kidneys Decoction • Huang Bo Cortex Phellodendri 6 g • Che Qian Zi Semen Plantaginis 6 g • Zhu Ling Polyporus 6 g • Zhi Mu Rhizoma Anemarrhenae 6 g • Rou Gui Cortex Cinnamomi 1.5 g • Jie Geng Radix Platycodi 3 g • Mu Tong Caulis Akebiae 3 g • Fu Ling Poria 6 g • Hua Shi Talcum 6 g – ZI SHUI QING GAN YIN
– Nourishing Water and Clearing the Liver Decoction • Shu Di Huang Radix Rehmanniae preparata 24 g • Shan Zhu Yu Fructus Corni 12 g • Shan Yao Rhizoma Dioscoreae 12 g • Ze Xie Rhizoma Alismatis 9 g • Mu Dan Pi Cortex Moutan 9 g • Fu Ling Poria 9 g • Suan Zao Ren Semen Zizyphi spinosae 9 g • Shan Zhi Zi Fructus Gardeniae 9 g • Dang Gui Radix Angelicae sinensis 9 g • Chai Hu Radix Bupleuri 5 g – ZI SU YIN – Perilla Decoction • Zi Su Ye Folium Perillae 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Da Fu Pi Pericarpium Arecae 4.5 g • Bai Shao Radix Paeoniae alba 6 g • Dang Gui Radix Angelicae sinensis 4.5 g • Chuan Xiong Rhizoma Chuanxiong 2 g • Ren Shen Radix Ginseng 6 g
• Gan Cao Radix Glycyrrhizae 3 g – ZI SU YIN Variation (Chapter 37, Feeling of Suffocation During Pregnancy, Stagnation of Qi with disharmony of Liver and Spleen) – Perilla Decoction Variation • Zi Su Ye Folium Perillae 6 g • Chen Pi Pericarpium Citri reticulatae 3 g • Da Fu Pi Pericarpium Arecae 4.5 g • Bai Shao Radix Paeoniae alba 6 g • Dang Gui Radix Angelicae sinensis 4.5 g • Chuan Xiong Rhizoma Chuanxiong 2 g • Ren Shen Radix Ginseng 6 g • Gan Cao Radix Glycyrrhizae 3 g • Huang Qin Radix Scutellariae 4.5 g – ZUO GUI WAN – Restoring the Left [Kidney] Pill • Shu Di Huang Radix Rehmanniae preparata 15 g • Shan Yao Rhizoma Dioscoreae 9 g • Shan Zhu Yu Fructus Corni 9 g • Gou Qi Zi Fructus Lycii 9 g • Chuan Niu Xi Radix Cyathulae 6 g • Tu Si Zi Semen Cuscutae 9 g
• Lu Jiao Jiao Colla Cornu Cervi 9 g • Gui Ban Jiao Colla Plastri testudinis 9 g – ZUO GUI WAN plus ER ZHI WAN Variation (Chapter 17, Flooding and Trickling, Kidney-Yin deficiency) – Restoring the Left [Kidney] Pill plus Two Solstices Pill Variation • Shu Di Huang Radix Rehmanniae preparata 15 g • Shan Yao Rhizoma Dioscoreae 9 g • Shan Zhu Yu Fructus Corni 9 g • Gou Qi Zi Fructus Lycii 9 g • Tu Si Zi Semen Cuscutae 9 g • Lu Jiao Jiao Colla Cornu Cervi 9 g • Gui Ban Jiao Colla Plastri Testudinis 9 g • Nu Zhen Zi Fructus Ligustri 9 g • Han Lian Cao Herba Ecliptae 9 g – ZUO GUI WAN and ER ZHI WAN Variation (Chapter 43, Habitual Miscarriage, Kidney-Yin deficiency) – Restoring the Left [Kidney] Pill and Two Solstices Pill Variation • Shu Di Huang Radix Rehmanniae preparata 15 g • Shan Yao Rhizoma Dioscoreae 9 g • Shan Zhu Yu Fructus Corni 9 g • Gou Qi Zi Fructus Lycii 9 g
• Tu Si Zi Semen Cuscutae 9 g • Lu Jiao Cornu Cervi 9 g • Gui Ban Jiao Colla Plastri Testudinis 9 g • Nu Zhen Zi Fructus Ligustri 12 g • Han Lian Cao Herba Ecliptae 9 g – ZUO GUI YIN – Restoring the Left [Kidney] Decoction • Shu Di Huang Radix Rehmanniae preparata 12 g • Shan Zhu Yu Fructus Corni 6 g • Gou Qi Zi Fructus Lycii 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Fu Ling Poria 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – ZUO GUI YIN plus SI WU TANG Variation (Chapter 16, No Periods, Liverand Kidney-Yin deficiency) – Restoring the Left [Kidney] Decoction plus Four Substances Decoction • Dang Gui Radix Angelicae sinensis 6 g • Chi Shao Radix Paeoniae rubra 4 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Shan Zhu Yu Fructus Corni 4 g • Tu Si Zi Semen Cuscutae 6 g
• Gou Qi Zi Fructus Lycii 6 g • Gui Ban Plastrum Testudinis 6 g • Zi He Che Placenta hominis 5 g • Shan Yao Rhizoma Dioscoreae 6 g • Huai Niu Xi Radix Achyranthis bidentatae 6 g – ZUO GUI YIN Variation (Chapter 58, Menopausal Problems, Kidney-Yin deficiency) – Restoring the Left [Kidney] Decoction Variation • Shu Di Huang Radix Rehmanniae preparata 12 g • Shan Zhu Yu Fructus Corni 6 g • Gou Qi Zi Fructus Lycii 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Fu Ling Poria 6 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Shou Wu Radix Polygoni multiflori preparata 6 g • Gui Ban Plastrum Testudinis 9 g – ZUO JIN WAN – Left Metal Pill • Huang Lian Rhizoma Coptidis 15 g • Wu Zhu Yu Fructus Evodiae 2 g
Empirical prescriptions (by order of chapter)
– EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai (Chapter 8, Early Periods, Stagnant Liver-Qi turning into Fire with Blood-Heat) • Dang Gui Radix Angelicae sinensis 6 g • Chi Shao Radix Paeoniae rubra 6 g • Chuan Xiong Rhizoma Chuanxiong 3.6 g • Chai Hu Radix Bupleuri 4.5 g • Bai Ji Li Fructus Tribuli 7.2 g • Shan Zhi Zi Fructus Gardeniae 4.5 g • Huang Qin Radix Scutellariae 3.6 g • Ban Xia Rhizoma Pinelliae preparatum 9 g • Ju Pi Luo Retinervus Fructi Citri reticulatae 4.5 g • Fu Ling Poria 6 g • Gan Cao Radix Glycyrrhizae 2.4 g – EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai (Chapter 9, Late Periods, Cold in the Uterus) • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Fu Ling Poria 6 g • Fu Shen Sclerotium Poriae pararadicis 6 g
• Rou Gui Cortex Cinnamomi 3.6 g • Ai Ye Folium Artemisiae argyi 3 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Zhi Gan Cao Radix Glycyrrhizae preparata 2.4 g • Sheng Jiang Rhizoma Zingiberis recens 2.4 g • Wu Zhu Yu Fructus Evodiae 2.4 g • Ban Xia Rhizoma Pinelliae preparatum 9 g • Chen Pi Pericarpium Citri reticulatae 4.5 g – EMPIRICAL PRESCRIPTION (Chapter 14, Painful Periods, Damp-Heat) • Qu Mai Herba Dianthi 6 g • Bian Xu Herba Polygoni avicularis 6 g • Mu Tong Caulis Akebiae 4.5 g • Che Qian Zi Semen Plantaginis 6 g • Huang Qin Radix Scutellariae 6 g • Chi Shao Radix Paeoniae rubra 6 g • Di Gu Pi Cortex Lycii 6 g • Chuan Lian Zi Fructus Toosendan 4.5 g • Yan Hu Suo Rhizoma Corydalis 9 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g – EMPIRICAL PRESCRIPTION by Dr Liu Geng Wu (Chapter 15, Bleeding
between Periods, Damp-Heat) • Qu Mai Herba Dianthi 6 g • Bian Xu Herba Polygoni avicularis 6 g • Chuan Lian Zi Fructus Toosendan 3 g • Yan Hu Suo Rhizoma Corydalis 6 g • Pu Gong Ying Herba Taraxaci 4.5 g • Bai Jiang Cao Herba Patriniae 4.5 g • Chi Shao Radix Paeoniae rubra 6 g • Bai Shao Radix Paeoniae alba 6 g – EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai (Chapter 16, No Periods, Blood deficiency) • Huang Qi Radix Astragali 9 g • Dang Shen Radix Codonopsis 9 g • Zhi Gan Cao Radix Glycyrrhizae preparata 3 g • Dang Gui Radix Angelicae sinensis 6 g • Bai Shao Radix Paeoniae alba 6 g • Sheng Di Huang Radix Rehmanniae 12 g • Suan Zao Ren Semen Zizyphi spinosae 4.5 g • Yuan Zhi Radix Polygalae 4.5 g • Fu Ling Poria 6 g • Fu Shen Sclerotium Poriae pararadicis 6 g
• Ban Xia Rhizoma Pinelliae preparatum 4.5 g • Chen Pi Pericarpium Citri reticulatae 3 g • Mu Xiang Radix Aucklandiae 2.4 g – EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai (Chapter 16, No Periods, Stagnation of Qi and Blood) • Chai Hu Radix Bupleuri 4.5 g • Xiang Fu Rhizoma Cyperi 4.5 g • Su Geng Caulis Perillae 4.5 g • Dang Gui Radix Angelicae sinensis 6 g • Ze Lan Herba Lycopi 4.5 g • Hou Po Cortex Magnoliae officinalis 2.4 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Shan Zhi Zi Fructus Gardeniae 4.5 g • Ban Xia Rhizoma Pinelliae preparatum 9 g • Chi Shao Radix Paeoniae rubra 6 g • Bai Ji Li Fructus Tribuli 7.2 g • Fu Ling Poria 6 g • Chen Pi Pericarpium Citri reticulatae 4.5 g • Gan Cao Radix Glycyrrhizae 2.4 g – EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai (Chapter 29, Morning Sickness, Stomach-Qi deficiency with Empty-Cold)
• Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Ban Xia Rhizoma Pinelliae preparatum 9 g • Zhi Gan Cao Radix Glycyrrhizae preparata 2.4 g • Mu Xiang Radix Aucklandiae 2.4 g • Sha Ren Fructus Amomi 2.4 g • Fu Ling Poria 9 g • Sang Ji Sheng Herba Taxilli 12 g • Chao Gu Ya Fructus Setariae germinatus (fried) 6 g • Chen Pi Pericarpium Citri reticulatae 4.5 g • Sheng Jiang Rhizoma Zingiberis recens 1.5 g – EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai (Chapter 31, Threatened Miscarriage, Qi and Blood deficiency) • Jing Jie Herba Schizonepetae 2.4 g • Chuan Bei Mu Bulbus Fritillariae cirrhosae 3 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Qiang Huo Rhizoma seu Radix Notopterygii 1.5 g • Zhi Ke Fructus Aurantii 8 g • Ai Ye Folium Artemisiae argyi 2.1 g • Huang Qi Radix Astragali 2.4 g • Hou Po Cortex Magnoliae officinalis 2.1 g
• Sheng Jiang Rhizoma Zingiberis recens 1.5 g • Dang Gui Radix Angelicae sinensis 4.5 g • Bai Shao Radix Paeoniae alba 4.2 g • Tu Si Zi Semen Cuscutae 4.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 1.5 g – EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan (Chapter 31, Threatened Miscarriage, Blood-Heat) • Huang Qin Radix Scutellariae 6 g • Di Yu Radix Sanguisorbae 6 g • Tian Hua Fen Radix Trichosanthis 4 g • Xu Duan Radix Dipsaci 4 g • Chen Pi Pericarpium Citri reticulatae 3 g • Zhi Ke Fructus Aurantii 3 g • Qing Pi Pericarpium Citri reticulatae viride 3 g • Xiang Fu Rhizoma Cyperi 3 g • Bai Shao Radix Paeoniae alba 6 g • Cang Zhu Rhizoma Atractylodis 4 g • Cao Guo Fructus Tsaoko 3 g • Ai Ye Folium Artemisiae argyi 3 g • Mu Li Concha Ostreae 6 g
• Gan Cao Radix Glycyrrhizae 3 g • Dang Gui Radix Angelicae sinensis 3 g • Shu Di Huang Radix Rehmanniae preparata 4 • Chuan Xiong Rhizoma Chuanxiong 1.5 g – EMPIRICAL PRESCRIPTION by Dr Xia Gui Cheng (Chapter 36, Convulsions during Pregnancy, Phlegm-Fire harassing upwards) • Lian Qiao Fructus Forsythiae 6 g • Xuan Shen Radix Scrophulariae 6 g • Mu Dan Pi Cortex Moutan 6 g • Yu Jin Radix Curcumae 6 g • Shi Chang Pu Rhizoma Acori tatarinowii 6 g • Dan Nan Xing Rhizoma Arisaematis preparatum 4 g • Tian Zhu Huang Concretio Bambusae silicea 4 g • Zhu Li Succus Bambusae 6 ml • Ling Yang Jiao Fen Cornu Saigae tataricae (powdered) 1 g – EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan (Chapter 37, Feeling of Suffocation during Pregnancy, Stagnation of Qi with disharmony of Liver and Spleen) • Dang Gui Radix Angelicae sinensis (without ‘tail’) 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Bai Shao Radix Paeoniae alba 6 g
• Zhi Ke Fructus Aurantii 4.5 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Huang Qin Radix Scutellariae 4.5 g • Xiang Fu Rhizoma Cyperi 3 g • Chen Pi Pericarpium Citri reticulatae 3 g • Hua Shi Talcum 6 g • Zi Su Ye Folium Perillae 6 g • Da Fu Pi Pericarpium Arecae 3 g – EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan (Chapter 37, Feeling of Suffocation during Pregnancy, Stagnation of Qi with deficiency of Blood and Kidneys) • Da Fu Pi Pericarpium Arecae 3 g • Bai Zhu Rhizoma Atractylodis macrocephalae 3 g • Ren Shen Radix Ginseng 1.5 g • Bai Shao Radix Paeoniae alba 3 g • Dang Gui Radix Angelicae sinensis 3 g • Chen Pi Pericarpium Citri reticulatae 1.5 g • Gan Cao Radix Glycyrrhizae 1.5 g • Zi Su Ye Folium Perillae 1.5 g – EMPIRICAL PRESCRIPTION by Dr J H F Shen (Chapter 44, Acupuncture and Herbal Treatment in Midwifery, Induction of labour)
• Dang Gui Radix Angelicae sinensis 4.5 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Hong Hua Flos Carthami 3 g • Tu Si Zi Semen Cuscutae 3 g • Hou Po Cortex Magnoliae officinalis 1.8 g • Qing Huo Rhizoma et Radix Notopterygii 4.5 g • Gan Jiang Rhizoma Zingiberis 3 g • Huang Qin Radix Scutellariae 3 g • Bai Shao Radix Paeoniae alba 4.5 g • Bai Zhu Rhizoma Atractylodis macrocephalae 4.5 g • Yi Mu Cao Herba Leonuri 4.5 g • Sheng Di Huang Radix Rehmanniae 4.5 g • Ai Ye Folium Artemisiae argyi 3 g – EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan (Chapter 44, Acupuncture and Herbal Treatment in Midwifery, Blood stasis and Qi stagnation) • Chen Pi Pericarpium Citri reticulatae 3 g • Wu Yao Radix Linderae 6 g • Zhi Ke Fructus Aurantii 6 g • Gan Jiang Rhizoma Zingiberis 2 g • Rou Gui Cortex Cinnamomi 2 g
• Mu Tong Caulis Akebiae 2 g • Yi Mu Cao Herba Leonuri 6 g • Dang Gui Radix Angelicae sinensis (‘tail’ only) 6 g • Hong Hua Flos Carthami 4 g • Sang Leng Rhizoma Sparganii 6 g • E Zhu Rhizoma Curcumae 6 g • Wu Ling Zhi Faeces Trogopterori 6 g • Chuan Niu Xi Radix Cyathulae 6 g • Xiang Fu Rhizoma Cyperi 6 g • Bai Zhi Radix Angelicae dahuricae 3 g – EMPIRICAL PRESCRIPTION by Dr Chen Jia Yuan (Chapter 52, Joint Pain after Childbirth, Liver-Blood and Kidney-Yang deficiency) • Yan Hu Suo Rhizoma Corydalis 4 g • Dang Gui Radix Angelicae sinensis 6 g • Gui Zhi Ramulus Cinnamomi 6 g • Du Zhong Cortex Eucommiae 6 g • Xu Duan Radix Dipsaci 6 g • Tao Ren Semen Persicae 4 g • Huai Niu Xi Radix Achyranthis bidentatae 6 g • Rice wine 100 ml
– EMPIRICAL PRESCRIPTION from Dr Chen Jia Yuan (Chapter 53, Breast Milk Not Flowing, Liver-Qi stagnation) • Lou Lu Radix Rhapontici 6 g • Zhu Di Pig’s trotter 1 trotter • Mu Tong Caulis Akebiae 3 g • Chen Pi Pericarpium Citri reticulatae 3 g • Wu Yao Radix Linderae 6 g • Bai Zhi Radix Angelicae dahuricae 3 g • Shan Zha Fructus Crataegi 6 g • Jie Geng Radix Platycodi 3 g • Chuan Xiong Rhizoma Chuanxiong 4 g • Dang Gui Radix Angelicae sinensis (‘tail’ only) 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Yi Mu Cao Herba Leonuri 6 g • Sheng Jiang Rhizoma Zingiberis recens 3 slices • Gui Zhi Ramulus Cinnamomi 3 g • Gan Cao Radix Glycyrrhizae 3 g – EMPIRICAL PRESCRIPTION by Dr Cong Chun Yu (Chapter 53, Breast Milk Not Flowing, Qi and Blood deficiency) • Dang Gui Radix Angelicae sinensis 30 g • Huang Qi Radix Astragali 24 g
• Lou Lu Radix Rhapontici 6 g • Dong Kui Zi Fructus Malvae 3 g • Wang Bu Liu Xing Semen Vaccariae 3 g • Gua Lou Fructus Trichosanthis 6 g • Tian Hua Fen Radix Trichosanthis 3 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Bai Shao Radix Paeoniae alba (fried in vinegar) 4.5 g • Tong Cao Medulla Tetrapanacis 4.5 g • Mu Tong Caulis Akebiae 3 g – EMPIRICAL PRESCRIPTION by Dr Shan Dao Wei (Chapter 57, Infertility, Kidney-Yin deficiency) • Sheng Di Huang Radix Rehmanniae 9 g • Bai Shao Radix Paeoniae alba 9 g • Di Gu Pi Cortex Lycii 4.5 g • Xuan Shen Radix Scrophulariae 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Qing Hao Herba Artemisiae annuae 4.5 g • Gou Qi Zi Fructus Lycii 6 g • Dan Shen Radix Salviae miltiorrhizae 4.5 g • Yi Mu Cao Herba Leonuri 4.5 g
– EMPIRICAL PRESCRIPTION by Dr Zhu Nan Sun (Chapter 57, Infertility, Kidney-Yin deficiency) • Dang Gui Radix Angelicae sinensis 6 g • Dan Shen Radix Salviae miltiorrhizae 4.5 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Sheng Di Huang Radix Rehmanniae 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Bai Shao Radix Paeoniae alba 6 g • Xuan Shen Radix Scrophulariae 6 g • Bei Sha Shen Radix Glehniae 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Shan Zhu Yu Fructus Corni 4.5 g • Zi He Che Placenta hominis 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Rou Cong Rong Herba Cistanches 6 g • Bai Zi Ren Semen Platycadi 6 g • Ba Ji Tian Radix Morindae officinalis 3 g – EMPIRICAL PRESCRIPTION by Dr Shang Xian Min (Chapter 57, Infertility, Kidney-Yang deficiency) • Yin Yang Huo Herba Epimedii 6 g • Ba Ji Tian Radix Morindae officinalis 6 g
• Tu Si Zi Semen Cuscutae 6 g • Fu Pen Zi Fructus Rubi 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Bai Shao Radix Paeoniae alba 6 g • Zi He Che Placenta hominis 6 g • Yi Mu Cao Herba Leonuri 4.5 g • Gou Qi Zi Fructus Lycii 6 g • Wu Wei Zi Fructus Schisandrae 3 g – EMPIRICAL PRESCRIPTION by Dr Shang Xian Min (Chapter 57, Infertility, Cold in the Uterus) • Xiao Hui Xiang Fructus Foeniculi 3 g • Rou Gui Cortex Cinnamomi 2 g • Wu Zhu Yu Fructus Evodiae 3 g • Gan Jiang Rhizoma Zingiberis 2 g • Wu Yao Radix Linderae 6 g • Yin Yang Huo Herba Epimedii 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g
• Pu Huang Pollen Typhae 4.5 g • Wu Ling Zhi Faeces Trogopterori 4.5 g • Chi Shao Radix Paeoniae rubra 6 g • Yan Hu Suo Rhizoma Corydalis 6 g • Cang Zhu Rhizoma Atractylodis 6 g – EMPIRICAL PRESCRIPTION (I) by Dr Shang Xian Min (Chapter 57, Infertility, Dampness in the Lower Burner) • Shan Zha Fructus Crataegi 6 g • Xian Mao Rhizoma Curculiginis 6 g • Yin Yang Huo Herba Epimedii 6 g • Tu Si Zi Semen Cuscutae 6 g • Fu Pen Zi Fructus Rubi 6 g • Dan Nan Xing Rhizoma Arisaematis preparatum 6 g • Ban Xia Rhizoma Pinelliae preparatum 6 g • Fu Ling Poria 6 g • Xiang Fu Rhizoma Cyperi 6 g • Zhi Ke Fructus Aurantii 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Ze Lan Herba Lycopi 4.5 g
– EMPIRICAL PRESCRIPTION (II) by Dr Shang Xian Min (Chapter 57, Infertility, Dampness in the Lower Burner) • Chai Hu Radix Bupleuri 6 g • Zhi Shi Fructus Aurantii immaturus 6 g • Chi Shao Radix Paeoniae rubra 6 g • Gan Cao Radix Glycyrrhizae 3 g • Yan Hu Suo Rhizoma Corydalis 6 g • Chuan Lian Zi Fructus Toosendan 3 g • Hong Teng Caulis Sargentodoxae 6 g • Bai Jiang Cao Herba Patriniae 6 g • Da Huang Radix et Rhizoma Rhei 6 g • Bi Xie Rhizoma Dioscoreae hypoglaucae 6 g • Lu Lu Tong Fructus Liquidambaris 6 g – EMPIRICAL PRESCRIPTION by Dr Shan Dao Wei (Chapter 57, Infertility, Dampness in the Lower Burner) – Prescription I (after the end of the period for 6 days) • Yin Yang Huo Herba Epimedii 6 g • Ba Ji Tian Radix Morindae officinalis 6 g • Lu Jiao Cornu Cervi 6 g • Tu Si Zi Semen Cuscutae 6 g • Shan Yao Rhizoma Dioscoreae 6 g
• Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Cang Zhu Rhizoma Atractylodis 6 g • Bai Jie Zi Semen Sinapis 2 g • Xiang Fu Rhizoma Cyperi 6 g • Dang Gui Radix Angelicae sinensis 6 g • Shi Chang Pu Rhizoma Acori tatarinowii 4.5 g • Dan Nan Xing Rhizoma Arisaematis preparata 4.5 g • Hai Zao Sargassum 6 g • Yi Mu Cao Herba Leonuri 4.5 g – Prescription II (mid-cycle, from 12th day after the first day of the period, for 6 days) • Dang Gui Radix Angelicae sinensis 9 g • Dan Shen Radix Salviae miltiorrhizae 4 g • Chuan Xiong Rhizoma Chuanxiong 4 g • Chi Shao Radix Paeoniae rubra 6 g • Liu Ji Nu Herba Artemisiae anomalae 4 g • Ji Xue Teng Caulis Spatholobi 6 g • Ze Lan Herba Lycopi 6 g • Xiang Fu Rhizoma Cyperi 6 g • Yi Mu Cao Herba Leonuri 6 g
• Hong Hua Flos Carthami 6 g • Rou Gui Cortex Cinnamomi 3 g • Zao Jiao Fructus Gleditsiae 6 g – EMPIRICAL PRESCRIPTION by Dr Zhu Nan Sun (Chapter 57, Infertility, Dampness in the Lower Burner) • Sheng Di Huang Radix Rehmanniae 6 g • Mu Dan Pi Cortex Moutan 6 g • Pu Gong Ying Herba Taraxaci 6 g • Hong Teng Caulis Sargentodoxae 6 g • Bai Jiang Cao Herba Patriniae 6 g • Zi Hua Di Ding Herba Violae 4.5 g • Yu Jin Radix Curcumae 6 g • Chai Hu Radix Bupleuri 6 g • Yan Hu Suo Rhizoma Corydalis 6 g • Liu Ji Nu Herba Artemisiae anomalae 4.5 g • Zhi Mu Rhizoma Anemarrhenae 4.5 g • Huang Bo Cortex Phellodendri 6 g – EMPIRICAL PRESCRIPTION by Dr Shang Xian Min (Chapter 57, Infertility, Stagnation of Qi) • Chai Hu Radix Bupleuri 6 g • Xiang Fu Rhizoma Cyperi 6 g
• He Huan Pi Cortex Albiziae 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chuan Xiong Rhizoma Chuanxiong 3 g • Bai Shao Radix Paeoniae alba 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Dan Shen Radix Salviae miltiorrhizae 4.5 g • Yue Ji Hua Flos Rosae chinensis 4.5 g • Chen Pi Pericarpium Citri reticulatae 3 g • Ju He Semen Citri reticulatae 3 g – EMPIRICAL PRESCRIPTION (I) by Dr Zhu Nan Sun (Chapter 57, Infertility, Stagnation of Qi) • Dan Shen Radix Salviae miltiorrhizae 4.5 g • Mu Dan Pi Cortex Moutan 4.5 g • Chi Shao Radix Paeoniae rubra 4.5 g • Xiang Fu Rhizoma Cyperi 6 g • Chai Hu Radix Bupleuri 6 g • Suo Luo Zi Semen Aesculi 6 g • Chuan Lian Zi Fructus Toosendan 6 g • Wang Bu Liu Xing Semen Vaccariae 4.5 g • Lu Lu Tong Fructus Liquidambaris 6 g
• Di Long Pheretima 3 g • Shi Chang Pu Rhizoma Acori tatarinowii 4.5 g – EMPIRICAL PRESCRIPTION (II) by Dr Zhu Nan Sun (Chapter 57, Infertility, Stagnation of Qi) • Chai Hu Radix Bupleuri 6 g • Chuan Lian Zi Fructus Toosendan 6 g • Xiang Fu Rhizoma Cyperi 6 g • Wang Bu Liu Xing Semen Vaccariae 4.5 g • Suo Luo Zi Semen Aesculi 6 g • Lu Lu Tong Fructus Liquidambaris 4.5 g • Di Long Pheretima 3 g • Shi Chang Pu Rhizoma Acori tatarinowii 4.5 g • Xiao Hui Xiang Fructus Foeniculi 3 g • Chen Xiang Lignum Aquilariae resinatum 3 g – EMPIRICAL PRESCRIPTION by Dr Shang Xian Min (Chapter 57, Infertility, Blood stasis) • Dang Gui Radix Angelicae sinensis 9 g • Chuan Xiong Rhizoma Chuanxiong 4.5 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Tao Ren Semen Persicae 6 g • Chuan Shan Jia Squama Manitis 6 g
• Lu Lu Tong Fructus Liquidambaris 6 g • Zao Jiao Fructus Gleditsiae 6 g • Hai Zao Sargassum 6 g • Xue Jie Resina Daemonoropis 6 g • Chai Hu Radix Bupleuri 3 g • Mu Xiang Radix Aucklandiae 3 g – EMPIRICAL PRESCRIPTION by Dr Zhu Nan Sun (Chapter 57, Infertility, Blood stasis) • Dan Shen Radix Salviae miltiorrhizae 6 g • Chi Shao Radix Paeoniae rubra 6 g • Chai Hu Radix Bupleuri 4.5 g • Yan Hu Suo Rhizoma Corydalis 6 g • Pu Huang Pollen Typhae 6 g • San Leng Rhizoma Sparganii 6 g • E Zhu Rhizoma Curcumae 6 g • Shi Jian Chuan Herba Salviae chinensis 6 g • Liu Ji Nu Herba Artemisiae anomalae 6 g • Mu Dan Pi Cortex Moutan 6 g • Chuan Lian Zi Fructus Toosendan 3 g • Ru Xiang Olibanum 4.5 g
• Di Long Pheretima 3 g • Xue Jie Resina Daemonoropis 4.5 g – EMPIRICAL PRESCRIPTIONS by Dr Xia Gui Cheng (Chapter 57, Infertility, Formulae by Chinese fertility specialists) – No. 1. After the period • Dang Gui Radix Angelicae sinensis 9 g • Sheng Di Huang Radix Rehmanniae 9 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Fu Ling Poria 6 g • Bai Shao Radix Paeoniae alba 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Mu Dan Pi Cortex Moutan 4.5 g • Ze Xie Rhizoma Alismatis 6 g – No. 2. Between periods • Dang Gui Radix Angelicae sinensis 9 g • Sheng Di Huang Radix Rehmanniae 9 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Tu Si Zi Semen Cuscutae 6 g • Chi Shao Radix Paeoniae rubra 4.5 g • Bai Shao Radix Paeoniae alba 6 g
• Shan Yao Rhizoma Dioscoreae 6 g • Xu Duan Radix Dipsaci 6 g • Hong Hua Flos Carthami 3 g – No. 3. Before the period • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 6 g • Sheng Di Huang Radix Rehmanniae 6 g • Shan Yao Rhizoma Dioscoreae 6 g • Xu Duan Radix Dipsaci 6 g • Tu Si Zi Semen Cuscutae 6 g • Lu Jiao Cornu Cervi 6 g • Xiang Fu Rhizoma Cyperi 4.5 g – No. 4. During the period • Dang Gui Radix Angelicae sinensis 9 g • Chi Shao Radix Paeoniae rubra 6 g • Ze Lan Herba Lycopi 6 g • Hong Hua Flos Carthami 3 g • Xiang Fu Rhizoma Cyperi 4.5 g • Chong Wei Zi Fructus Leonuri 6 g – No. 5. In case of obstruction of tubes
• Gui Zhi Ramulus Cinnamomi 9 g • Dang Gui Radix Angelicae sinensis 9 g • Mu Dan Pi Cortex Moutan 6 g • Fu Ling Poria 9 g • Tao Ren Semen Persicae 6 g • Yi Yi Ren Semen Coicis 15 g – EMPIRICAL PRESCRIPTIONS by Dr Lian Fang and Dr Sun Ning Quan (Chapter 57, Infertility, Formulae by Chinese fertility specialists) – No. 1. After the period (from 4th to 11th day of cycle) • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Han Lian Cao Herba Ecliptae 6 g • Dang Gui Radix Angelicae sinensis 9 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Xiang Fu Rhizoma Cyperi 4.5 g • Mu Xiang Radix Aucklandiae 3 g • Wu Yao Radix Linderae 4.5 g • Ze Xie Rhizoma Alismatis 6 g – No. 2. During ovulation (3 days before and 3 after ovulation) • Gui Zhi Ramulus Cinnamomi 6 g • Hong Hua Flos Carthami 3 g
• Dang Gui Radix Angelicae sinensis 9 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Xiang Fu Rhizoma Cyperi 6 g • Mu Xiang Radix Aucklandiae 3 g • Wu Yao Radix Linderae 6 g • Ze Xie Rhizoma Alismatis 6 g – No. 3. Before the period (from the 17th to 28th day of cycle) • Yin Yang Huo Herba Epimedii 6 g • Xian Mao Rhizoma Curculiginis 6 g • Nu Zhen Zi Fructus Ligustri lucidi 6 g • Han Lian Cao Herba Ecliptae 4.5 g • Dang Gui Radix Angelicae sinensis 9 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Xiang Fu Rhizoma Cyperi 6 g • Mu Xiang Radix Aucklandiae 3 g • Wu Yao Radix Linderae 6 g • Ze Xie Rhizoma Alismatis 6 g – No. 4. During the period (from the 1st to the 4th day of the cycle) • Tao Ren Semen Persicae 3 g • Zi Su Geng Caulis Perillae 6 g
• Dang Gui Radix Angelicae sinensis 6 g • Dang Shen Radix Codonopsis 6 g • Xiang Fu Rhizoma Cyperi 6 g • Mu Xiang Radix Aucklandiae 3 g • Wu Yao Radix Linderae 4.5 g • Ze Xie Rhizoma Alismatis 6 g – EMPIRICAL PRESCRIPTION by Dr Zhu Nan Sun (Chapter 57, Infertility, Formulae by Chinese fertility specialists) – No. 1. After the period • Sheng Di Huang Radix Rehmanniae 12 g • Shu Di Huang Radix Rehmanniae preparata 12 g • Huang Jing Rhizoma Polygonati 12 g • Bei Sha Shen Radix Glehniae 6 g • Mai Men Dong Radix Ophiopogonis 6 g • Dang Gui Radix Angelicae sinensis 9 g • Dan Shen Radix Salviae miltiorrhizae 12 g • Bai Shao Radix Paeoniae alba 9 g • Sang Ji Sheng Herba Taxilli 12 g • Gou Qi Zi Fructus Lycii 12 g • Xu Duan Radix Dipsaci 12 g
• Tu Si Zi Semen Cuscutae 12 g • Han Lian Cao Herba Ecliptae 12 g • Nu Zhen Zi Fructus Ligustri lucidi 12 g – No. 2. During ovulation • Sheng Di Huang Radix Rehmanniae 12 g • Shu Di Huang Radix Rehmanniae preparata 12 g • Tu Si Zi Semen Cuscutae 12 g • Han Lian Cao Herba Ecliptae 12 g • Xu Duan Radix Dipsaci 12 g • Yin Yang Huo Herba Epimedii 12 g • Zi Shi Ying Fluoritum 12 g • Shi Nan Ye Folia Photiniae serrulatae 12 g • Gui Ban Plastrum Testudinis (powder) 3 g • Nu Zhen Zi Fructus Ligustri lucidi 12 g • Sang Ji Sheng Herba Taxilli 12 g – EMPIRICAL PRESCRIPTIONS by Dr Shan Dao Wei (Chapter 57, Infertility, Formulae by Chinese fertility specialists) – No ovulation • Zi He Che Placenta hominis 10 g • Lu Jiao Shuang Cornu Cervi degelatinatum 10 g
• Shan Zhu Yu Fructus Corni 6 g • Yin Yang Huo Herba Epimedii 6 g • Dang Gui Radix Angelicae sinensis 6 g • Chi Shao Radix Paeoniae rubra 6 g • Dan Shen Radix Salviae miltiorrhizae 6 g • Chuan Xiong Rhizoma Chuanxiong 6 g – Corpus luteum defect • Yin Yang Huo Herba Epimedii 9 g • Rou Cong Rong Herba Cistanches 6 g • Zi He Che Placenta hominis 6 g • Lu Rong Cornu Cervi pantotrichum (as a powder) 2 g – Underdeveloped uterus • Zi Shi Ying Fluoritum 9 g • Yang Qi Shi Actinolitum 9 g • Xian Ling Pi Herba Epimedii 9 g • Tu Si Zi Semen Cuscutae 6 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Xiang Fu Rhizoma Cyperi 6 g • Sha Ren Fructus Amomi 3 g – Blocked fallopian tubes
• Chuan Shan Jia Squama Manitis 6 g • Lu Lu Tong Fructus Liquidambaris 6 g • San Leng Rhizoma Sparganii 6 g • E Zhu Rhizoma Curcumae 6 g • Yi Mu Cao Herba Leonuri 9 g – EMPIRICAL PRESCRIPTIONS by the Shanghai College of Traditional Chinese Medicine (Chapter 57, Infertility, Formulae by Chinese fertility specialists) – Blocked fallopian tubes – TONG GUAN TANG – Freeing the Tubes Decoction • Dang Gui Radix Angelicae sinensis 9 g • Shu Di Huang Radix Rehmanniae preparata 9 g • Chi Shao Radix Paeoniae rubra 9 g • Bai Shao Radix Paeoniae alba 9 g • Chuan Xiong Rhizoma Chuanxiong 9 g • Tao Ren Semen Persicae 12 g • Yi Yi Ren Semen Coicis 12 g • Hong Hua Flos Carthami 12 g • Wu Zie Gu Endoconcha Sepiae 20 g • Qian Cao Gen Radix Rubiae 9 g
• Xiang Fu Rhizoma Cyperi 12 g • Lu Lu Tong Fructus Liquidambaris 15 g • Shi Chang Pu Rhizoma Acori tatarinowii 9 g • Zao Jiao Fructus Gleditsiae 9 g • Bai Jiang Cao Herba Patriniae 15 g • Hong Teng Caulis Sargentodoxae 15 g – TONG GUAN II HAO FANG – Freeing the Tubes No. 2 Formula • Shu Di Huang Radix Rehmanniae preparata 9 g • Dang Gui Radix Angelicae sinensis 9 g • Bai Shao Radix Paeoniae alba 9 g • Chuan Xiong Rhizoma Chuanxiong 6 g • Tao Ren Semen Persicae 12 g • Hong Hua Flos Carthami 12 g • Tu Si Zi Semen Cuscutae 15 g • Yin Yang Huo Herba Epimedii 9 g • Rou Cong Rong Herba Cistanches 9 g • Lu Jiao Shuang Cornu Cervi degelatinatum 9 g • Xiang Fu Rhizoma Cyperi 12 g • Bai Jiang Cao Herba Patriniae 15 g
– EMPIRICAL PRESCRIPTION by Dr Meng Jing Chun (Chapter 58, Menopausal Problems, Kidney-Yin deficiency) • Sheng Di Huang Radix Rehmanniae 6 g • Shu Di Huang Radix Rehmanniae preparata 6 g • Gui Ban Plastrum Testudinis 12 g • Mu Li Concha Ostreae 12 g • Gou Teng Ramulus Uncariae cum Uncis 6 g • Suan Zao Ren Semen Zizyphi spinosae 4.5 g • Fu Ling Poria 6 g • Fu Shen Sclerotium Poriae pararadicis 6 g – EMPIRICAL PRESCRIPTION by Dr Meng Jing Chun (Chapter 58, Menopausal Problems, Kidney-Yin and Kidney-Yang deficiency) • Yin Yang Huo Herba Epimedii 4.5 g • Xian Mao Rhizoma Curculiginis 4.5 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • Dang Shen Radix Codonopsis 6 g • Mu Xiang Radix Aucklandiae 3 g • Gou Teng Ramulus Uncariae cum Uncis 6 g • Fu Ling Poria 6 g • Fu Shen Sclerotium Poriae pararadicis 6 g • Sheng Di Huang Radix Rehmanniae 6 g
– EMPIRICAL PRESCRIPTION (Chapter 60, Abdominal Masses, Stasis of Blood knotted in the Interior) • Dang Gui Radix Angelicae sinensis 9 g • Chi Shao Radix Paeoniae rubra 6 g • Tao Ren Semen Persicae 6 g • Hong Hua Flos Carthami 3 g • San Leng Rhizoma Sparganii 6 g • E Zhu Rhizoma Curcumae 6 g • Su Mu Lignum Sappan 3 g • Shi Jian Chuan Herba Salviae chinensis 6 g • Di Bie Chong Eupolyphaga 4.5 g • Shan Zha Fructus Crataegi 6 g – EMPIRICAL PRESCRIPTION by Dr Huang Tao Qiang (Chapter 60, Abdominal Masses, Ovarian cysts) • Sheng Di Huang Radix Rehmanniae 15 g • Chi Shao Radix Paeoniae rubra 6 g • Bai Shao Radix Paeoniae alba 6 g • Liu Ji Nu Herba Artemisiae anomalae 10 g • Ban Zhi Lian Herba Scutellariae barbatae 20 g • Hong Teng Caulis Sargentodoxae 20 g • Bai Jiang Cao Herba Patriniae 20 g
• Ji Nei Jin Endothelium Corneum gigeriae galli 9 g • Dang Gui Radix Angelicae sinensis 10 g • Huang Yao Zi Rhizoma Dioscoreae bulbiferae 10 g • Gan Qi Resina Toxicodendri 12 g • Xia Ku Cao Spica Prunellae 15 g • Hai Zao Sargassum 20 g • Gan Cao Radix Glycyrrhizae 6 g – EMPIRICAL PRESCRIPTION BY Dr Yao Shi An (Chapter 60, Abdominal Masses, Ovarian cysts) • Huang Qi Radix Astragali 30 g • San Leng Rhizoma Sparganii 15 g • E Zhu Rhizoma Curcumae 15 g • Zao Jiao Ci Spina Gleditsiae 15 g • Hai Zao Sargassum 15 g • Kun Bu Thallus Eckloniae 15 g • Xia Ku Cao Spica Prunellae 18 g • Bai Jie Zi Semen Sinapis 10 g • Shui Zhi Hirudo (as a powder) 4 g – EMPIRICAL PRESCRIPTION by Dr Tian Jing Feng (Chapter 60, Abdominal Masses, Cervical dysplasia) • Huang Qi Radix Astragali 9 g
• Dang Gui Radix Angelicae sinensis 6 g • Bai Zhu Rhizoma Atractylodis macrocephalae 6 g • E Zhu Rhizoma Curcumae 6 g • San Leng Rhizoma Sparganii 6 g • Bai Hua She She Cao Herba Hedyotis diffusae 6 g • Xian He Cao Herba Agrimoniae 6 g • Ban Zhi Lian Herba Scutellariae barbatae 4.5 g • Bai Jiang Cao Herba Patriniae 4.5 g – EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai (Chapter 61, Excessive Vaginal Discharge, Kidney-Yang deficiency) • Bai Ji Tian Radix Morindae officinalis 6 g • Sang Ji Sheng Herba Taxilli 12 g • Gui Zhi Ramulus Cinnamomi 3.6 g • Huang Qi Radix Astragali 7.2 g • Qiang Huo Rhizoma seu Radix Notopterygii 2.4 g • Fang Feng Radix Saposhnikoviae 3.6 g • Bai Shao Radix Paeoniae alba 6 g • Ban Xia Rhizoma Pinelliae preparatum 9 g • Chen Pi Pericarpium Citri reticulatae 4.5 g • Zhi Gan Cao Radix Glycyrrhizae preparata 2.4 g
• Fu Ling Poria 6 g • Fu Shen Sclerotium Poriae pararadicis 6 g – EMPIRICAL PRESCRIPTION by Dr Zhang Jian Zhai (Chapter 61, Excessive Vaginal Discharge, Kidney-Yin deficiency) • Chai Hu Radix Bupleuri 4.5 g • Mu Li Concha Ostreae 12 g • Nu Zhen Zi Fructus Ligustri lucidi 4.5 g • Dang Gui Radix Angelicae sinensis 6 g • Ze Xie Rhizoma Alismatis 4.5 g • Chi Xiao Dou Semen Phaseoli 12 g • Shu Di Huang Radix Rehmanniae preparata 12 g • Mu Dan Pi Cortex Moutan 6 g • Huai Niu Xi Radix Achyranthis bidentatae 4.5 g • Bai Shao Radix Paeoniae alba 6 g • Ren Dong Teng Caulis Lonicerae 9 g • Che Qian Zi Semen Plantaginis 7.2 g • Gan Cao Radix Glycyrrhizae 2.4 g – EMPIRICAL PRESCRIPTION (Chapter 62, Vaginal Itching, Candida infection) • Huo Xiang Herba Pogostemonis 30 g • She Chuang Zi Fructus Cnidii 30 g
• Tu Fu Ling Rhizoma Smilacis glabrae 30 g – EMPIRICAL PRESCRIPTION by Dr Liu Geng Wu (Chapter 66, Polycystic Ovary Syndrome, Dampness or Damp-Heat) • Qu Mai Herba Dianthi 6 g • Bian Xu Herba Polygoni avicularis 6 g • Chuan Lian Zi Fructus Toosendan 3 g • Yan Hu Suo Rhizoma Corydalis 6 g • Pu Gong Ying Herba Taraxaci 4.5 g • Bai Jiang Cao Herba Patriniae 4.5 g • Chi Shao Radix Paeoniae rubra 6 g • Bai Shao Radix Paeoniae alba 6 g
APPENDIX 2 Suggested Substitutions of Chinese Herbs The following is a partial list of suggested substitutions for Chinese herbs that are forbidden to use in Western countries. This may be because they are animal or mineral substances, because they are toxic or because they come from protected species. Please note that some herbs may be banned in certain countries and not in others. Please note also that certain Chinese herbs are wrongly thought to be toxic and their inclusion in this list does not signify my agreement with such a view. Indeed, in some cases, some herbs (e.g. Fang JiRadix Stephaniae tetrandrae) are banned not because they are toxic but because of the possibility of wrong identification of the herb. In fact, (Han) Fang JiRadix Stephaniae tetrandrae is not toxic but, because when ordering it may be substituted with (Guang) Fang JiRadix Aristolochiae Fangchi which is potentially toxic, (Han) Fang Ji is also banned. Many Chinese herbs have of course more than one action and it is therefore impossible to recommend a single substitution in such cases. For example, Chuan Shan JiaSquama Manitis Pentadactylae may be used to invigorate Blood or to soften masses. In some cases, a herb cannot be substituted by a single herb and it needs two herbs to replicate the action of the herb being substituted. Toxicity issues
• Fang JiRadix Stephaniae tetrandrae (see above) • Fu Zi RadixAconiti lateralis preparata • Huang Yao ZiRadix Dioscoreae bulbiferae
• Mu TongCaulis Akebiae trifoliatae
Animal products
• Bie JiaCarapax Trionycis • Chuan Shan JiaSquama Manitis Pentadactylae • Gui BanPlastrium Testudinis • Long ChiFossilia Dentis Mastodi • Long GuMastodi Ossis fossilia • She XiangMoschus • Xi JiaoCornu Rhinoceri
Mineral products
• Ci ShiMagnetitum • Mu LiConcha Ostreae • Shi Jue MingConcha Haliotidis • Zhen Zhu MuConcha Margatiriferae usta
Protected species issues
• Bai JiRhizoma Bletillae • Gou JiRhizoma Cibotii
• Shi HuHerba Dendrobii • Tian MaRhizoma Gastrodiae
Table A2.1 lists the above herbs and their substitutions in the same order as above. Table A2.1 Herbal substitutions
Herb
FANG JI Radix Stephaniae tetandrae
Substitution (Action) 1
Substitution (Action) 2
Yi Yi Ren Semen Coicis with Fu Ling Poria with Cang ZhuRhizoma Huang Bo Atractylodis (to resolve CortexPhellodendri Dampness and remove (to resolve Dampobstructions from the Heat in the Lower channels in Painful Burner) Obstruction (Bi)
Syndrome) Rou GuiCortex FU ZI Cinnamomi (to Radix Aconiti tonify Yang and the lateralis Fire of the Gate of preparata Life)
Gui ZhiRamulus Cinnamomi cassiae (to warm the channels in Painful Obstruction Syndrome)
HUANG YAO ZI Radix Dioscoreae bulbiferae
Ban XiaRhizoma Pinelliae preparatum with Bai Hua She She CaoHerba Hedyotidis diffusae
MU TONG Caulis Akebiae trifoliatae
Tong CaoMedulla Tetrapanacis (to remove obstructions from the Connecting channels)
Fu LingPoria with Huang BoCortex Phellodendri (to resolve Damp-Heat)
BIE JIA Carapax Trionycis
Huang JingRhizoma Polygonati with Gou Qi ZiFructus Lycii chinensis (to nourish Yin)
Yi Yi RenSemen Coicis (to soften masses)
CHUAN SHAN JIA Squama Manitis
Wang Bu Liu XingSemen Vaccariae (to invigorate Blood)
Yi Yi RenSemen Coicis (to soften masses)
Pentadactylae GUI BAN Plastrium Testudinis
Huang JingRhizoma Polygonati with Gou Qi ZiFructus Lycii chinensis
LONG CHI Fossilia Dentis Mastodi
Suan Zao RenSemen Ziziphi spinosae
Suan Zao LONG GU RenSemen Ziziphi Mastodi Ossis spinosae (to calm fossilia the Mind)
Yi Yi RenSemen Coicis (to soften masses)
Shi Chang SHE XIANG PuRhizoma Acori Moschus tatarinowii XI JIAO Cornu Rhinoceri
Shui Niu JiaoCornu Bubali
CI SHI Magnetitum
Suan Zao RenSemen Ziziphi spinosae
MU LI Concha Ostreae
Suan Zao RenSemen Ziziphi spinosae
Yi Yi Ren Semen Coicis (to soften masses)
SHI JUE MING Concha Haliotidis
Gou TengRamulus cum Uncis Uncariae
ZHEN ZHU Gou TengRamulus Suan Zao RenSemen MU cum Uncis Ziziphi spinosae (to Concha Uncariae (to calm the Mind) Margatiriferae subdue Liver-Yang) usta BAI JI Rhizoma Bletillae
Xian He CaoHerba Agrimoniae
GOU JI Rhizoma Cibotii
Du ZhongCortex Eucommiae ulmoidis
SHI HU Herba Dendrobii
Yu ZhuRhizoma Polygonati odorati
TIAN MA Rhizoma Gastrodiae
Gou TengRamulus cum Uncis Uncariae
Pinyin–english glossary of chinese terms
General
Ba Kuo
Bao
Eight Ramparts
Uterus in women and Room of Sperm in men
Bao Luo
Uterus Channel
Bao Mai
Uterus Vessel
Ben
Root
Bian Bing the disease
Identification of
Bian Zheng patterns
Identification of
Biao
Manifestation
Puerperium
Chan Ru
Cou Li (also space between the skin and muscles)
Cun
Cavities and texture
Cun (acupuncture unit of measurement)
Dan Tian
Field of Elixir
Fen Rou Fu Superficial layer of skin
Fat and muscles
Gao
Ge
Huang
Ji
Fat Tissue
Deep layer of skin
Membranes
Subcutaneous muscles
Jie ‘Streets’, ‘avenues’, ‘crossroads’ (symbols for channels of the abdomen controlled by the Penetrating Vessel)
Jin
Sinews
Jing Gong (or Palace of Essence)
Palace of Sperm
Jing Guan
Sperm Gate
Jing Shi Essence)
Room of Sperm (or
Ju Ci
Opposite needling
Liu Qi
Six Climates
Liu Xie pathogenic factors)
Six Evils (external
Liu Yin (excessive climates)
Six Excesses
Miu
Ci
Contralateral
needling
Eye System
Mu Xi
Rebellious Qi
Ni (Qi)
Qi Mechanism
Qi Ji
Pathways of Qi
Qi Jie
Qing
Emotion
Rou
San Bing puerperium)
Muscles or flesh
Three Diseases (of
San Chong (of puerperium)
Three Rebellions
San Ji (of puerperium)
Three Emergencies
San Shen (of puerperium)
Three Questions
Shan Zhong thorax
Centre of the
Shao Fu abdominal area
Lateral, lower
Shao Huo
Lesser Fire
Shun (Qi) (as opposed to rebellious Qi)
Tian
Heaven (or Heavenly)
Five Wheels
Wu Lun
Xiang
Xiao Fu abdominal area
Conforming Qi
Image
Central, lower
Xie
Pathogenic factor
Xie Lei
Hypochondrium
Xie Qi
Pathogenic factor
Xin xia xyphoid process
Xu Li channel of the Stomach (manifesting in apical pulse)
Area below the
Great Connecting
Diffusing (of Lung-
Xuan Fa Qi)
Pores (including
Xuan Fu sebaceous glands)
Yin Jing
Yun Hua and transportation (of the Spleen)
Penis
Transformation
Exhuberant
Zhuang Huo Fire
Zi Bao
Zong Jin
Uterus
Ancestral Muscle
Symptoms and signs
Hidden labour
An chan (miscarriage within 1 month of gestation)
Ban
Ban chan Ban
Hemiplegia
Macule (in tongue diagnosis, Red spots)
Half labour Shen
Bu
Sui
‘Nose pool’
Bi Yuan (sinusitis)
Cao Za
Gnawing hunger
Chui Ru
Blow Breast
Chuan
Cui jiao
Breathlessness
Brittle foot (of
pregnancy)
Dao Han
Du Ru
Duan Qi breath
Duo Qi (very feeble voice with interrupted speech)
Duo Tai
Night sweating
Begrudging milk
Shortness of
Robbing of Qi
Falling fetus
Hiccup
E Ni
Nausea
E Xin
Emission of heat,
Fa Re fever
Fan Wei food
Fan
Zao
Regurgitation of
Mental
restlessness and agitation (restlessness of limbs)
Wheal
Feng Tuan Feng
Yin
Zhen
Wind hidden rash (urticaria)
Wind rash
Feng Zhen (German measles)
Gan Ou low sound Han
Short retching with Re
Wang
Lai
Alternation of chills and fever
Shivers
Han Zhan
Tidal fever
Hu Re
Slippery fetus
Hua Tai
Ji
Blood masses
Jia
Qi masses
Leg Qi
Jiao Qi
Jie
Accumulation (or nodules)
Fear
Jing Ji palpitations
Ju
Qi masses
and
Jue
Breakdown
Sweating from
Jue Han breakdown
Cough
Ke Sou
Kou Chuang Kou
Mouth ulcers Yan
Wai
Xie
Deviation of eye and mouth
Li Ji Anxiety, internal urgency (in the context of rebellious Qi of the Penetrating Vessel) Li Ji Hou Zhong
Difficulty in defaecation
Liu Lei
Streaming eyes
Trickling Breast
Lou Ru
Numbness and/or
Ma Mu tingling
Hemp rash
Ma Zhen (measles)
Man
Feeling of fullness
Men
Feeling of oppression
Quivering eyeball
Mu Chan
Mu Hua floaters Mu Hun Mu Yun
Nao Ming
Blurred vision and Clouded vision Blurred vision
Brain noise
Reverse period
Ni Jing
Nong Pao
Pustule
Nong Tai
Playing fetus
Ou
Ou Tu
Vomiting (with sound)
Vomiting
Pao
Pi
Vesicle
Feeling of stuffiness
Weak breathing
Qi Shao
Qi oedema
Qi Zhong
Qing
Bluish-greenish (colour)
Qiu Zhen
Papule
Re Du
Toxic-Heat
Ru E tonsils)
Milky mouth (swollen
Ru Yong
Shang Qi
Breast Carbuncle
Rebellious-Qi
breathing
Feeling of
Shen Zhong heaviness of the body
Shi
Shi E tonsils)
Shi Tai
Full, Fullness, excess
Stone moth (swollen
Testing fetus
Eczema
Shi Zhen
Shou Chan hands Shou
Tremor of the Zhi
Luan
Contraction of the fingers
Shui Dou (chicken pox)
Water pox
Vesicle
Shui Pao
Oedema
Shui Zhong
Four Rebellious
Si Ni
Tai Lou during pregnancy Tai
Restless fetus
Vaginal bleeding Dong
Bu
An
Tai
Qi
Shang
Ni
Fetus = Qi rebelling upwards
Phlegm nodules
Tan He
Phlegm fluids (or
Tan Yin Phlegm fluids in Stomach and Intestines) Tou Fa
Bian
Bai
Greying of the hair Tou
Tuo
Luo
Fa
Alopecia
Drooping head
Tou Qing
Dizziness
Tou Yun
Feeling of
Tou Zhong heaviness of the head
Tu
Vomiting (without sound)
Tuo
Collapse
Fear of Cold (in
Wei Han exterior invasions of Wind)
Five Retardations
Wu Chi
Aversion to Wind
Wu Feng
Wu Han Wu
Han
Fa
Aversion to Cold Re
(Simultaneous) Aversion to Cold and fever
Wu Ruan Wu
Xin
Five-palm heat
Xiao
Wheezing
Fa
Five Flaccidities Re
Xiao Chan
Xie Tong pain
Small labour
Hypochondrial
Xie Xie
Diarrhoea
Xin Fan
Mental restlessness
Xin Ji
Palpitations
Xin
Zhong
Ao
Nong
Heart feeling vexed
Xu
Empty, Emptiness, deficiency
Xuan Yin hypochondrium
Phlegm fluids in the
Xuan Yun
Dizziness
Yan Chi eyes
Discharge from the
Yan Shi
Aversion to food
Yi Jing
Seminal emissions
Yi Niao urine
Incontinence of
Phlegm fluids in the
Yi Yin limbs
Swimming menses
You Jing
Depression
Yu Zheng
Yue
Zhan Han
Long retching with loud sound
Shiver sweating
Zhang
Zhen
Zheng
Zheng Chong throbbing
Zhi Yin
Feeling of distension
Rash
Blood masses
Panic
Phlegm fluids above
the diaphragm
Zhong
Zhou Jiao pregnancy)
Feeling of heaviness
Wrinkled foot (in
Zi Fan
Anxiety in pregnancy
Zi Lin pregnancy
Urinary Syndrome in
Fullness of pregnancy
Zi Man
Qi of pregnancy
Zi Qi
Convulsions in
Zi Xian pregnancy
Feeling
Zi Xuan suffocation (in pregnancy)
Zi Yin
Aphonia in pregnancy
of
Zi Yun
Zi Zhong pregnancy
Zu Chan
Dizziness in pregnancy
Oedema
of
Tremor of the feet
Disease-symptoms Bai
He
Bing
Lilium Syndrome
Bai Yin
Bai Zhuo
Ben Tun Syndrome
Spermatorrhoea
White Turbidity
Running Piglet
Beng Lou Trickling
Flooding and
Bi Jing
No Periods
Bi Qiu
Stuffy nose
Bi Yuan (sinusitis)
‘Nose pool’
Painful
Bi Zheng Obstruction Syndrome
Cao Za
Chan Zheng
Chi Dai
Chi Zhuo
Gnawing hunger
Tremors
Cretinism
Red Turbidity
Chui Ru
Blow Breast
Dullness and
Dian Kuang mania
Dian Xian
Du Ru
E Ni
Epilepsy
Begrudging milk
Hiccup
Fan Wei food Fei
Regurgitation of Xu
Lao
Lung exhaustion
German
Feng Zhen measles
Gan
Childhood nutritional impairment
Gao Lin Syndrome
Ji Dai Disorder (in children)
Ji Ju
Jing Bing
Sticky Urinary
Accumulation
Abdominal masses
Convulsions
Jing Ji palpitations Jing
Fear Jian
Qi
Chu
and Xue
Bleeding between Periods
Fright Cry
Jing Ti
Jing Zhuo Turbidity Jue
Essence Xin
Tong
Breakdown Heart pain
Breakdown
Jue Zheng Syndrome
Ke Sou
Lao Lin Syndrome
Cough
Fatigue Urinary
Li Ji Li
Dysentery Jie
(Feng)
Multiple joints (Wind)
Lin Zheng Syndrome
Long Bi
Urinary
Urinary retention
Scrofula
Luo Li
Ma Zhen Mei
Measles He
Qi
Plum-Stone Syndrome
Mian Tan
Facial paralysis
Nao Lou
Brain discharge
Nue Ji
Malaria
Pi Kuai
Pi masses
Qi Lin Syndrome
Qi Zhong
Qi
Qi oedema
Urinary
Stuffy nose and
Qiu Ti sneezing
Ru He
Re Lin Syndrome
Ru Lao
Ru Li
Breast nodule
Heat Urinary
Breast exhaustion
Breast scrofula
Ru Pi Ru
Breast lump Shi
Yong
Breast Stone Carbuncle
Ru Yan
Ru Yong
Breast lump
Breast Carbuncle
Shan
Shi Lin Syndrome
Shi Zhen (dermatitis)
Shui Dou
Shui Zhong
Hernial and genito-urinary disorders
Stone Urinary
Eczema
Chicken pox
Oedema
Tan He
Tan Huan
Tu Suan
Tun Suan
Wan Bi Obstruction Syndrome
Nodules
Paralysis
Sour vomiting
Sour regurgitation
Stubborn Painful
Wei Zheng Syndrome
Wen Bing
Wen Yi pathogenic factor
Wu Chi
Wu Ruan
Atrophy
Warm disease
Warm epidemic
Five Retardations
Five Flaccidities
Hypochondrial
Xie Tong pain
Xie Xie
Diarrhoea
Xin Ji Xin
Palpitations Ji
Palpitations and anxiety
Zheng
Chong
Xin Tong
Heart pain
Xu Lao
Exhaustion
Xu Sun
Exhaustion
Xue Lin Syndrome
Blood Urinary
Yang Wei
Impotence (erectile
dysfunction)
Dysphagia and
Ye Ge blockage
Yi
Yi Jing
Yi Niao urine
Hysteria
Seminal emissions
Incontinence of
Vulvar sores
Yin Chuang
Silent Scrofula
Yin Luo
Ying
Yu Zheng Yue
Goitre
Jing
Guo
Depression Duo
Heavy Periods Yue
Jing
Scanty Periods Yue
Jing
Late Periods Yue Jing
Xian
Irregular Periods Yue
Jing
Guo
Shao
Hou
Hou
Wu
Xian
Qi
Ding
Qi
Qi
Early Periods
Zang Zao Zhen
Agitation Xin
Tong
True Heart pain
Zheng Chong throbbing
Zheng Jia masses (in women)
Panic
Abdominal
Wind-stroke
Zhong Feng
Zhuo
Zi Lin of Pregnancy
Zi Yun Pregnancy
Zi
Zhong
Turbidity
Urinary Syndrome
Dizziness
of
Oedema
of
Pregnancy
Vital substances
Gui Hou
Ghost, spirit, soul of dead person Tian Zhi
Post-Natal Qi
Hun
Ethereal Soul
Jing
Essence
Qi
Channel Qi
Jing Qi
Jun Huo
Emperor Fire
Ming Men Ming
Gate of Life
Fire of the Gate of Life
Men
Huo
Po
Corporeal Soul
Physiological
Shao Huo Fire of the body
Shen Mind (the Shen of the Heart) or Spirit (the complex of Heart-Shen, Corporeal Soul, Ethereal Soul, Intellect and Will-Power)
Sui
Tian Gui
Marrow
Heavenly Gui
Tuo
Spittle
Defensive Qi
Wei Qi
Xian Xian
Saliva Tian
Zhi
Qi
Pre-Natal Qi
Xiang Huo
Minister Fire
Yi
Intellect
Ying Qi
Nutritive Qi
Yuan Qi
Original Qi
Zhen Qi
True Qi
Zheng Qi
Upright Qi
Zhi
Zhong Qi
Zhuang Huo Fire (pathological)
Zong Qi the chest)
Will-Power
Central Qi
Exuberant
Gathering Qi (of
Emotions
Ai
Bei
(or Hao
Sadness
Jing
Shock
Kong
Fear, fright
) Love
Lü
Reflection
Nu
Anger
Si
Pensiveness
Xi
Joy
You
Worry
Yu
Craving
Channels and points Ah
Shi
xue
Ah Shi point
Bao Luo
Uterus Channel
Bao Mai
Uterus Vessel
Ben Biao (of channels)
Root and Branch
Penetrating
Chong Mai Vessel
Cou Li and muscles (also cavities and texture)
Dai Mai
Du Mai
Fu Luo Connecting channel
Space between skin
Girdle Vessel
Governing Vessel
Superficial
Gen Jie Concentration (of channels)
He Xue
Origin
and
Sea point
Hui Xue
Gathering point
Jing Bie
Divergent channel
Jing Jin
Muscle channel
Jing Mai
Main channel
Jing Xue
Well point
Jing Xue
River point
Ju Ci
Jue Yin
Opposite needling
Terminal Yin
Luo Mai channel
Luo Xue
Connecting
Connecting point
Miu Ci needling
Contralateral
Mu Xue points
Front-Collecting
Pathways of Qi
Qi Jie
Ren Mai
Directing Vessel
Shao Yang
Lesser Yang
Lesser Yin
Shao Yin
Shu Xue (Bei)
Stream point Shu
Xue
Back-Transporting points
Minute
Sun Luo Connecting channel
Greater Yang
Tai Yang
Tai Yin Wu
Greater Yin Shu
Xue
Five Transporting points
Accumulation point
Xi Xue
Bright Yang
Yang Ming Yang
Qiao
Mai
Yang Stepping Vessel Yang
Wei
Mai
Yang Linking Vessel Yin
Qiao
Mai
Yin Stepping Vessel Yin
Wei
Mai
Yin Linking Vessel
Ying Xue
Spring point
Yuan Xue
Source point
Zong Mai
Ancestral Vessel
Pulse positions
Chi
Cun
Guan
Rear
Front
Middle
Pulse qualities
Long
Chang
Chen
Deep
Chi
Slow
Cu
Hasty
Da
Big
Dai
Irregular or Intermittent
Dong
Moving
Duan
Short
Fu
Floating
Fu
Hidden
Ge
Hong
Hua
Huan
Ji
Leather
Overflowing
Slippery
Slowed-Down
Hurried
Jie
Knotted
Jin
Tight
Kou
Lao
Ru
Hollow
Firm
Soggy
Ruan
Ruo
San Se Choppy Shi Full Shu Rapid Wei Minute Xi Fine Xian Wiry Xu Empty
Soggy
Weak
Scattered
Tongue diagnosis Ban Spots Bian Wai Deviated Chi Gen Teethmarks Dan Bai Pale Dian Red points (on the tongue) Fu Mouldy Hong Red Hua Slippery (tongue coating) Lie Wen Cracked Ni Sticky (tongue coating)
Nong
Qiang Geng
She Tai
Moving
Stiff
Tongue coating
She Ti
Tongue body shape
She Zhi
Tongue body
Zhan
Quivering
Zhong
Swollen
Zi
Purple
Methods of treatment
An Tai
Bu
De Qi sensation
Gong Xia downwards
Calm the fetus
Tonify (or reinforce as a needle technique)
Obtaining needling
Moving
Dispel stasis (of
Gong Yu Blood)
Consolidate
Gu
Gu Biao Exterior
Consolidate collapse
Gu Tuo
Hua
Consolidate the
Shi
Resolve
Dampness
Hua Tan
Resolve Phlegm
Hua Yu Blood)
Eliminate stasis (of
Huan Ji
Moderate urgency
Huo Xue
Invigorate Blood
Jie Biao Exterior
Jie Yu (of Qi)
Kai Qiao
Li Hou
Release the
Eliminate stagnation
Open the orifices
Benefit the throat
Brighten the eyes
Li Mu
Move Qi
Li Qi
Resolve Dampness
Li Shi
Li Shui transformation Li
Promote Water Shui
Dao
Regulate the Water passages
Liu Wei Qi
Ping Gan
Circulate Defensive
Calm the Liver
Po Xue
Break-up Blood
Qing Re
Clear Heat
Qu Feng Wind
Qu Yu Blood)
San Han Cold
San Jie accumulation or dissipate nodules
Expel (external)
Eliminate stasis (of
Expel (or scatter)
Dissipate
Promote healing
Sheng Xin of tissues
Pacify (the
Shu (Gan) Liver)
Relax the sinews
Shu Jin
Shun Qi Tiao
Rectify Qi He
Ying
Wei
Harmonize Nutritive and Defensive Qi
Tiao Jing period
Tong Fu Yang Organs
Tong Li passages by promoting diuresis
Regulate the
Penetrating the
Open the Water
Tong Luo obstructions from the Connecting channels
Tong Qiao Tong
Ru
Remove
Open the orifices Luo
Remove obstructions from the breast Connecting channels
Tong Shun obstructions by restoring the correct direction of Qi flow
Remove
Tong Xia obstructions by moving downwards Tong
Remove Yang
Open (the chest)
Wen Jing
Warm the menses
Xi Feng (internal)
Extinguish Wind
Xie
Xie
Xie
Xie
Reduce (as a needle technique)
Clear (Heat)
Drain (Fire)
Drain (method of treatment as opposed to Bu
, tonify)
Xie Xia Xin
Kai
Ku
Move downwards Jiang
Use pungent herbs to open and bitter ones to make Qi descend
Promote
Xing Zhi resuscitation
Xuan Fei diffusing of Lung-Qi Xuan
Restore the Tong
Bi
Open the nose
Yang (Xue) (Blood)
Nourish
Pathogenic factors
Wind-Cold
Feng Han
Wind-Heat
Feng Re
Han
Cold
Huo
Fire
Re
Heat
Toxic-Heat
Re Du
Shi
Dampness
Shu
Summer-Heat
Tan
Phlegm
Tan Yin GENERAL and also Phlegm fluids in the Stomach
Phlegm fluids in
Wen Yi pathogenic factor
Warm epidemic
Xie
Xie Qi
Pathogenic factor
Pathogenic factor
Phlegm fluids in
Xuan Yin the hypochondrium
Phlegm fluids in the
Yi Yin limbs
Zao
Zhi Yin diaphragm
Dryness
Phlegm fluids in the
English–pinyin glossary of chinese terms
General
Ancestral muscle Zong Jin Area below the
xyphoid
process
Xin
xia
Cavities and texture (also space between the skin and muscles) Cou
Li Central,
lower
Centre
of
abdominal
the
thorax
Xiao
area
Shan
Fu
Zhong
Conforming Qi Shun Qi Contralateral
needling
Miu
Ci
Cun (acupuncture unit of measurement) Cun
Deep layer of skin Ge Diffusing (of
Lung-Qi)
Xuan
Fa
Eight Ramparts Ba Kuo
Emotion Qing
Eye system Mu Xi Exhuberant
Fire
Zhuang
Huo
Fat and muscles Fen Rou
Fat tissue Gao
Field of Elixir Dan Tian
Five Wheels Wu Lun Great Connecting channel of the Stomach (manifesting in apical
pulse) Xu Li
Heaven (or Heavenly) Tian
Hypochondrium Xie Lei Identification of
Identification
Image Xiang
of
the
disease
patterns
Bian
Bian
Bing
Zheng
Lateral,
lower
Lesser Fire Shao Huo
Manifestation Biao
Membranes Huang
Muscles or flesh Rou
abdominal
area
Shao
Fu
Opposite needling Ju Ci Palace of Sperm (or
Pathogenic factor Xie
Pathogenic factor Xie Qi
Pathways of Qi Qi Jie
Palace
of
Essence)
Jing
Gong
Penis Yin Jing Pores (including
sebaceous
glands)
Xuan
Fu
Essence)
Jing
Shi
Puerperium Chan Ru
Qi mechanism Qi Ji
Rebellious Qi Ni Qi Room of Sperm
(or
Root Ben
Sinews Jin
Six Climates Liu Qi Six Evils (external
pathogenic
Six Excesses (excessive climates)
factors)
Liu
Xie
Sperm Gate Liu Yin
Jing
Guan ‘Streets’, ‘avenues’, ‘crossroads’ (symbols for channels of the
abdomen controlled by the Penetrating Vessel) Jie
Subcutaneous muscles Ji Superficial layer of skin Fu Three Diseases (of
puerperium)
San
Bing
Three
Emergencies
(of
Three
Questions
(of
Three
Rebellions
(of
San
puerperium)
puerperium)
puerperium)
San
San
Ji
Shen
Chong
Transformation and transportation (of the Spleen) Yun Hua
Uterus Zi Bao also called ‘Bao’)
Uterus Channel Bao Luo
Uterus Vessel Bao Mai
(sometimes
Symptoms and Signs
Accumulation (or nodules) Jie Alopecia Tou
Fa
Alternation
fever
of
chills
and
Tuo
Han
Re
Luo
Wang
Lai
Anxiety (in the context of rebellious Qi of the Penetrating Vessel) Li
Ji Anxiety
in
pregnancy
Zi
Fan
Aphonia in pregnancy Zi
Aversion to Cold Wu Han Aversion to Cold and fever, simultaneous Wu Han Fa Re
Aversion to food Yan Shi
Aversion to Wind Wu Feng
Begrudging milk Du Ru
Blood masses Ji
Blood masses Zheng
Blow Breast Chui Ru
Bluish-greenish (colour) Qing Blurred vision and
Blurred vision Mu Yun
Brain noise Nao Ming
Breakdown Jue
floaters
Mu
Hua
Breast Carbuncle Ru Yong
Breathlessness Chuan Brittle foot
(of
pregnancy)
Cui
jiao
Clouded vision Mu Hun
Collapse Tuo Contraction
of
the
fingers
Shou
Zhi
Luan
Convulsions
Cough Ke Sou
Deficiency Xu
Depression Yu Zheng
in
pregnancy
Zi
Xian
Deviation
of
Diarrhoea Xie Xie Difficulty in
Discharge
eye
and
mouth
defaecation
from
the
Kou
Li
Ji
eyes
Yan
Wai
Xie
Hou
Zhong
Yan
Chi
Distension, feeling of Zhang
Dizziness Tou Yun
Dizziness Xuan Yun Dizziness in
Drooping head Tou Qing
pregnancy
Zi
Yun
Eczema Shi Zhen Emission of
Empty Xu
Emptiness Xu
Excess Shi
heat,
fever
Fa
Re
Falling fetus Duo Tai Fear of Cold (in Exterior invasions
Fear
and
Feeling of distension Zhang
palpitations
of
Wind) Wei
Jing
Han
Ji
Feeling of fullness Man
Feeling of heaviness Zhong Feeling of heaviness of the body Shen Zhong Feeling of heaviness of the head Tou Zhong
Feeling of oppression Men
Feeling of stuffiness Pi Feeling of suffocation
(in
pregnancy)
Zi
Xuan
Five Flaccidities Wu Ruan Five-palm heat
Fetus
Qi
rebelling
Four Rebellious Si Ni
Wu
upwards
Xin
Tai
Fa
Qi
Shang
Re
Ni
Full Shi
Fullness Shi
Fullness, feeling of Man Fullness of
Five Retardations Wu Chi
pregnancy
Zi
man
Floaters Mu Hua Fetus = Qi rebelling upwards Tai Qi Shang Ni Four Rebellious Si Ni
Full, Fullness, excess Shi
Gnawing hunger Cao Za Greying of the hair Tou Fa Bian Bai
Half labour Ban Chan Heart feeling vexed
Xin
Zhong
Ao
Nong
Heaviness, feeling of Zhong Heaviness of the head,
Hemiplegia Ban Shen Bu Sui Hemp rash
feeling
(measles)
of
Ma
Tou
Zhong
Zhen
Hiccup E Ni Hidden labour (miscarriage within 1 month of gestation) An chan
Hypochondrial
Incontinence
Internal urgency Li Ji
Leg Qi Jiao Qi
Xie
pain
of
urine
Tong
Yi
Niao
Long retching with loud sound Yue
Macule (in tongue diagnosis, red spots) Ban
Manifestation Biao Mental restlessness and agitation (restlessness of limbs) Fan Zao
Mental
restlessness
Xin
Fan
Milky
mouth
(swollen
Ru
tonsils)
E
Mouth ulcers Kou Chuang
Nausea E Xin
Night sweating Dao Han
Nodules Tan He ‘Nose pool’
(sinusitis)
Bi
Yuan
Numbness
and/or
tingling
Ma
Mu
Oppression, feeling of Men
Oedema Shui Zhong Oedema of
pregnancy
Zi
zhong
Palpitations Xin Ji Panic throbbing
Zheng
Chong
Papule Qiu Zhen Phlegm fluids (or Phlegm fluids in Stomach and Intestines) Tan Yin
Phlegm
fluids
above
the
diaphragm
Zhi
Yin
Phlegm
Phlegm
fluids
in
fluids
Playing fetus Nong Tai
the
in
hypochondrium
the
limbs
Xuan
Yin
Yi
Yin
Pustule Nong Pao
Qi oedema Qi Zhong
Qi of pregnancy Zi Qi
Qi masses Jia
Qi masses Ju
Qi oedema Qi Zhong Quivering eyeball Mu Chan
Rash Zhen Rebellious Qi breathing Shang Qi Regurgitation of food Fan Wei Restless fetus Tai
Dong
Bu
Reverse period Ni Jing Robbing of Qi (very feeble voice with interrupted speech) Duo Qi Seminal emissions Yi Jing
An
Shivers Han Zhan Shiver
Short
Shortness
Zhan
sweating
retching
with
of
low
breath
Han
Gan
sound
Duan
Ou
Qi
Slippery fetus Hua Tai
Small labour Xiao Chan Stone moth
Streaming eyes Liu Lei
Stuffiness, feeling of Pi
(swollen
tonsils)
Shi
E
Sweating
from
Swimming
Testing fetus Shi Tai
Tidal fever Hu Re
Jue
breakdown
menses
You
Han
Jing
Toxic-Heat Re Du Tremor of
Tremor
of
Trickling Breast Lou Ru Urinary Syndrome
the
feet
the
hands
in
Pregnancy
Zu
Chan
Shou
Chan
Zi
Lin
Vaginal
bleeding
Vesicle Pao
Vesicle Shui Pao
Vomiting (with sound) Ou
during
pregnancy
Tai
Lou
Vomiting (without sound) Tu
Vomiting Ou Tu Water pox
Weak breathing Qi Shao
Wheal Feng Tuan
(chicken
pox)
Shui
Dou
Wheezing Xiao Wind hidden
rash
Wind
(German
Wrinkled
rash
foot
(urticaria)
(in
Feng
Yin
Zhen
measles)
Feng
Zhen
pregnancy)
Zhou
Jiao
Disease-symptoms
Abdominal masses Ji Ju Abdominal masses
Accumulation
Agitation Zang Zao Atrophy
(in
Disorder
Syndrome
women)
(in
children)
Wei
Zheng
Jia
Ji
Dai
Zheng
Begrudging milk Du Ru Bleeding between Periods
Blood
Urinary
Jing
Syndrome
Jian
Qi
Xue
Chu
Xue
Lin
Blow Breast Chui Ru
Brain discharge Nao Lou Breakdown Heart
Breakdown
pain
Syndrome
Jue
Xin
Jue
Tong
Zheng
Breast Carbuncle Ru Yong
Breast nodule Ru He
Breast exhaustion Ru Lao
Breast lump Ru Pi
Breast lump Ru Yan
Breast scrofula Ru Li Breast Stone
Carbuncle
Chicken pox Shui Dou
Childhood nutritional impairment Gan
Cough Ke Sou
Ru
Shi
Yong
Cretinism Chi Dai
Convulsions Jing Bing
Depression Yu Zheng
Diarrhoea Xie Xie Dizziness of
pregnancy
Zi
Yun
Dullness
and
Dysentery Li Ji Dysphagia
Early
Eczema
and
Periods
Dian
Mania
blockage
Yue
(dermatitis)
Jing
Shi
Kuang
Ye
Ge
Xian
Qi
Zhen
Epilepsy Dian Xian Erectile
Essence
Exhaustion Xu Lao
dysfunction
turbidity
Yang
Jing
Wei
Zhuo
Exhaustion Xu Sun
Facial paralysis Mian Tan Fatigue Urinary
Fear
and
Syndrome
palpitations
Lao
Lin
Jing
Ji
Five Flaccidities Wu Ruan
Five Retardations Wu Chi Flooding and
Fright Cry Jing Ti German
measles
Beng
Trickling
Feng
Lou
Zhen
Gnawing hunger Cao Za
Goitre Ying Heat
Urinary
Heart pain Xin Tong Heavy Periods
Syndrome
Yue
Jing
Re
Lin
Guo
Duo
Hernial and genito-urinary disorders Shan
Hiccup E Ni Hypochondrial
Hysteria Yi Impotence
Xie
pain
(erectile
dysfunction)
Tong
Yang
Wei
Incontinence
of
Irregular
Yue
Late
Lilium
Periods
Periods
Syndrome
Yi
urine
Jing
Xian
Yue
Hou
Jing
Bai
Niao
Wu
Hou
He
Ding
Qi
Qi
Bing
Lung
Fei
exhaustion
Xu
Lao
Jie
(Feng)
Malaria Nue Ji
Measles Ma Zhen Multiple joints
(Wind)
Li
No Periods Bi Jing ‘Nose pool’
Oedema Shui Zhong Oedema of
(sinusitis)
pregnancy
Bi
Zi
Yuan
Zhong
Panic
Painful
Zheng
throbbing
Obstruction
Palpitations Xin Ji Palpitations and
anxiety
Bi
Syndrome
Xin
Chong
Ji
Zheng
Zheng
Chong
Paralysis Tan Huan
Pi Masses Pi Kuai
Phlegm Nodules Tan He Plum-Stone Syndrome
Mei
He
Qi
Qi oedema Qi Zhong Qi Urinary
Syndrome
Qi
Lin
food
Fan
Wei
Red turbidity Chi Zhuo Regurgitation of
Running
Scanty
Piglet
Periods
Syndrome
Yue
Jing
Ben
Tun
Guo
Shao
Scrofula Luo Li
Seminal emissions Yi Jing
Silent scrofula Yin Luo
Sour regurgitation Tun Suan
Sour vomiting Tu Suan
Spermatorrhoea Bai Yin Sticky Urinary
Syndrome
Gao
Lin
Stone
Syndrome
Shi
Lin
Stubborn
Urinary
Painful
Obstruction
Syndrome
Wan
Bi
Stuffy nose Bi Qiu Stuffy nose
and
Tremors Chan Zheng True Heart
pain
sneezing
Zhen
Qiu
Xin
Ti
Tong
Turbidity Zhuo
Urinary retention Long Bi Urinary Syndrome
Urinary
Syndrome
of
Lin
Pregnancy
Zheng
Zi
Lin
Vulvar sores Yin Chuang
Warm disease Wen Bing Warm epidemic
White turbidity Bai Zhuo
Wind-stroke Zhong Feng
pathogenic
factor
Wen
Yi
Vital substances
Central Qi Zhong Qi
Channel Qi Jing Qi
Corporeal Soul Po
Defensive Qi Wei Qi
Emperor Fire Jun Huo
Essence Jing
Ethereal Soul Hun Exuberant Fire
Fire
of
the
(pathological)
Gate
of
Life
Zhuang
Ming
Men
Huo
Huo
Gate of Life Ming Men Gathering Qi (of
the
Ghost, spirit, soul of dead person Gui
Heavenly Gui Tian Gui
Intellect Yi
chest)
Zong
Qi
Marrow Sui
Mind (the Shen of the Heart) Shen
Minister Fire Xiang Huo
Nutritive Qi Ying Qi
Original Qi Yuan Qi Physiological Fire
of
the
body
Shao
Huo
Post-Natal
Pre-Natal
Qi
Qi
Hou
Tian
Zhi
Qi
Xian
Tian
Zhi
Qi
Saliva Xian Spirit (the complex of Heart-Shen, Corporeal Soul, EtherealSoul,
Intellect and Will-Power) Shen
Spittle Tuo
True Qi Zhen Qi
Upright Qi Zheng Qi
Will Power Zhi
Emotions
Anger Nu
Craving Yu
Fear, fright Kong
Joy Xi
Love Ai
Pensiveness Si
Reflection Lü
Sadness Bei
Shock Jing
(or Hao
)
Worry You
Channels and points
Accumulation point Xi Xue Ah Shi point
Ancestral
Back-Transporting
Ah
Zong
Vessel
points
Shi
(Bei)
xue
Mai
Shu
Xue
Bright Yang Yang Ming Cavities and
Connecting
Cou
texture
channel
Connecting point Luo Xue Contralateral needling
Luo
Miu
Li
Mai
Ci
Directing Vessel Ren Mai
Divergent channel Jing Bie Five Transporting
Front-Collecting
points
points
Wu
Shu
Mu
Xue
Xue
Gathering point Hui Xue
Girdle Vessel Dai Mai
Governing Vessel Du Mai
Greater Yang Tai Yang
Greater Yin Tai Yin
Lesser Yang Shao Yang
Lesser Yin Shao Yin
Main channel Jing Mai Minute Connecting
Muscle channel Jing Jin
channel
Sun
Luo
Opposite needling Ju Ci Origin and Concentration
Pathways of Qi Qi Jie Penetrating
River point Jing Xue
Vessel
(of
channels)
Chong
Gen
Jie
Mai
Root
and
Branch
(of
channels)
Ben
Biao
Sea point He Xue
Source point Yuan Xue Space between
Spring point Ying Xue
skin
and
muscles
Cou
Li
Stream point Shu Xue Superficial Connecting
Terminal Yin Jue Yin
Uterus Channel Bao Luo
Uterus Vessel Bao Mai
channel
Fu
Luo
Well point Jing Xue Yang Linking
Vessel
Yang
Wei
Mai
Yang
Stepping
Vessel
Yang
Qiao
Mai
Yin
Linking
Vessel
Yin
Wei
Mai
Yin
Stepping
Vessel
Yin
Qiao
Mai
Pulse positions
Front Cun
Middle Guan
Rear Chi
Pulse qualities
Big Da
Choppy Se
Deep Chen
Empty Xu
Fine Xi
Firm Lao
Floating Fu
Full Shi
Hasty Cu
Hidden Fu
Hollow Kou
Hurried Ji
Irregular or Intermittent Dai
Knotted Jie
Leather Ge
Long Chang
Minute Wei
Moving Dong
Overflowing Hong
Rapid Shu
Scattered San
Short Duan
Slippery Hua
Slow Chi
Slowed-Down Huan
Soggy Ru
Soggy Ruan
Tight Jin
Weak Ruo
Wiry Xian
Tongue diagnosis
Cracked Lie Wen
Deviated Bian Wai
Spots Ban
Mouldy Fu
Moving Nong
Pale Dan Bai
Purple Zi
Quivering Zhan
Red Hong
Red points (on the tongue) Dian
Slippery (tongue coating) Hua
Sticky (tongue coating) Ni
Stiff Qiang Geng
Swollen Zhong
Teethmarks Chi Gen
Tongue body She Zhi
Tongue body shape She Ti
Tongue coating She Tai
Methods of treatment
Benefit the throat Li Hou
Break up Blood Po Xue
Brighten the eyes Li Mu
Calm the fetus An Tai
Calm the Liver Ping Gan Circulate Defensive
Liu
Qi
Wei
Clear Heat Qing Re
Clear (Heat) Xie
Consolidate Gu Consolidate
collapse
Gu
Tuo
Consolidate
Dispel
Dissipate
the
stasis
Exterior
(of
accumulation
Gu
Gong
Blood)
San
Biao
Yu
Jie
Dissipate nodules San Jie
Drain (method of treatment as opposed to Bu
,
tonify) Xie
Drain (Fire) Xie Eliminate stagnation
(of
Qi)
Jie
Yu
Eliminate
stasis
(of
Blood)
Hua
Yu
Eliminate
stasis
(of
Blood)
Qu
Yu
Expel
(external)
Expel Cold San Han Extinguish Wind
Wind
(internal)
Qu
Xi
Feng
Feng
Harmonize
Nutritive
and Defensive
Invigorate Blood Huo Xue Moderate urgency
Move downwards Xie Xia
Qi Tiao He Ying Wei
Huan
Ji
Move
Move Qi Li Qi Nourish
Obtaining
Open
Gong
downwards
Yang
(Blood)
needling
(the
Xia
De
sensation
chest)
(Xue)
Tong
Qi
Yang
Open
the
nose
Open the orifices Kai Qiao Open the
orifices
Xuan
Tong
Tong
Bi
Qiao
Open the Water passages by promoting diuresis Tong Li
Pacify
(the
Penetrate
the
Yang
Promote
healing
of
Promote
Shu
Liver)
resuscitation
organs
tissues
Xing
(Gan)
Tong
Fu
Sheng
Xin
Zhi
Promote
Water
Li
transformation
Shui
Rectify Qi Shun Qi
Reduce (as a needle technique) Xie
Reinforce (as a needle technique) Bu Regulate the period
Tiao
Jing
Regulate
the
Water
Relax the sinews Shu Jin Release the
passages
Exterior
Li
Shui
Jie
Dao
Biao
Remove obstructions from the breast Connecting channels Tong Ru Luo
Remove obstructions from the Connecting channels Tong Luo
Remove
obstructions
by
moving
downwards
Tong
Xia
Remove obstructions by restoring the correct direction of Qi flow
Tong Shun Resolve
Dampness
Hua
Shi
Resolve Dampness Li Shi
Resolve Phlegm Hua Tan Restore the diffusing
Scatter Cold San Han
of
Lung-Qi
Xuan
Fei
Tonify (or reinforce as a needle technique) Bu Use pungent herbs to open and bitter ones to make Qi descend Xin Kai Ku Jiang
Warm
the
menses
Wen
Jing
Pathogenic factors
Cold Han
Dampness Shi
Dryness Zao
Fire Huo
Heat Re
Pathogenic factor Xie
Pathogenic factor Xie Qi
Phlegm Tan Phlegm fluids in general and also Phlegm fluids in the Stomach Tan Yin
Phlegm
fluids
in
the
hypochondrium
Xuan
Yin
Phlegm
Phlegm
fluids
fluids
Summer-Heat Shu
in
in
the
the
limbs
diaphragm
Yi
Yin
Zhi
Yin
Toxic-Heat Re Du Warm epidemic
Wind-Cold Feng Han
Wind-Heat Feng Re
pathogenic
factor
Wen
Yi
Cross-Reference of Chinese DiseaseSymptoms with Western Diseases Abdominal Masses (Ch. 60) 793 Carcinoma of the cervix 353, 805 Cervical dysplasia 807 Endometrial carcinoma 805 Endometriosis 275, 805 Myoma 276, 804 Ovarian cysts 804 Polycystic ovary disease 805 Breast Lumps (Ch. 59) 769 Breast pain and nodularity 790 Cysts 789 Duct ectasia 790 Epithelial hyperplasia 790 Fat necrosis 791 Fibroadenoma 790 Galactocele 791 Lipomas 790
Mastitis 790 Papilloma 790 Breast Milk Not Flowing (Ch. 53) 657 Acute mastitis 664 Collapse after Childbirth (Ch. 55) 673 Septic shock 677 Convulsions after Childbirth (Ch. 56) 679 Tetanus 682 Convulsions during Pregnancy (Ch. 36) 513 Dizziness during Pregnancy (Ch. 35) 509 Eclampsia 499, 512, 517 Excessive Vaginal Discharge (Ch. 61) 813 Candida albicans infection 825, 832 Cervical neoplasm 825 Cervical erosion 825 Endometrial neoplasm 825 Trichomonas vaginalis infection 825, 832 Urinary tract fistulae 825 Vaginal neoplasm 825 Fever after Childbirth (Ch. 51) 639
Breast infection 649, 664 Genital tract infection 649 Mastitis 664 Respiratory tract infection 649 Thrombophlebitis 649 Urinary tract infection 649 Flooding and Trickling (Ch. 17) 319 Carcinoma of the cervix 353, 805 Carcinoma of the uterus 353 Endometrial polyps 354 Endometriosis 275, 353, 805 Myomas 276, 353, 804 Infertility (Ch. 57) 685 Cervical hostility 724 Cervical incompetence 724 Cushing’s syndrome 722 Endometriosis 275, 353, 805 Hyperthyroidism 725 Hypothyroidism 725 Ovulatory failure 722 Polycystic ovary 889
Salpingitis 723 Uterine myomas 353, 724, 804 No Periods (Ch. 16) 295 Absent or hypoplastic uterus 315 Addison’s disease 315 Andrenogenital syndrome 315 Anorexia nervosa 315 Congenital absence of the vagina 315 Congenital absence of the ovaries 315 Cushing’s syndrome 722 Diabetes mellitus 315 Generalized hypothalamic defect 315 Hyperthyroidism 300, 725 Hypogonadotropic hypogonadism 315 Hypothyroidism 300, 725 Imperforate hymen 315 Isolated gonadotropin deficiency 315 Nephritis 315 Oophoritis 315 Ovarian hyperthecosis 315 Ovarian neoplasms 315
Ovarian dysfunction 315 Ovarian failure 315 Polycystic ovary 889 Pituitary tumours 315 Primary gonadal disorder (gonadal dysgenesis) 315 Psychosis 315 Rheumatoid arthritis 315 Severe pelvic inflammatory disease 315 Transverse vaginal system 299 Tuberculosis 315 Oedema during Pregnancy (Ch. 33) 495 Eclampsia 499, 512, 517 Painful Periods (Ch. 14) 255 Endometriosis 275, 805 Myoma 276, 804 Pelvic inflammatory disease 275 Vaginal Itching (Ch. 62) 827 Candida albicans infection 825, 832 Genital eczema 832 Trichomonas vaginalis infection 825, 832 Vulvar Sores (Ch. 64) 841
Behçet’s disease 847 Calymmatobacterium granulomatis infection 847 Candida albicans infection 833, 842, 856 Crohn’s disease 847 Dermatitis 846 Herpes simplex infection 846 Leukoderma 846 Nevi 847 Non-infectious vulvitis 846 Psoriasis 846 Pyoderma infection 847 Treponema pallidum infection 847 Vestibular adenitis 846 Vitiligo 846 Vulvar neoplasm 846
Cross-Reference of Western Diseases with Chinese Disease-Symptoms Addison’s disease 315 No Periods (Ch. 16) 295 Behçet’s disease 847 Vulvar Sores (Ch. 64) 841 Breast cysts 789 Breast Lumps (Ch. 59) 769 Breast epithelial hyperplasia 790 Breast Lumps (Ch. 59) 769 Breast fat necrosis 791 Breast Lumps (Ch. 59) 769 Breast infection 649, 664 Fever After Childbirth (Ch. 51) 639 Breast papilloma 790 Breast Lumps (Ch. 59) 769 Candida albicans infection 825, 832 Excessive Vaginal Discharge (Ch. 61) 813
Vaginal Itching (Ch. 62) 827 Vulvar Sores (Ch. 64) 841 Carcinoma of the uterus 353, 804 Abdominal Masses (Ch. 60) 793 Excessive Vaginal Discharge (Ch. 61) 813 Flooding and Trickling (Ch. 17) 319 Cervical carcinoma 807 Abdominal Masses (Ch. 60) 793 Excessive Vaginal Discharge (Ch. 61) 813 Flooding and Trickling (Ch. 17) 319 Cervical dysplasia 807 No corresponding Chinese disease-symptoms (but see Ch. 60, Abdominal Masses) 793 Cervical erosion 825 Excessive Vaginal Discharge (Ch. 61) 813 Crohn’s disease 847 Vulvar Sores (Ch. 64) 841 Cushing’s syndrome 722 Infertility (Ch. 57) 685 No Periods (Ch. 16) 295 Dermatitis 846
Vulvar Sores (Ch. 64) 841 Diabetes mellitus 315 No Periods (Ch. 16) 295 Duct ectasia 790 Breast Lumps (Ch. 59) 769 Eclampsia 499, 512, 517 Convulsions during Pregnancy (Ch. 36) 513 Dizziness during Pregnancy (Ch. 35) 509 Oedema during Pregnancy (Ch. 33) 495 Endometrial polyps 354 Flooding and Trickling (Ch. 17) 319 Endometriosis 275, 353, 805 Abdominal Masses (Ch. 60) 793 Flooding and Trickling (Ch. 17) 319 Infertility (Ch. 57) 685 Painful Periods (Ch. 14) 255 Fibroadenoma 790 Breast Lumps (Ch. 59) 769 Fistulae 825 Excessive Vaginal Discharge (Ch. 61) 813
Galactocele 790 Breast Lumps (Ch. 59) 769 Genital eczema 832 Vaginal Itching (Ch. 62) 827 Genital tract infection 649 Fever after Childbirth (Ch. 51) 639 Herpes simplex infection 846 Vulvar Sores (Ch. 64) 841 Hyperthyroidism 315, 725 Infertility (Ch. 57) 685 No Periods (Ch. 16) 295 Hypothyroidism 315, 725 Infertility (Ch. 57) 685 No Periods (Ch. 16) 295 Leukoderma 846 Vulvar Sores (Ch. 64) 841 Mastitis 664, 790 Breast Lumps (Ch. 59) 769 Breast Milk Not Flowing (Ch. 53) 657 Fever After Childbirth (Ch. 51) 639
Myoma 276, 804 Abdominal Masses (Ch. 60) 793 Flooding and Trickling (Ch. 17) 319 Infertility (Ch. 57) 685 Painful Periods (Ch. 14) 255 Nephritis 315 No Periods (Ch. 16) 295 Oophoritis 315 No Periods (Ch. 16) 295 Ovarian cysts 804, 805 Abdominal Masses (Ch. 60) 793 Ovarian hyperthecosis 315 No Periods (Ch. 16) 295 Ovarian neoplasm 315 Abdominal Masses (Ch. 60) 793 No Periods (Ch. 16) 295 Ovulatory failure 315 Infertility (Ch. 57) 685 No Periods (Ch. 16) 295 Pelvic inflammatory disease 275
No Periods (Ch. 16) 295 Painful Periods (Ch. 14) 255 Pituitary tumour 315 No Periods (Ch. 16) 295 Polycystic ovary syndrome 889 Amenorrhoea (Ch. 16) 295 Infertility (Ch. 57) 685 Abdominal Masses (Ch. 60) 793 Psoriasis 846 Vulvar Sores (Ch. 64) 841 Respiratory tract infection 649 Fever after Childbirth (Ch. 51) 639 Rheumatoid arthritis 315 No Periods (Ch. 16) 295 Salpingitis 723 Infertility (Ch. 57) 685 Septic shock 677 Collapse after Childbirth (Ch. 55) 673 Tetanus 682 Convulsions after Childbirth (Ch. 56) 679
Thrombophlebitis 650 Fever after Childbirth (Ch. 51) 639 Trichomonas vaginalis infection 834, 841 Excessive Vaginal Discharge (Ch. 61) 813 Vaginal Itching (Ch. 62) 827 Tuberculosis 300 No Periods (Ch. 16) 295 Urinary tract infection 649 Fever after Childbirth (Ch. 51) 639 Vaginal neoplasm 825 Excessive Vaginal Discharge (Ch. 61) 813
Chronology of Chinese Dynasties Xia: 21st to 16th century BC Shang: 16th to 11th century BC Zhou: 11th century to 771 BC Spring and Autumn period: 770–476 BC Warring States period: 475–221 BC Qin: 221–207 BC Han: 206 BC–AD 220 Three Kingdoms period: AD 220–280 Jin: 265–420 Northern and Southern dynasties: 420–581 Sui: 581–618 Tang: 618–907 Five Dynasties: 907–960 Liao: 906–1125 Song: 960–1279 Jin: 1115–1234 Yuan: 1271–1368 Ming: 1368–1644
Qing: 1644–1911 Republic of China: 1912–1949 People’s Republic of China: 1949–present
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. Chongqing: Science and Literature Publishing House; 1985. Qin Wang Ke. Theory of the Mind in Chinese Medicine. In Zhong Yi Shen Zhu Xue Shuo
. Ancient Chinese Medical Texts Publishing House; 1988. Tai Wang Xue. Medical Records of Famous Contemporary Chinese Acupuncturists. In Zhong Guo Dang Dai Zhen Jiu Ming Jia Yi An
. Jilin: Jilin Science and Technology Press; 1991. (chief ed.) Tai Wang Xue. Great Treatise of Chinese Acupuncture. In Zhong Guo Zhen Jiu Da Quan
. Henan Science and Technology Publishing House; 1995. Zhen Wu Da. Hundred Methods for the Treatment, Prevention and Dietary Therapy of Menstrual Irregularities. In Yue Jing Bing Fang Zhi He Shi Liao
100 Fa
100 House; 1994.
. Beijing: China Medicinal Herbs Scientific Publishing
Xiangtong Z. Research on Acupuncture, Moxibustion and Acupuncture Anesthesia. Beijing: Science Press, 1980. San Yang Jia. Great Dictionary of Chinese Acupuncture. In Zhong Guo Zhen Jiu Da Ci Dian
. Beijing: Beijing Physical Training College Publishing House; 1988. San Yang Jia. Acupuncture. In Zhen Jiu Xue
. Beijing: People’s Hygiene Publishing House; 1989. Yu Zhang Bo. Chinese Internal Medicine. In Zhong Yi Nei Ke Xue
. Shanghai: Shanghai Science and Technology Press; 1986. Wen Zhang Qi. Menstrual Diseases. In Yue Jing Bing Zheng
. Beijing: People’s Hygiene Publishing House; 1995. Kai Zhang Yuan. Medical Collection of Four Families from Meng He. In Meng He Si Jia Yi Ji
. Nanjing: Jiangsu Science Publishing House; 1985. Xi Zhu Dan. The Heart and Essence of Dan Xi’s Methods of Treatment. In: (Dan Xi Zhi Fa Xin Yao
. Beijing: People’s Health Publishing House; 1983:1280-1358. Zhu Dan Xi
Modern texts (english)
Betts D. The Essential Guide to Acupuncture in Pregnancy and Childbirth. Brighton: Journal of Chinese Medicine, 2006. Budd S. Complementary Therapies for Pregnancy and Childbirth. London: Baillière Tindall, 1995. Cheng Xia Gui. Concise Traditional Chinese Gynaecology. Jiangsu Science and Technology Publishing, 1988. Clavey S. Fluid Physiology and Pathology in Traditional Chinese Medicine. Edinburgh: Churchill Livingstone, 1995. Maciocia G. The Practice of Chinese Medicine. Edinburgh: Churchill Livingstone, 1994. Min Shang Xian. Practical Traditional Chinese Medicine and Pharmacology – Clinical Experiences. Beijing: New World Press, 1990. Revolutionary Health Committee of Hunan Province. A Barefoot Doctor’s Manual. London: Routledge & Kegan, 1978.
Western medicine texts Baum M., Saunders C., Meredith S. Breast Cancer. Oxford: Oxford University Press, 1994. Clarke-Pearson D.L. Green’s Gynaecology: Essentials of Clinical Practice. Dawood M Y. Little. Boston: Brown and Co,. 1977. Clarke-Pearson D.L., Dawood M.Y. Green’s Gynaecology: Essentials of Clinical Practice. In Little. Boston: Brown and Co; 1990. Dick-Read G. Childbirth Without Fear. London: Heinemann Medical Books, 1945. Evans W.C. Pharmacognosy. London: W B Saunders, 1996. Gomel V., Munro M. Gynaecology. In A Practical Approach. Williams and Wilkins, Baltimore; 1989. Govan A., Hart D., Callander R. Gynaecology Illustrated. Edinburgh: Churchill Livingstone, 1993.
Jones H.W., Seegar Jones G. Gynaecology. Baltimore: Williams and Wilkins, 1980. Lewis T.L.T., Chamberlain G.V.P. Obstetrics by Ten Teachers. London: Edward Arnold, 1994. McPherson A. Women’s Problems in General Practice. Oxford: Oxford University Press, 1993. Symonds E.M. Essential Obstetrics and Gynaecology. Edinburgh: Churchill Livingstone, 1994.
Journals (chinese) Journal of the Nanjing College of Traditional Chinese Medicine (Nanjing Zhong Yi Xue Yuan Xue Bao
), Nanjing University of Traditional Chinese Medicine, Nanjing. Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi
), China Academy of Traditional Chinese Medicine, Beijing,
Journals (english) Acupuncture in Medicine, BMJ Publishing Group, England.
American Journal of Acupuncture, USA. American Journal of Chinese Medicine, World Scientific Publishing, Singapore. American Journal of Epidemiology, Oxford University Press, USA. Anatomical Pathology, Lippincott Williams & Wilkins, USA. Annals of Internal Medicine, American College of Physicians, American Society of Internal Medicine, USA. Birth, Wiley Blackwell, USA. Breast Cancer Research, BioMed Central Ltd, England. British Journal of Obstetrics and Gynaecology, Blackwell Scientific Publications, England. British Medical Journal, British Medical Association, England. Clinical Endocrinology, Blackwell Publishing, England. Complementary Therapies in Medicine, Elsevier, Scotland. European Menopause Journal, PMSI Bugamor B V, The Netherlands. Foetal Diagnosis and Therapy, Karger S, Switzerland. International Journal of Cancer, Wiley-Liss, USA. International Journal of Clinical Acupuncture, Allerton Press Inc., USA. Journal of Alternative and Complementary Medicine, Mary Ann Liebert Inc., USA. Journal of Chinese Medicine, England. Journal of Clinical Endocrinology and Metabolism, Endocrine Society, USA. Journal of Nursing Research, Taiwan Nurses Association, China. Journal of Reproductive Medicine, Science Printers and Publishers Inc., USA Journal of the American College of Traditional Chinese Medicine, American College of Traditional Chinese Medicine, USA. Journal of the American Medical Association, JAMA, USA.
Journal of the British Menopause Society, England. Lancet, Lancet Publishing Group, England. New England Journal of Medicine, Massachusetts Medical Society, USA. Obstetrics and Gynaecology, Lippincott Williams & Wilkins, USA. Paediatrics, American Academy of Paediatrics, USA. The Journal of Maternal–Fetal and Neonatal Medicine, Informa Healthcare, England.
Index
Note: Page numbers followed by b indicate boxes, f indicate figures and t indicate tables.
A
abdomen cold to touch, 108 lesser abdomen (Shao Fu), 20f, 21, 22, 102, 102f palpation, 108–109 small abdomen (Xiao Fu), 19, 20f, 22, 102, 102f abdominal masses, 109, 126, 793–811 aetiology, 794 case histories, 801b endometriosis treated as, 860 malignant tumours, 803 myomas as, 924 pathology, 794 pattern identification/treatment, 794–795 Blood masses, 798–803 Blood stasis knotted in the Interior, 799–800 Qi and Blood stagnation, 798 Qi masses, 795–797 food retention and Phlegm, 796–797 Liver-Qi stagnation, 795–796 prognosis/prevention, 803–804 Western view, 804–805 abdominal pain acupuncture, 170b, 189b after childbirth, 601–605 aetiology, 601 pathology, 601–602 pattern identification/treatment, 602–605 Blood deficiency, 602–603 Blood stasis, 603–604 retention of food, 604–605 prognosis/prevention, 605
in diagnosis, 102, 109 in pregnancy, 469–476 pathology, 469 pattern identification/treatment, 470–473 Blood deficiency, 470–471 Blood stasis, 473 Empty-Cold, 472 Qi stagnation, 471 prognosis/prevention, 473 Western view, 473–474 threatened miscarriage, 479, 488 abortion, 104 complete, 488 incomplete, 488 inevitable See miscarriage, inevitable missed, 488 recurrent See miscarriage, habitual spontaneous See miscarriage threatened See miscarriage, threatened acupressure labour, 561–562 clinical trials, 562 points, 561 specific points See also acupuncture points by seed-pressure, 279–280 clinical trial, 276–277 acupuncture abdominal masses, 795, 796–797, 798, 799, 802 abdominal pain after childbirth, 602, 603, 604–605 abdominal pain in pregnancy, 470, 471, 472, 473 amenorrhoea, 314 Empty conditions, 298–299, 300, 303, 304, 306, 307, 308 Full conditions, 309, 312, 313 ancient prescriptions abdominal pain after childbirth, 605
amenorrhoea, 314 Breast Milk not Flowing, 663 difficult labour, 565 fever at period time, 427 Flooding and Trickling, 352 infertility, 716–717 irregular periods, 230 oedema during menstruation, 409 painful periods, 274 Persistent Lochial Discharge, 612 pre-menstrual syndrome, 376 prolapse of uterus, 837 retention of lochia, 614 threatened miscarriage, 487 vaginal discharge, excessive, 824–825 vaginal itching, 831 anxiety during pregnancy, 502, 503, 504, 505, 506 aphonia, 523 auricular, 558–559, 567 clinical trials, 727 bleeding between periods, 286–287, 288, 289, 290, 292 body aches, 416, 418 Breast Carbuncle, 665–667 breast distension, pre-menstrual, 383–384, 385, 386, 387, 388, 389, 390, 392 breast lumps, 775, 778, 781, 782–783, 784, 785, 786, 788 breast milk flow, 669–670 Breast Milk not Flowing, 658–659, 660 breech presentation, 556, 557 cervical intra-epithelial neoplasia, 809 collapse after childbirth, 674, 675 constipation after childbirth, 629–631 constipation during pregnancy, 540, 541, 542, 543 convulsions after childbirth, 680, 681 convulsions during pregnancy, 514, 515, 516 cost-effectiveness trial, 279 cough, 526, 527
diarrhoea at period time, 412, 413 Directing Vessel, 160, 171–181 opening points, 171 dizziness at period time, 446–448 dizziness during pregnancy, 510, 511 early periods, 202, 204, 205, 207–208 electro-acupuncture, 280, 579–580 endometriosis, 861–862, 862f, 863, 865, 867, 868–869, 870, 871, 872 clinical trials, 882–884 combined patterns, 873, 874, 875, 877 point combination, 863, 864f, 865, 866f, 867, 867f, 869, 869f epistaxis/haemoptysis, 430, 431 extra points, gynecological, 189–190 Extraordinary Vessels, 157–168 areas of influence, 160, 160t reasons for choice, 160–162 Fetus not Growing, 491, 492 Fever after Childbirth, 641, 643–644, 645, 646, 647, 648 fever at period time, 422, 423, 424–425, 426, 427 Flooding and Trickling, 322, 323, 327, 328–329, 336, 337–338, 352 Empty conditions, 344, 346, 348, 349, 351 Full conditions, 331, 333, 334, 335–336, 340, 341, 342, 343 Girdle Vessel, 160, 185–187 Governing Vessel, 160, 181–185 habitual miscarriage, 546, 547, 548–550, 551, 552 haemorrhoids external, 635, 636 internal, 633, 634, 635 headaches during menstruation, 396, 398, 399, 400, 401, 402 heavy periods, 232, 234, 235, 236–237 infertility, 690, 717 ancient prescriptions, 716–717 clinical trials, 725–728 Empty conditions, 693–694, 698, 699 case histories, 697, 700 Full conditions, 701, 704–705, 709–710, 712, 714–715 case histories, 714
irregular periods, 226, 227–228, 229, 230 joint pain after childbirth, 652, 653, 654, 655 labour, 557–564 analgesia, 558–559, 578–580, 581, 583 breech presentation, 575–577 case histories, 568b cervical ripening, 582 clinical trials, 575–583 and contractions, 579 delayed labour, 559 difficult labour, 562–565 duration, 583 history, 559–561 induction, 558, 568b, 577–578 testimonials, 569b, 570b laser stimulation, 576 late periods, 212, 214, 215, 217, 220 lochia Persistent Lochial Discharge, 608, 609, 610 retention of lochia, 612–613 long periods, 250, 251, 252, 253 and massage, 278 menopause, 738–739, 740–742, 745–746, 747, 748, 749, 750 clinical trials, 755–761 morning sickness, 458–460, 461, 463–464, 465–466, 467–468 case histories, 462, 464b, 467 Directing Vessel, 459 distal points, 459–460 Kidney channel, 459 Penetrating Vessel, 459 Stomach channel, 458–460 mouth ulcers, 434, 435, 436, 442, 443 with moxa, 128, 129, 133, 144, 145, 150, 154–155, 169, 171, 172, 178 myomas, 930, 931–932, 933 oedema during menstruation, 406, 407, 408, 409 oedema during pregnancy, 496, 497, 498 opening points, 158
Directing Vessel, 171 Gongsun (SP-4), 189 Governing Vessel, 181–182 Neiguan (P-6), 189 Penetrating Vessel, 158, 162, 163f Yin Linking Vessel, 189 Yin Stepping Vessel, 188 Zhubin (KI-9), 189 painful periods, 258, 268, 269, 274 clinical trials, 276–277 Empty conditions, 270, 271, 273 Full conditions, 259, 260, 261, 264, 267 Penetrating Vessel, 140, 158–159, 160, 162–168 placenta, retained, 566 polycystic ovary syndrome, 898, 899–902, 903, 904, 905, 906, 907 case histories, 912 clinical trials, 914–916 modern literature, 908–910 post-natal depression, 595, 596, 597, 598–599 pre-menstrual syndrome, 371, 376 Empty conditions, 369, 371, 372, 373, 375 Full conditions, 358, 360–361, 362–363, 364, 365–366, 368 special empirical treatment, 366 in pregnancy, 451 prescriptions of Dr Guo Cheng Jie, 778 principles, 122 prolapse of uterus, 836, 837 Qinglong Baiwei method, 279 scanty periods, 240, 241–242, 243, 244, 245–246 skin eruptions, 440, 441 stagnant Liver-Qi turning into Fire, 206 suffocation, feeling of, 520, 521 Sweating afer Childbirth, 626, 627 threatened miscarriage, 481, 483, 484, 486, 487 tonifying/eliminating, 123 Transporting Shu points, 160, 167 UK maternity services, 555–556
urinary problems after childbirth, 616, 617, 618, 619, 620, 621–622 urinary retention after delivery, 567 during pregnancy, 534, 535, 536 urinary syndrome, 530, 531 vaginal discharge, excessive, 816, 817, 818–819, 820, 822, 824 vaginal itching, 828, 830, 831 eczema, genital, 833, 834 Vulvar Sores, 842, 843–844, 845 Yang Linking Vessel, 160 Yang Stepping Vessel, 159, 160 Yin Linking Vessel, 160, 189 Yin Stepping Vessel, 160, 188 Acupuncture for Childbirth Team (ACT), 556 acupuncture points, 163 Baihuanshu (BL-30), 176, 186 Baihui (Du-20), 72, 145, 146, 174, 176, 179, 181, 182, 184, 185, 898 in clinical trials, 280 Baohuang (BL-3), 190, 809 Baomen, 190 Burong (ST-19), 153, 458–459 Changqiang (Du-1), 38–40, 183–184 Chengjiang (Ren-24), 37, 184 Chengman (ST-20), 153, 459 Chengqi (ST-1), 37 Chize (LU-5), 153 Chongmen (SP-12), 188 Ciliao (BL-32), 180, 561 Dadu (SP-2), 165 Dadun (LIV-1), 176 Dahe (KI-12), 165, 862 Daimai (G.B.-26), 40, 134, 140, 141, 176, 185–186, 187, 188 Daju (ST-27), 165, 189 Dajuxu/Shangjuxu (ST-37), 35, 37f, 171 Daling (P-7), 151, 152 Dashu (BL-11), 35, 37f
Dazhong (KI-4), 188 Dazhui (Du-14), 184 Feishu (BL-13), 183–184 Fengchi (G.B.-20), 143, 154 Fengfu (Du-16), 143, 183–184 Fenglong (ST-40), 460, 775 Fuliu (KI-7), 128, 129, 131, 172, 173, 175 Futonggu (KI-20), 163, 168 Ganshu (BL-18), 28, 133, 147, 757, 775, 809 Geshu (BL-17), 28, 133, 140, 150, 151, 775 Gongsun (SP-4), 58, 140, 158, 162, 163, 165, 168, 169, 170, 171, 460, 862, 898 in clinical trials, 277–278 Guanyuan (Ren-4), 28, 71, 72, 128, 129, 130, 131, 133, 154–155, 157, 158, 166, 168, 169, 171, 172–174, 176, 179, 181–182, 184, 185, 186, 757, 775, 809, 862, 898 in clinical trials, 277–278, 280 Guilai (ST-29) in clinical trial, 277–278 Hegu (L.I.-4), 142, 143, 163, 169, 170, 171, 173, 561, 562–564, 579, 862 in clinical trials, 277–278, 280 Henggu (KI-11), 158–159, 165 Houding (Du-19), 184–185 Houxi (S.I.-3), 72, 158, 159–160, 181–182, 862, 898 Huangmen (BL-51), 171, 190 Huangshu (KI-16), 68t, 154, 163, 165, 167, 169 Huiyin (Ren-1), 37, 171–181 Hunshe (extra point), 178 Jianjing (G.B.-21), 173, 561, 562 Jianli (Ren-11), 459, 898 Jianshi (P-5), 186 Jinggong, 190 Jingzhong, 189–190 Jiuwei (Ren-15), 150, 154, 174, 178, 179–180, 182, 184–185, 773, 773f Jueyinshu (BL-14), 151 Jueyun, 190 Juliao (G.B.-29), 183–184 Juque (Ren-14), 150, 151, 152, 178, 179, 459
Kongzui (LU-6), 153 Kunlun (BL-60), 561, 563 Laogong (P-8), 775 Liangmen (ST-21), 459 Liangqiu (ST-34), 460 Lieque (LU-7), 71, 72, 153, 158, 159, 171, 173, 176, 180, 181–182, 188, 189, 809, 862, 898 Ligou (LIV-5), 59, 134, 140, 141, 809 Mingmen (Du-4), 129, 184 Naoshu (S.I.10), 159 Neiguan (P-6), 58, 64, 134, 140, 151, 158, 162, 163, 165, 168, 169, 170, 171, 176, 181, 186, 459–460, 561, 775, 862, 898 in clinical trials, 277–278 Pangguangshu (BL-28), 183–184 Pishu (BL-20), 7, 28, 144, 145, 147, 148, 178, 460, 757, 809 Qichong (ST-30), 32, 34, 35, 64, 163, 164–168, 183–184 in clinical trials, 277–278 Qihai (Ren-6), 71, 145, 158, 171, 173, 175–176, 178, 185, 186, 188, 773, 773f, 775, 898 in clinical trials, 277–278, 280 Qimen (extra point), 154–155, 189–190 Qimen (LIV-14), 134, 140, 141, 165, 775 Qixue (KI-13), 128, 129, 130, 131, 154–155, 157, 158–159, 163, 166, 168, 169, 775 Quchi (L.I.-11), 141, 142, 152, 775 Qugu (Ren-2), 172 Ququan (LIV-8), 28, 133, 775 Rangu (KI-2), 166, 176 Sanjiaoshu (BL-22), 59, 148, 775, 809 Sanyinjiao (SP-6), 28, 62, 130, 131, 133, 144, 145, 147, 148, 150, 169, 171, 172, 173, 175, 176, 178, 186, 561, 562–564, 757, 758, 775, 809, 862 in clinical trials, 280 electrostimulation, 280 Shangjuxu/Dajuxu (ST-37), 35, 37f, 171 Shangliao (BL-31), 183–184 Shangqiu (SP-5), 175 Shangwan (Ren-13), 153, 459
Shanzhong (Ren-17), 151, 898 Shaofu (HE-8), 62 Shaohai (HE-3), 151, 152 Shaoze (S.I.-1), 32 Shencang (KI-25), 151 Shenmai (BL-62), 72, 158, 159–160, 181–182, 862, 898 in clinical trials, 277–278 Shenmen (HE-7), 150, 151 in clinical trials, 277–278, 280 Shenque (Ren-8), 177–178, 177f, 179, 729–730 with moxa, 694 Shenshu (BL-23), 7, 28, 34, 128, 129, 130, 131, 173, 176, 181–182, 184, 757, 775, 809 in clinical trials, 280 Shenting (Du-24), 179, 182, 184 Shiguan (KI-18), 163, 167 Shimen (Ren-5), 173, 174–175, 177, 178, 898 Shiqizhuixia (extra point), 177, 183–185 Shufu (KI-27), 34 Shuidao (ST-28), 59, 148, 180, 187, 189, 775, 898 Shuifen (Ren-9), 148, 177, 178, 775, 898 Shuigou (Du-26), 898 Siman (KI-14), 58, 140, 158–159, 163, 166, 171, 775, 862, 898 Taibai (SP-3), 757 Taichong (LIV-3), 134, 140, 141, 143, 147, 154, 163, 165, 169, 171, 172, 176, 181, 186, 189, 757, 775, 862, 898 in clinical trials, 277–278 Taixi (KI-3), 128, 129, 130, 131, 757, 775 in clinical trials, 277–278 Tiachong (LIV-3), 58 Tianshu (ST-25), 172 in clinical trials, 277–278 Tonggu (KI-20), 459 Tongli (HE-5), 62, 154 Waiguan (T.B.-5), 142, 143, 154, 158, 185, 186, 187, 188 Waisiman, 190 Weidao (G.B.-28), 40, 185–186, 187
Weishu (BL-21), 144, 145, 148, 460 Wushu (G.B.-27), 40, 185–187 Xiajuxu (ST-39), 35, 37f, 165, 171 Xialiao (BL-34), 183–184, 809 Xiawan (Ren-10), 153, 178–179, 459 Ximen (P-4), 151 Xingjian (LIV-2), 62, 141, 142, 775 Xinshu (BL-15), 150, 151, 152 Xuehai (SP-10), 58, 140, 151, 152, 775, 898 Yanglingquan (G.B.-14), 134, 140, 141, 147 in clinical trials, 280 Yaoshu (Du-2), 183–184 Yaoyangguan (Du-3), 898 Yinbai (SP-1), 146 Yindu (KI-19), 163, 167–168 Yinglingquan (SP-9), 173, 180 Yingu (KI-10), 130, 131, 176 Yinjiao (Du-28) (Ren-7), 38–40, 171, 173, 177 Yinlingquan (SP-9), 59, 148, 187, 775, 809 Yintang (extra point), 184 Yinxi (HE-6), 150, 173 Yongquan (KI-1), 561 Youmen (KI-21), 34, 158–159, 163, 168, 459 Zhangmen (LIV-13), 40–41, 134, 140, 141, 147, 185–187 Zhaohai (KI-6), 42–43, 71, 72, 130, 131, 150, 158, 159, 171, 173, 176, 180, 181–182, 188, 189, 809, 862, 898 Zhigou (T.B.-6), 134, 775 Zhishi (BL-52), 128, 129, 130, 131 Zhiyin (BL-67), 45, 561, 562 with moxa, 556, 557 Zhongfu (LU-1), 153 Zhongji (Ren-3), 59, 154–155, 172–173, 176, 177, 180, 185, 809, 862, 898 in clinical trials, 280 Zhongwan (Ren-12), 123, 144, 145, 147, 148, 176, 178, 179, 180, 184, 459, 775 Zhubin (KI-9), 130, 131, 179 Zigong (extra point), 173, 862
in clinical trials, 277–278 Zigongxue, 190 Zihu, 190 Zulinqi (G.B.-41), 158, 185, 186, 187, 188, 775, 777 Zusanli (ST-36), 28, 133, 144, 145, 147, 148, 150, 176, 177, 460, 775 in clinical trials, 277–278 aetiology, 77–95 aetiological factors, 77, 78, 78f alcohol consumption, 95, 737 aldosterone, 377 amenorrhoea (no periods), 295–318 aetiology, 295–296 case histories, 302b, 313b clinical trials, 316–317 pathology, 296–298 pattern identification/treatment, 298 Empty conditions, 298–309 Blood deficiency, 300–301 Heart- and Kidney-Yin deficiency, 307 Heart- and Spleen-Blood deficiency, 308–309 Liver and Kidney deficiency, 298–300 Liver- and Kidney-Yin deficiency, 304–305 Lung-Yin and Blood deficiency, 306–307 Spleen- and Kidney Yang deficiency, 303–304 Full conditions, 298 Damp-Phlegm in Lower Burner, 312, 314 Qi and Blood stagnation, 309–314 in PCOS, 896 physiology, 9 pregnancy, differentiating from, 298, 298t prognosis/prevention, 314 pulse, 106 shock, 32 Western view
causes by site, 316t primary amenorrhoea, 315–316 secondary amenorrhoea, 315–317 anger, 81, 95 ankles, swollen, 108 anovulation, 720 clinical trials, 725–726, 728–733 in PCOS, 890, 891, 892f anxiety acupuncture, 182, 183f, 189b during pregnancy, 501–507 aetiology/pathology, 501 pattern identification/treatment, 501–507 Empty-Heat from Yin deficiency, 505–506 Heart-Blood deficiency, 501–502 Liver-Fire, 504 Liver-Qi stagnation, 503 Lung- and Heart-Qi stagnation, 502 Phlegm-Fire harassing the Mind, 506–507 prognosis/prevention, 507 aphonia, 523–524 arometase inhibitors, 857 asthma, 71 auricular acupuncture, 558–559, 567 clinical trials, 727 auscultation, 117 avenues of Qi of the abdomen See Penetrating Vessel
B
back pain, 488 bacterial vaginosis, 825 bacteriuria, 532, 532f Bao in men and women, 8, 8f basal body temperature (BBT), 689, 723, 724f after childbirth, 591 endometriosis, 859–860, 859f Behçet disease, 847 birth canal injury, 676t Bladder anatomy, 93f after hysterectomy, 94 prolapse, 30–31 urinary problems after childbirth, 615, 619 Bladder-Heat and Kidney-Yin deficiency, 621–622 bleeding chronic, 211–212 complex pathological conditions, 324f Stopping Bleeding herbs, 135, 136 treatment, aims and steps of, 325f vaginal in early pregnancy, 477, 478, 479 in later pregnancy See miscarriage, threatened See also haemorrhage bleeding between periods, 285–293 aetiology, 285–286
case history, 291 pathology, 286 pattern identification/treatment, 286–291 Blood stasis, 289–290 Damp-Heat, 287–288 Liver- and Kidney-Yin deficiency with Empty-Heat, 286–287 Spleen- and Kidney-Yang deficiency, 290–291 prognosis/prevention, 292–293 Blood and birthweight, 45 cooling, 136 descending, 20 drying up, 45 exhaustion, 103 Fever after Childbirth, 642, 643t formation, 30 harmonizing Qi and Blood, 199 invigorating, 23, 134–135 classification, 135–140 combined methods, 137–140 in pregnancy, 135 nourishing, 24, 138 pathology, 64–67, 67f, 68t in pregnancy, 44 blood coagulation disturbance, 676t Blood-Cold, 65–67, 154–155 Blood deficiency, 68t, 109 abdominal pain after childbirth, 602–603 abdominal pain in pregnancy, 469, 470–471 amenorrhoea, 300–301 body aches, 416–417 complexion in, 110 constipation after childbirth, 629–630 constipation during pregnancy, 540
contraceptive pill, 94 diet, 83 dizziness at period time, 445–446 endometriosis, 872 Fever after Childbirth, 645–646 habitual miscarriage, 551 headaches during menstruation, 396 infertility, 686, 699, 700b joint pain after childbirth, 652–653 labour, 108 late periods, 212–213 menstrual cycle, 99, 101 painful periods, 257 of Penetrating Vessel, 896 polycystic ovary syndrome, 896, 897, 904 post-menstrual phase, 20 in pregnancy, 44, 449 pulse, 105 scanty periods, 240–241, 246–247 after surgery, 93 tongue, 111, 113–114, 115–116 Blood deficiency and Blood-Heat, 633 Blood deficiency and Kidney deficiency, 49 Blood deficiency and Kidney deficiency with Qi stagnation, 521 Blood deficiency and Lung deficiency, 306–307 Blood deficiency and Qi collapse, 674–675 Blood deficiency and Qi deficiency amenorrhoea, 297 Breast Milk not Flowing, 658–660 difficult labour, 564, 571–572 Fetus not Growing, 491–492 painful periods, 270–271
threatened miscarriage, 483–484 Blood deficiency and Yang deficiency, 271–272 Blood deficiency and Yin deficiency with Empty-Wind, 680 Blood deficiency with Qi deficiency and Blood stasis, 931–932 Blood deficiency with Swollen Tongue, 115–116 Blood deficiency with Wind-Heat, 440–442 Blood deficiency with Yang rising, 416–417 Blood deficient and dry, 833–834 Blood dried up, 297 Blood Empty-Cold, 68t Blood Empty-Heat, 68t Flooding and Trickling, 321, 326, 336–337 Blood Full-Cold, 68t Blood Full-Heat, 68t Blood-Heat, 205–209 complexion, 110 Directing Vessel deficiency, 110 fever at period time, 422–423 Flooding and Trickling, 321–324, 325–326, 329, 330–332, 333b, 334b habitual miscarriage, 549–550 haemorrhoids, 634, 635–636 heavy periods, 233–234 infertility, 688, 708–709 labour, 108 lip colour, 111 long periods, 251–252 menstrual cycle, 99, 101
miscarriage, 104 mouth ulcers, 442–443 Persistent Lochial Discharge, 610–611 pulses in, 105, 108 threatened miscarriage, 484–485 tongue, 111 Uterus, 111 Blood-Heat and Blood deficiency, 633 Blood-Heat and Blood stasis, 352 Blood-Heat and Damp-Heat, 257 Blood-Heat and Spleen-Yang deficiency, 124–125 Blood masses, 793 pattern identification/treatment, 798–803 Blood stasis, 7, 65, 68t, 70, 109 abdomen in, 109 abdominal masses, 799–800, 801b abdominal pain after childbirth, 603–604 abdominal pain in pregnancy, 469, 473 bleeding between periods, 289–290 body aches, 418–419 breast lumps, 771, 788 collapse after childbirth, 675–676 contraceptive pill, 94 ectopic pregnancy, 474–475 elimination and Liver pacification, 134–140 endometriosis, 859, 873, 874, 875–877 Fever after Childbirth, 646–647 Flooding and Trickling, 321–322, 326, 329, 337–339 habitual miscarriage, 552 haemorrhoids, 635–636 heavy periods, 235 infertility, 688, 689, 712–713, 716
joint pain after childbirth, 654 knotted in the Interior, 799–800 leading to bleeding, 322f menopause, 750–751 menstrual cycle, 99 painful periods, 256, 257, 258 Persistent Lochial Discharge, 609–610 polycystic ovary syndrome, 897, 902–903 post-natal depression, 594 post-partum, 286 pulses in, 105 retained placenta, 566 scanty periods, 244–245 after surgery, 93 tongue, 112, 114 and tongue colour, 112 Blood stasis and Blood-Heat, 352 Blood stasis and Cold myomas, 930 retained placenta, 574 Blood stasis and Cold stagnation, 613–614 Blood stasis and Damp-Phlegm and Kidney-Yang deficiency, 905–906 Blood stasis and Damp-Phlegm and Kidney-Yin deficiency, 906 Blood stasis and Dampness and Kidney-Yin deficiency, 907–908 Blood stasis and Heat, 426 Blood stasis and Kidney-Yang deficiency infertility, 716 myomas, 932 Blood stasis and Phlegm, 931
Blood stasis and Qi and Blood deficiency, 931–932 Blood stasis and Qi and Yin deficiency, 352 Blood stasis and Qi deficiency, 475 Blood stasis and Qi stagnation abdominal masses, 798 amenorrhoea, 297, 309–311 difficult labour, 564–565, 572 myomas, 929–930 retention of lochia, 612–613 Blood stasis and upright Qi deficiency, 802–803 Blood stasis in Uterus, 103, 105 body aches, 415–419 aetiology, 415–416 pathology, 416 pattern identification/treatment, 416–419 Blood deficiency, 416–417 Blood stasis, 418–419 prognosis/prevention, 419 Brain and Governing Vessel connections, 73f Breakdown Syndrome, 680 breast(s), 136 adipose tissue, 772, 773, 774f channels influencing, 382–383 channels of, 776–777 Connecting channels, 162 connective tissue, 772, 773, 774, 774f jealous/envious breast, 664 lumps/swellings See breast lumps Penetrating Vessel, 162 problems after childbirth, 665f
steaming breast, 647–648 breast abscess, 664 breast arteries, 162f breast cancer, 791t diagnosis, 113, 116 historical writings, 770 and hot flushes, 759 and HRT, 753–754, 755 and menstruation, 86 and pregnancy, 86 Breast Carbuncle, 664, 665 breast distension, pre-menstrual, 381–393 aetiology, 381–382 case histories, 385b, 386b, 391b pathology, 382 pattern identification/treatment, 383–393 Damp-Heat, 382, 389 Heart-Qi stagnation, 382, 387–388 Kidney- and Liver-Yin deficiency, 382, 392–393 Liver-Blood stasis, 382, 388–389 Liver-Qi stagnation, 382, 383–385 Lung-Qi stagnation, 382, 386–387 Phlegm with Qi stagnation, 382, 390 prognosis/prevention, 393 breast infection, 649 breast lumps, 769–791 aetiology, 771–772 benign tumours, 790 carbuncles, 769, 770 carcinoma See breast cancer cysts, 789–791, 791t diagnosis, 776–777
duct ectasia, 790 epithelial hyperplasia, 790 fat necrosis, 791 historical writings, 769, 770, 771, 772, 774 nodules, 770, 790, 791t pathology/treatment principles, 772–775 pattern identification/treatment, 777–787 Directing and Penetrating Vessel disharmony, 782–783 Liver- and Kidney-Yin deficiency, 786–787 Liver-Qi stagnation, 777–780 Liver-Qi stagnation turned into Fire, 784 Spleen-Yang deficiency with Phlegm, 781–782 Toxic-Heat, 785 prevention, 787–788 prognosis, 788 treatment principles, 775, 777 types, comparison of, 776t, 791 Western view, 788–791 See also breast cancer breast milk Breast Milk not Flowing, 657–667 aetiology, 657 pathology, 657–658 pattern identification/treatment Liver-Qi stagnation, 660–663 Qi and Blood deficiency, 658–660 prognosis/prevention, 663 Western view, 663–664 formation, 30, 32, 33f, 44, 69–70 spontaneous flow, 669–671 aetiology/pathology, 669 Liver-Fire, 670–671 prognosis/prevention, 671 Spleen- and Stomach-Qi deficiency, 669–670 breastfeeding excessive, 211–212 Stomach, influence of, 32
breech presentation, 556–557 acupuncture/moxibustion, 556, 557, 575–577 herbal treatments, 573 bromocriptine, 377 buserelin, 856t
C
Calymmatobacterium (Klebsiella) granulomatis, 847 Candida albicans/candidiasis, 116, 180b vaginal discharge, 825, 826 vaginal itching, 832 vulval sores, 846 carbuncles, 769, 770 cervical carcinoma, 353, 805, 807, 808, 825 cervical dysplasia, 807–810 cervical erosion, 825 cervical hostility, 724 cervical incompetance, 724 cervical intra-epithelial neoplasia (CIN), 807, 808, 808f diagnosis, 809 treatment, 809–810 cervical ripening, 582 cervical secretions, 21–22, 22f infertility, 689 in ovulation, 22 cervix in ovulation, 21–22, 22f childbirth diseases after, 587–588, 587b, 588b, 589, 589b, 590–591, 590b treatment mistakes, 589, 590 treatment principle, 588, 589
Western view, 591 excessive exercise after, 85 Flooding and Trickling, 320 frequent, 87 bleeding between periods, 285–286 early periods, 202 irregular periods, 226 late periods, 211 long periods, 249 menopause, 737 scanty periods, 239 haemorrhage abdominal pain, 601 Persistent Lochial Discharge, 607 post-natal depression, 594 hygiene rules, 94–95 interrogation, 103 painful periods, 256 as pathogenic factor, 87–88 prolapse of uterus, 835 rest after, 590–591 Chinese disease-symptoms/-patterns cross-reference with Western diseases, 1031–1032 diagnosis, 97–98, 98f and Western diseases, 125–127 Chinese diseases, multiple, 126–127 Chinese dynasties, 1035 Chinese medicine in midwifery, 555–585 and Western concepts, 97, 102 with Western diagnosis, 98, 109 Chlamydia trachomatis, 826
climacteric, 45–46 climacteric syndrome See menopause/menopausal syndrome clinical trials see under specific conditions and treatments clomifene citrate (Clomid), 16–17, 895 coelomic metaplasia, 850 Cold collapse after childbirth, 673 complexion, 110 Empty and Full conditions, 926, 926f endometriosis, 859 external, invasion of, 84, 85 abdominal pain after childbirth, 601 endometriosis, 858 infertility, 686, 687–688, 689 late periods, 211 myomas, 924–925 painful periods, 256 Persistent Lochial Discharge, 607 invading Lower Burner, 255 lip colour, 111 as pathogenic factor, 79 retained placenta, 566 scanty periods, 239 scattering, 138–139 stagnation, 99 painful periods, 257, 264–266 tongue, 114, 115 Cold and Blood stasis myomas, 930 retained placenta, 574 Cold and Damp, exposure to, 211
Cold and Hot symptoms See Hot and Cold symptoms Cold and Yang deficiency, 326 Cold-Dampness, 103 Exterior, 103 infertility, 689 cold foods/drinks, 83 Cold in limbs, 56, 108 Cold in Uterus, 56, 65, 108 constipation, 101 diet, 83 Empty-Cold, 213 endometriosis, 875–877 Full-Cold, 213 infertility, 701–702 Cold retention, 844–845 Cold stagnation, 109 endometriosis, 865–866, 865f Cold stagnation and Blood stasis, 613–614 collapse after childbirth, 673–677 aetiology/pathology, 673–674 Flaccid Syndrome, 673, 674–675 pattern identification/treatment Blood stasis, 675–676 Qi collapse with Blood deficiency, 674–675 prognosis/prevention, 676–677 Tense Syndrome, 673, 675–676 Western view, 677 complexion, 109–110
conception, 43–44 factors, 43, 43f Connecting (Luo) channels, 136 constipation after childbirth aetiology/pathology, 629 pattern identification/treatment Blood deficiency, 629–630 Kidney-Yang deficiency, 630–631 Kidney-Yin deficiency, 631–632 prognosis/prevention, 632 Western view, 632 and menstrual cycle, 101 during pregnancy, 539–543 aetiology/pathology, 539–540 pattern identification/treatment Blood deficiency, 540 Kidney-Yang deficiency, 541 Kidney-Yin deficiency, 542 Liver-Qi stagnation, 543 prognosis/prevention, 543 contraceptive pill, 94 amenorrhoea, 296 and diagnosis, 98 in endometriosis, 852–853 late periods, 222 pre-menstrual syndrome, 377 scanty periods, 240 side effects, 853 contractions, 579 weak, 676t convulsions after childbirth, 679–682
aetiology/pathology, 679 differential diagnosis, 679–680 pattern identification/treatment Blood- and Yin deficiency with Empty-Wind, 680 toxin invasion, 681 prognosis/prevention, 682 Western view, 682 during pregnancy, 513–517, 677, 680 aetiology/pathology, 513 case history, 517 pattern identification/treatment, 513–516 Empty-Wind, 516 Liver-Wind agitating within, 513–514 Phlegm-Fire harassing upwards, 515 prognosis/prevention, 517 Western view, 517 Corporeal Soul (Po), 43–44, 83 corpus luteum, 14, 15 defects, 720 Western medicine, 15 cough, 525–528 Lung-Qi deficiency, 525–526 Lung-Yin deficiency, 526–527 Phlegm-Heat in Lungs, 527–528 prolapse of uterus, 835 Crohn’s disease, 847 cystitis, 532, 532f cystocele, 839, 839f cysts breast, 789–791, 791t endometriomas (chocolate cysts), 851 ovarian, 801b, 804, 805–807
aetiology/pathology, 805 clinical trials, 887–888 in PCOS, 896
D
Damp and Cold, exposure to, 211 Damp-Heat, 103 bleeding between periods, 287–288 breast distension, pre-menstrual, 382, 389 endometriosis, 866 haemorrhoids, 634–636 male sterility, 734 painful periods, 268 polycystic ovary syndrome, 900–901 pulse, 108 vaginal discharge, 813 excessive, 820–822 Damp-Heat and Blood-Heat, 257 Damp-Heat and Liver-Fire and Toxic-Heat, 842 Damp-Heat in Bladder, 127, 536–537 Painful Urination Syndrome, 165 urinary syndrome, 530–531 Damp-Heat in Liver channel, 59, 60t, 103 polycystic ovary syndrome, 897, 903–904, 912 vaginal itching, 828–829, 833 Damp-Heat in Lower Burner, 103, 115 Damp-Heat in Uterus Flooding and Trickling, 343 polycystic ovary syndrome, 912 Damp-Phlegm, 109 endometriosis, 859 infertility, 714–715
male sterility, 734 myomas, 928 polycystic ovary syndrome, 897 Damp-Phlegm and Kidney-Yang deficiency, 905, 910–911 Damp-Phlegm and Kidney-Yang deficiency with Blood stasis, 905–906 Damp-Phlegm and Kidney-Yin deficiency with Blood stasis, 906 Damp-Phlegm in Lower Burner, 312, 314 Damp-Phlegm in Uterus, 868–869 endometriosis, 877 polycystic ovary syndrome, 899–900 Damp-Phlegm in Uterus with Kidney-Yang deficiency, 715 Damp-Phlegm obstructing Uterus, 297–298 Dampness diet, 83 endometriosis, 859, 866–868, 867f, 873, 874, 875–877 and Girdle Vessel, 72–73 haemorrhoids, 634 infertility, 688, 689, 708b, 715–716 invasion of excessive vaginal discharge, 814–815 Vulvar Sores, 841 menopause, 738 painful periods, 256 as pathogenic factor, 79 polycystic ovary syndrome, 900–901 resolving, 147–148 tongue, 113 urinary retention, 533 Dampness and Kidney-Yang deficiency, 715–716, 907
Dampness and Kidney-Yin deficiency with Blood stasis, 907–908 Dampness and Liver-Blood deficiency, 55 Dampness and Spleen-Blood deficiency, 61t Dampness and Spleen-Qi deficiency, 829–830 Dampness in Lower Burner, 704–707 Dampness in Uterus, 107 Dampness obstructing Uterus, 22 danazol, 855–857 depression, 32, 72, 78, 136, 182, 182f, 600 acupuncture, 189b menopausal, 765–766 and sexual frustration, 91 See also post-natal depression depressive neurosis, 600 dermatitis, 846 diabetes, 894 diagnosis, 97–117 auscultation, 117 Chinese disease-symptoms/-patterns, 97–98, 98f and Western diseases, 125–127 hearing, 117 interrogation, 98–104 observation, 109–116 palpation, 104–109 smelling, 117 Western medicine, 98 diarrhoea after menstruation, 101
at period time, 411–414 aetiology, 411 pathology, 411 pattern identification/treatment, 411–414 Kidney-Yang deficiency, 413–414 Liver-Qi stagnant and invading Spleen, 412–413 Spleen-Qi deficiency, 411–412 prognosis/prevention, 414 diathermy, 857, 895 diet amenorrhoea, 296 after childbirth, 591 inadequate, 83 body aches, 415–416 menopause, 737 irregular, 83, 416, 439 abdominal masses, 794 abdominal pain after childbirth, 601 anxiety during pregnancy, 501 bleeding between periods, 285 breast distension, pre-menstrual, 381–382 breast lumps, 772 constipation during pregnancy, 539–540 convulsions during pregnancy, 513 cough, 525 diarrhoea at period time, 411 dizziness at period time, 445 early periods, 201 endometriosis, 858 excessive vaginal discharge, 814–815 fever at period time, 421–422 Flooding and Trickling, 320 heavy periods, 231 infertility, 686 late periods, 211 long periods, 249
menopause, 737 mouth ulcers, 433 myomas, 926 oedema during pregnancy, 495 pre-menstrual syndrome, 357 scanty periods, 239–240 threatened miscarriage, 478 urinary retention, 533 urinary syndrome, 529 vaginal itching, 827 Vulvar Sores, 841 and menstrual cycle, 95 in pregnancy, 451–452, 453–455 Directing Vessel (Ren Mai), 36–38, 71 and abdomen temperature, 108 acupuncture, 158–162, 171–181, 459 areas of influence, 160, 160t combination of points, 174f in endometriosis, 862 with Governing Vessel, 182, 182f, 183f opening points, 158, 171 breast lumps, 771–772, 772f, 773–774, 774f case histories, 180b course, 37f, 40f deficiency, 110 disharmony with Penetrating Vessel, 449–450, 771–772, 782–783 Emptiness, 110 exhaustion, 109 Flooding and Trickling, 322 and Governing Vessel, 39, 40 herbal treatments, 191, 193–196 Damp-Heat, 195 Damp/stasis, 195–196 deficient/Cold, 194 Empty, 193–196 Empty-Heat, 194–195
Full-Cold, 194 Full-Heat, 195 stagnant Heat, 195 unstable, 194 historical writings, 3 hypothalamus–pituitary–ovarian axis, 17–18, 18f, 40, 41f infertility, 688–689 menstrual cycle, 19, 21 menstruation, 15, 24, 38, 200 ovulation, 15, 22 pathology, 71 polycystic ovary syndrome, 897, 898–899 in pregnancy, 44, 450 pulse, 106 skin eruptions, 440 in threatened miscarriage, 478 disease-patterns, Chinese (bian zheng), 97–98, 98f disease prevention, 94–95 disease-symptoms, Chinese (bian bing), 97–98, 98f, 124–125 cross-reference with Western diseases, 1031–1032 and Western diseases, 125–127 distension (zhang), 53 See also breast distension, pre-menstrual diuretics, 377 dizziness at period time, 445–448 aetiology, 445 pathology, 445 pattern identification/treatment Blood deficiency, 445–446 Kidney- and Liver-Yin deficiency with Liver-Yang rising, 446–447 Phlegm with Spleen-Qi deficiency, 447–448 prognosis/prevention, 448
during pregnancy, 509–512 aetiology/pathology, 509 pattern identification/treatment, 509–511 Liver- and Kidney-Yin deficiency with Liver-Yang rising, 510–511 Liver-Blood deficiency with Liver-Yang rising, 509–510 prognosis/prevention, 512 Spleen deficiency with Liver-Yang rising and Phlegm, 511 Western view, 512 duct ectasia, 790 dysmenorrhia See painful periods
E
ear acupuncture See auricular acupuncture early periods, 201–210 aetiology, 201–202 pathology, 202, 202f pattern identification/treatment, 202 Heart-Fire, 207–208 Kidney-Qi not firm, 204 Kidney-Yin deficiency, 208–209 Liver Blood-Heat, 205–206 Liver-Qi stagnation, 206–207 Liver-Yin deficiency, 208–209 Spleen-Qi deficiency, 202–203 prognosis/prevention, 209–210 eclampsia, 107, 517, 680 imminent, 517 See also pre-eclampsia ectopic pregnancy Chinese medicine, 474–475 pattern identification/treatment Blood stasis, 474–475 Blood stasis and Qi deficiency, 475 Yang, collapse of, 475 Western view, 473–474 eczema, genital, 832 pattern identification/treatment Blood deficient and dry, 833 Damp-Heat in Liver channel, 833 electro-acupuncture clinical trials dysmenorrhoea, 280
infertility, 727 menopause, 758, 760–761 polycystic ovary syndrome, 914, 915–916 in labour, 558–559, 579–580 elimination vs tonification, 122–123 embryology, Chinese, 452–453 emotional problems acupuncture, 182, 760–761 anxiety during pregnancy, 501 breast lumps, 771–772, 788 breast milk flow, 669 Breast Milk not Flowing, 657 and childbirth, 87 convulsions during pregnancy, 513 cough, 525 Fever after Childbirth, 640 and Governing Vessel, 40, 72 joint pain after childbirth, 651 and Penetrating Vessel, 161 post-natal depression, 594 puberty, 80 threatened miscarriage, 478 tongue, 114 urinary syndrome, 529 vaginal itching, 827–828 emotional stress, 255–256 abdominal masses, 794 abdominal pain after childbirth, 601 amenorrhoea, 295–296 body aches, 415–416 breast distension, pre-menstrual, 381–382 case history, 82b constipation during pregnancy, 539–540 diarrhoea at period time, 411
dizziness at period time, 445 early periods, 201 endometriosis, 858 epistaxis/haemoptysis, 429 fever at period time, 421–422 Flooding and Trickling, 320 headaches during menstruation, 395 heavy periods, 231 irregular periods, 225–226 late periods, 211–212 Liver patterns, 79–80 Liver-Qi stagnation, 53, 54 long periods, 249 Lung-Qi stagnation, 64 menopause, 737 menstruation, 32, 61, 80, 80f myomas, 925 oedema during menstruation, 405 oedema during pregnancy, 495 as pathogenic factor, 79–82 pre-menstrual syndrome, 357–358 scanty periods, 239 vaginal discharge, excessive, 814 Vulvar Sores, 841 Emperor Fire, 26–27, 27f, 63 Emptiness, 122 of Blood, 111 Directing Vessel, 110 Penetrating Vessel, 35, 110 Uterus, 105 Empty-Cold, 154, 469, 472 Empty-Cold with Stomach-Qi deficiency, 461–462 Empty-Heat, 56, 108
in Blood-Heat/Cold, 68t clearing, 129, 130, 131 complexion, 110 Flooding and Trickling, 329 Hot and Cold symptoms, 66f tongue, 111, 112 from Yin deficiency, 505–506 Empty-Heat and Heart-Yin deficiency, 62–63 Empty-Heat and Kidney-Yin deficiency, 108, 253–254, 531 Empty-Heat and Kidney-Yin deficiency and Liver-Yin deficiency, 286–287, 423– 425 Empty-Heat and Kidney-Yin/Yang deficiency, 50 Empty-Heat in Heart, 111 Empty-Heat in Liver, 111 Empty-Wind, 516, 680 endometrial cancer, 755, 805 endometrial implants, 857 endometrial polyps, 354 endometriomas (chocolate cysts), 851 endometriosis, 87, 849–888 abdominal masses, 805, 860 case histories, 801b, 876b, 878b Chinese view, 276, 858–862 aetiology, 858–862 pathology, 859 pattern identification/treatment Blood deficiency, 872
Blood stasis, 873, 874, 875–877 Cold in Uterus, 875–877 Cold stagnation, 865–866, 865f combined patterns, 873–877 Damp-Phlegm in Uterus, 868–869, 877 Dampness, 866–868, 867f, 873, 874, 875–877 Kidney-Yang deficiency, 869–870, 870f, 873, 875–877 Kidney-Yin deficiency, 871, 874 Liver-Blood stasis, 862–864, 864f treatment, 861–872 modern literature, 878–882 principles, 860–861 clinical trials, 882–888 in infertility, 725 PCOS, compared with, 897–898 Western view, 275–276, 353, 849–857 aetiology, 849–850 clinical manifestations, 851–852 definition, 849–857 diagnosis, 852 immunologic factors, 850 incidence/prevalence, 849 lymphatic dissemination, 850 pathology, 851 risk factors, 850 treatment, 852–857 surgical, 857 English–Pinyin glossary, 1021–1029 envious breast, 664 epilepsy, 680 epistaxis/haemoptysis, 429–432 aetiology, 429 pathology, 429–430 pattern identification/treatment
Liver-Qi stagnation turning into Fire, 430–431 Lung- and Kidney-Yin deficiency, 431 prognosis/prevention, 432 Essence and fertility, 89 and Minister Fire, 88, 89f and sexual activity, 89–90 Yin/Yang aspects, 27f pathological conditions, 686–687, 687f Uterus, 686–687, 687f exercise See physical work/exercise Extraordinary Vessels acupuncture, 157–168 areas of influence, 160, 160t reasons for choice, 160–162 herbal treatments, 191–193 and internal organs, 43f Li Shi Zhen’s pulses of, 106 and menstruation, 33–43 and Minister Fire, 26f opening points, 158 pathology, 67–74 in PCOS treatment, 898–899 regulating/tonifying, 157 relationships between, 42f treatment, 157–196 according to four pathologies, 192 and Uterus, 35f See also Directing Vessel See also Girdle Vessel See also Governing Vessel See also Penetrating Vessel See also Yin Stepping Vessel Extraordinary Yang organs, 9f
F
Falling Fetus (Duo Tai), 477, 478 Fallopian tube problems, 718, 720–721, 722, 723–724 clinical trials, 728–730 tubal reflux, 850 falls, 478–479, 486–487 fat necrosis, 791 fear, 81 febrile disease See fever fertility and Essence, 89 interrogation, 103 See also infertility fetus calming herbs, 450–451 in close-succession pregnancy, 574–575 diseases, 574–575 Falling Fetus (Duo Tai), 477, 478 fetal growth measurement, 493 Fetus not Growing, 491–493 Western view, 493 Heat, 575 malposition, 562–563, 563f malpresentation, 562, 563f possession, 574–575 Qi rebelling upwards, 519 Qi rebellious, 162–163 Restless Fetus (Tai Dong Bu An), 477, 478 shock, 575
slippery (Hua Tai), 477, 478 Wind-Heat, 575 Wind-Phlegm, 575 fetus education, 453–455 fever febrile disease, 478 Fever after Childbirth, 639–649 aetiology/pathology, 639–640 pattern identification/treatment, 640–648 Blood deficiency, 645–646 Blood stasis, 646–647 external Wind, 643–644 food retention, 648 steaming breast, 647–648 toxins, 640–642 prognosis/prevention, 649 Western view, 649 at period time, 421–427 aetiology, 421–422 pathology, 422 pattern identification/treatment, 422–427 Blood-Heat, 422–423 Blood stasis with Heat, 426 Kidney- and Liver-Yin deficiency with Empty-Heat, 423–425 Qi and Kidney-Yin deficiency and Blood deficiency, 424 prognosis/prevention, 427 steaming breast, 647–648 fibroadenoma, 790, 791t fibrocystic disease, 789–791 fibroids See myomas Field of Elixir, lower (Dan Tian), 7, 8, 89 Fire
epistaxis/haemoptysis, 430–431 painful periods, 269–270 at Qi level, 112 Fire of the Gate of Life See Minister Fire Flaccid Syndrome, 673, 674–675 Flooding and Trickling (Beng Lou), 62, 319–356 aetiology, 320 Blood Empty-Heat, 321 Blood-Heat, 321–324, 329 Blood stasis, 321–322, 329 case histories, 323b, 327b, 333b, 340b Empty conditions, 345b, 347b, 348b, 351b Full conditions, 334b, 340b, 342b clinical trials, 354–355 Directing Vessel (Ren Mai), 322 Empty-Heat, 329 endometriosis treated as, 860 Kidney deficiency, 321 pathology, 321–324, 322t complex conditions, 323–324, 323b pattern identification/treatment, 330 Blood Empty-Heat, 336–337 Blood-Heat, 330–332 Blood stasis, 337–339 Blood stasis and Blood-Heat, 352 complex patterns, 351–352 Damp-Heat in Uterus, 339–343 Empty conditions, 343–350 Full conditions, 330–343 Kidney-Yang deficiency, 346–347 Kidney-Yin deficiency, 349–350 Liver-Qi stagnation turning into Heat, 332–336 Qi and Kidney-Yin deficiency and Blood stasis, 352 Qi and Yin deficiency, 352 Penetrating Vessel (Chong Mai), 322
prognosis/prevention, 353 Qi deficiency, 321 Spleen- and Kidney-Qi deficiency, 329 treatment according to four phases, 329 principles, 324–329, 333, 334–335 astringe, 326 harmonize Blood, 325–326, 328–329 stop bleeding, 328–329 treat cause of bleeding, 325–326, 328 treat Qi, 326, 328 steps, 326–327 vs heavy periods, 232t Western view, 353–354 flushing, 110 See also hot flushes folk remedies for Breast Milk not Flowing, 660, 662, 667 follicle-stimulating hormone (FSH) and acupuncture, 916 follicular phase, 14 in infertility, 722–723, 723f luteal phase, 16, 17 in menopause, 753 in PCOS, 891, 892f follicular phase, 14, 15 Food-Qi, 144 food retention abdominal pain after childbirth, 604–605 Fever after Childbirth, 640, 648 and Phlegm, 796–797 Four Seas, 162 Full-Cold, 154
Full-Heat, 108 in Blood-Heat/Cold, 68t Heart-Fire, 207–208 Liver-Blood Heat, 205–206 stagnant Liver-Qi turning into Fire, 206 tongue, 111 Fullness, 122
G
galactocele, 791 Gall Bladder Muscle channel, 383, 777 Gardnerella vaginalis, 826 Gate of Life (Ming Men), 25, 26–27 Gathering Qi (Zong Qi), 25, 144 gender differences pulse diagnosis, 104 sexual differences, 90f in treatment, 121 genital herpes, 845b genital tract infection, 649 Gestrinone, 886–887 Girdle Vessel (Dai Mai), 40–41 acupuncture, 160, 185–187 areas of influence, 160, 160t case histories, 187b opening point, 158 course, 40–41, 41f deficiency, 73 excess, 73 herbal treatments, 192 pathologies, 41, 72–73 pulse, 106 slackness, 41, 73 glossaries
English–Pinyin, 1021–1029 Pinyin–English, 1011–1019 gonadotropin, 44 gonadotropin releasing hormone (GnRH), 17, 18f gonadotropin releasing hormone (GnRH) agonists, 854–855 types, 856t goserelin, 856t Governing Vessel (Du Mai), 38–40 abdominal branch, 39f acupuncture, 158–162, 181–185 areas of influence, 160, 160t case history, 185b with Directing Vessel, 182, 182f, 183f, 184–185 in endometriosis, 862 opening point, 158 connections, 73f course, 38, 40f and Directing Vessel, 39, 72 genital branch, 38f herbal treatments, 191–193 hypothalamus–pituitary–ovarian axis, 17–18, 18f, 40, 41f menstrual cycle, 15–16, 19, 21, 71–72 menstruation, 39–40 ovulation, 22 mental-emotional problems, 40 pathology, 71–72 polycystic ovary syndrome, 897 treatment, 898–899 secondary channels, 39f greasy food, 83, 737 grief, 64, 79–80 Lungs, 32
in miscarriage, 103 as pathogenic factor, 80 guilt, 81–82 gynecological and systemic manifestations, 124–125 coexistence, 124–125 contradiction, 125 interaction, 125
H
haemoglobin, 44–45 haemoptysis See epistaxis/haemoptysis haemorrhage after childbirth convulsions, 679 Fever after Childbirth, 639 skin eruptions, 439 Western/Chinese treatment principles, 676t during childbirth abdominal pain, 601 collapse, 673 Persistent Lochial Discharge, 607 post-natal depression, 594 Sweating afer Childbirth, 625 dizziness at period time, 445 during labour Breast Milk not Flowing, 657 joint pain after childbirth, 651 pulse in, 105 scanty periods, 239–240 See also bleeding haemorrhoids, 632–633 external, 635–636 internal, 633–635 pattern identification/treatment, 633 Half Labour (Ban Chan), 477, 478 headaches after hysterectomy, 94 during menstruation, 101, 395–403 aetiology, 395
case histories, 397b, 400b, 401b pathology, 395–396 pattern identification/treatment, 396–402 Blood deficiency, 396 Blood stasis, 401–402 Liver-Fire blazing, 398 Liver-Yang rising, 398–399 prognosis/prevention, 402–403 pre-menstrual, 101 Heart, 31–32 Governing Vessel connections, 73f in menstrual cycle, 19, 19f menstruation, 31–32 not harmonized with Kidneys, 748 pathology, 61–64, 64f treatment, 149–152 physiology, 9, 9f tongue, 114 Uterus, connection to, 61 Heart-Blood descending, 12 menstrual cycle, 9 nourishing, 61 stasis, 64 Heart-Blood deficiency, 62, 63, 103, 108 anxiety during pregnancy, 501–502 complexion, 110 due to Liver-Blood deficiency, 56 and menstruation, 32 post-natal depression, 595 treatment, 149–150 Heart-Blood deficiency and Spleen-Blood deficiency, 308–309 Heart-Blood Heat, 32, 63
treatment, 152 Heart-Blood stasis, 32, 598–599 treatment, 151 Heart channel, 31, 32, 61 Fire in, 62 Heart Empty-Heat, 71, 111 Heart-Fire, 62 early periods, 207–208 menstrual cycle, 101 morning sickness, 467–468 mouth ulcers, 433–434 tongue, 111, 113–114 treatment, 151 urinary syndrome, 529–530 Heart-Heat haemorrhoids, internal, 634–635 Hot and Cold symptoms, 65f pre-menstrual syndrome, 365 tongue, 114 Heart Muscle channel, 383, 777 Heart-Qi descending, 12, 20 menstrual cycle, 9, 22, 62 rebelling upwards, 63 rebellious, 153 Heart-Qi deficiency, 63 morning sickness, 467 Heart-Qi stagnation, 62 breast distension, pre-menstrual, 382, 387–388 breast lumps, 771
Heart-Qi stagnation and Lung-Qi stagnation, 502 Heart-Yang in menstruation, 11 Heart-Yin deficiency post-natal depression, 597–598 treatment, 150 Heart-Yin deficiency and Kidney-Yin deficiency, 307 Heart-Yin deficiency and Kidney-Yin deficiency with Empty-Heat, 434–435 Heart-Yin deficiency with Empty-Heat, 62–63 Heat clearing, 139 external heat, 201 heavy periods, 231 painful periods, 257 at Nutritive-Qi/Blood level, 112 as pathogenic factor, 79 in pregnancy, 44 at Qi level, 111 and red tongue, 111, 112 tongue coating, 115 Heat and Blood stasis, 426 Heat and Cold See Hot and Cold symptoms Heavenly Gui (Tian Gui) crystal analigy, 27–28 formation, 24 historical writings, 3 meaning of term, 11 menstruation, 24, 25 and Minister Fire, 26 physiology, 7, 9, 10–11, 11f
Heavy Periods (Yue Jing Guo Duo), 231–237 aetiology, 231 case history, 236b endometriosis treated as, 860 pathology, 232 pattern identification/treatment, 232–235 Blood-Heat, 233–234 Blood stasis, 235 Qi deficiency, 232–233 prognosis/prevention, 237 vs Flooding and Trickling, 232t herbs Ai Ye, 138, 154, 192, 326, 861 Ba Ji Tian, 127, 192, 692 Bai Hua She She Cao, 787 Bai Ji Li, 143 Bai Shao, 4, 29, 132, 144, 192, 326, 717 Bai Zhu, 5, 132, 144, 787, 902 Bai Zi Ren, 149, 861 Ban Xia, 124, 132, 192, 193 Ban Zhi Lian, 928 Bao Shao, 691–692 Bei Sha Shen, 148 Bie Jia, 191, 787 Bo herbs, 29 Bu Gu Zhi, 691 Cang Zhu, 124, 132, 147, 192 Chai Hu, 29, 132, 138, 140, 326, 692 Chen Pi, 124, 132, 662 Chen Xiang, 153, 191–192, 692–693 Chi Shao, 134–135, 136, 137, 139, 152, 325–326, 693 Chuan Jiao, 191, 694 Chuan Lian Zi, 133, 191–192, 692 Chuan Niu Xi, 20, 124, 134–135, 136, 137 Chuan Shan Jia, 134–135, 136, 137, 662, 787, 928, 929 Chuan Xiong, 4, 134–135, 136, 137, 138, 140, 192
Cong Bai, 140, 191–192 Da Fu Pi, 133, 153 Da Huang, 112, 138, 139, 142 Dan Dou Chi, 141 Dan Nan Xing, 192, 693 Dan Shen, 20, 134–135, 136, 137, 139, 151, 861 Dang Gui, 4, 29, 124, 132, 144, 149, 191–192, 325, 717, 752 Dang Shen, 132, 144, 692, 787 Deng Xin Cao, 151 Di Bie Chong, 134–135, 137 Di Gu Pi, 129 Di Long, 692 Di Yu, 326 Ding Xian, 154 Dong Gua Ren, 139–140 Dong Kui Zi, 140 Du Zhong, 127, 192, 322, 326 E Jiao, 191, 325 E Zhu, 132, 134–135, 693, 860, 928 Fang Feng, 4, 127, 192 Fang Ji, 192 Fo Shou, 133 Fu Ling, 124, 139 Fu Pen Zi, 127, 129, 192, 692 Fu Zi, 127–128, 129, 131, 138, 154, 191, 326, 692 Gan Cao, 132, 192, 787 Gan Jiang, 138, 191 Gao Ben, 191 Gou Ji, 192 Gou Qi Zi, 25, 29, 52, 129, 131, 132, 191, 192, 691, 761 Gou Teng, 143, 153 Gua Lou, 192 Gui Ban, 129, 191–192, 193, 322 Gui Zhi, 4, 127–128, 131, 138, 139, 154, 191, 192, 861 Hai Zao, 787, 860 Han Lian Cao, 52, 129, 326 Hong Hua, 132, 134–135, 136, 137, 326, 761
Hong Teng, 692 Huang Bo, 124, 142, 191, 192, 193, 693 Huang Lian, 112, 132, 142, 151, 325 Huang Qi, 132, 138, 144, 146, 192, 326, 692, 787 Huang Qin, 4, 5, 112, 139, 142, 151, 325 Ji Xue Teng, 134–135, 136, 137 Jiang Kan, 787 Jie Geng, 138 Jin Yin Hua, 787 Ju Hua, 143, 153, 787 Ju Luo, 775, 775f Kun Bu, 761, 787 Lian Zi Xin, 151 Liu Ji Nu, 693 Long Chi, 153 Long Dan Cao, 112, 142 Long Gu, 129, 153, 192 Long Ran You, 132 Lu Gen, 141, 153 Lu Jiao, 191, 691, 692 Lu Jiao Jiao, 52, 691 Lu Jiao Shuang, 191, 192, 691 Lu Lu Tong, 134–135, 136, 137, 692, 911 Lu Rong, 129, 131, 191, 691 Ma Bian Cao, 692 Ma Huang, 127, 192 Mai Men Dong, 4, 148, 150 Mai Ya, 667 Mang Xiao, 139, 667 Mei Gui Hua, 133 Meng Chong, 135 Mo Yao, 134–135, 137, 693 Mu Dan Pi, 129, 132, 134–135, 136, 139, 152, 325–326 Mu Li, 129, 326, 333, 787 Mu Tong, 140 Mu Xiang, 132, 133 Niu Xi, 132, 138
Nu Zhen Zi, 52, 129, 326 Pao Jiang, 138 Pu Gong Ying, 662, 692, 787 Pu Huang, 23, 134–135, 136, 325, 326, 693 Qian Cao Gen, 23, 135, 136, 325, 326, 333 Qian Hu, 153 Qian Shi, 192 Qiang Huo, 127 Qin Jiao, 129 Qing Hao, 129, 326 Qing Pi, 133, 191–192, 787 Ren Shen, 144, 148, 326, 752 Rou Cong Rong, 692 Rou Gui, 127–128, 129, 131, 138, 154, 191, 692 Ru Xiang, 134–135, 136, 693 San Leng, 134–135, 136, 137, 693, 860, 928 San Qi, 23, 134–135, 136, 325, 326, 693 Sang Ji Sheng, 132, 192, 693 Sang Piao Xiao, 192 Sang Shen Zi, 761 Sha Ren, 137, 147, 148 Shan Ci Gu, 928 Shan Yao, 144, 192, 692 Shan Zha, 667, 761 Shan Zhi Zi, 141, 325 Shan Zhu Yu, 25, 129, 326, 692 Sheng Di Huang, 25, 29, 129, 139, 191, 325–326, 717 Sheng Ma, 132, 192, 326, 763 Shi Chang Pu, 192, 693 Shi Gao, 111, 325 Shi Hu, 148 Shi Jian Chuan, 693, 928 Shi Jue Ming, 153 Shu Di Huang, 4, 25, 29, 129, 132, 325–326, 691–692 Shu Mi, 192 Shui Zhi, 135 Si Gua Luo, 134–135, 136, 137, 693, 775f
Si Wu Tang, 132 Su Mu, 134–135, 136, 137 Su Zi, 153 Suan Zao Ren, 129, 149, 192, 861 Suo Yang, 127 Tai Zi Shen, 148 Tan Xiang, 137 Tao Ren, 132, 134–135, 136–137, 138, 139, 191–192, 326 Tian Ma, 143, 153 Tian Men Dong, 129, 150 Tong Cao, 660 Tu Bie Chong, 134–135 Tu Fu Ling, 787 Tu Si Zi, 52, 124, 127, 131, 691 Wang Bu Liu Xing, 134–135, 136, 137, 662, 692, 787 Wu Ling Zhi, 134–135, 136, 137 Wu Mei, 133 Wu Wei Zi, 129, 131, 192 Wu Yao, 133, 137 Wu Zhu Yu, 138, 153, 191–192 Xi Xin, 191, 694 Xi Yang Shen, 148 Xia Ku Cao, 142 Xian Mao, 129, 692 Xiang Fu, 124, 132, 133, 137, 191–192 Xiao Hui Xiang, 138, 191–192, 692–693 Xu Duan, 127, 192, 322, 323, 326, 861 Xuan Fu Hua, 153 Xuan Shen, 129, 191 Xue Jie, 693 Yan Hu Suo, 132, 134–135, 136, 137, 191–192, 692 Yang Jing, 316 Yi Mu Cao, 134–135, 136, 137, 140, 326 Yi Yi Ren, 124, 139–140, 667, 787, 860 Yi Zhi Ren, 691 Yin Yang Huo, 52, 127, 692 Yu Jin, 134–135, 136, 137, 191–192
Yuan Zhi, 192 Ze Lan, 20, 124, 134–135, 136, 137, 140, 928 Ze Xie, 129 Zhe Bei Mu, 787, 860, 928 Zhen Zhu Mu, 153 Zhen Zu Mu, 143 Zhi Gan Cao, 192, 326, 787 Zhi Ke, 133, 137, 138 Zhi Mu, 129, 191, 192, 193, 693 Zhi Shi, 133, 153 Zhu Ru, 153 Zhu Ye, 111, 141, 151 Zi Cao, 787 Zi He Che, 131, 191, 691, 692 Zi Shi Ying, 692 Zi Su Geng, 153 Zi Su Ye, 153 herbal treatments, 269–270, 338–339, 530–531, 699 abdominal masses, 795–796, 797, 798, 799–800, 802–803 case histories, 801–802 ovarian cysts, 806–807 abdominal pain after childbirth, 602–603, 604, 605 in pregnancy, 470–471, 472 amenorrhoea clinical trials, 316–317 Empty conditions, 299–301, 302, 303–305, 306–307, 308–309 Full conditions, 309–311, 312, 313, 314 ancient prescriptions, 825 anxiety during pregnancy, 502, 503, 504, 505–507 aphonia, 523–524 Blood invigorating, 134–135 classification, 135–140 body aches, 416–417, 418–419 Breast Carbuncle, 665–667 breast distension, pre-menstrual, 384–389, 390, 391–393
breast lumps, 774, 775, 778–780, 781–782, 783, 784, 785, 786, 787, 788 breast milk flow, 670, 671 Breast Milk not Flowing, 659–660, 661–663 external treatment, 662 breech presentation, 573 cervical intra-epithelial neoplasia, 809–810 collapse after childbirth, 674–676 constipation after childbirth, 630, 631, 632 during pregnancy, 540, 541, 542, 543 convulsions after childbirth, 680, 681 during pregnancy, 514, 515, 516, 517 cough, 526–528 diarrhoea at period time, 412, 413–414 Directing Vessel, 191, 193 dizziness at period time, 446, 447, 448 during pregnancy, 510–511 ectopic pregnancy, 475 endometriosis, 860, 861, 863–864, 865–866, 867–868, 869, 870, 871, 872, 876 case histories, 801–802, 877, 878 clinical trials, 884–888 combined patterns, 873, 874, 875, 877 epistaxis/haemoptysis, 430–431 Extraordinary Vessels, 157, 191–193 fetus calming, 450–451 Fetus not Growing, 491–493 fever after childbirth, 641–642, 644, 645–648 at period time, 422–423, 424, 425, 426 Flooding and Trickling, 322, 325–326, 327, 336–337 case history, 323, 327b clinical trials, 354–355 Empty conditions, 344–345, 346, 347, 348, 349–350 Full conditions, 331–332, 333, 334, 335, 336, 341, 343
Girdle Vessel, 192 Governing Vessel, 191–193 haemorrhoids external, 635–636 internal, 633, 634, 635 headaches during menstruation, 396, 397, 398, 399, 400, 401, 402 infertility clinical trials, 726–727, 728–733 Combined patterns, 715, 716 Empty conditions, 694–696, 698 case histories, 696, 697, 700, 701 Full conditions, 701–702, 705–707, 709, 710–713, 715 case histories, 703, 704, 708 herb combinations, 691–693 nourishing Kidney Essence, 691 Japanese, 281–282, 284, 317, 921–922 See also prescriptions See also Dang Gui Shao Yao San See also prescriptions See also Wen Jing Tang joint pain after childbirth, 652–654, 655 Korean, 281–284 labour clinical trials, 583–584 difficult labour, 571–572 lochia Persistent Lochial Discharge, 608–609, 610, 611 retention of lochia, 613, 614 menopause, 738, 739–740, 741, 742–743, 744, 745, 746–747, 748, 749, 750–751 clinical trials, 761–766 miscarriage habitual, 546–547, 548, 549, 550–551, 552 threatened, 480, 481–482, 483–485, 486–487 morning sickness, 460, 461–462, 463, 464, 465, 466, 467, 468 mouth ulcers, 434–436, 442–443 myomas, 276, 928–929, 930, 931, 932 clinical trials, 933–934, 934t oedema during menstruation, 406, 407, 408–409
during pregnancy, 496–499 ovarian cysts, 887–888 ‘penetrating downwards’, 861 Penetrating Vessel, 191–192, 193 periods bleeding between, 287, 288–291 early, 203, 204, 205–206, 208–209 heavy, 232–233, 234, 235, 237 irregular, 226–227, 228, 229–230 late, 212–213, 214, 215, 217–221 long, 250, 251–254 painful, 268, 271–272 clinical trials, 281–284 Empty-Cold, 264–266 Empty conditions, 270–271, 273, 274 Full-Cold, 266 Full conditions, 259–260, 261–262, 263, 267 scanty, 240–241, 242, 243, 244–245, 246 pharmacological actions, 137 polycystic ovary syndrome, 898, 900, 901, 902–904, 905, 906, 907–908 case histories, 911, 912, 913–914 clinical trials, 914–915, 916–922 modern literature, 909, 910 post-natal depression, 595, 596–598, 599 pre-menstrual syndrome, 371 Empty conditions, 369–370, 371, 372, 373, 374–376 Full conditions, 359–360, 361, 362, 363–364, 365, 366–367, 368–369 prescription formulae, 935–1008 prolapse of uterus, 836, 837 retained placenta, 573–574 Shakuyakukanzoto, 284, 921–922 See also prescriptions See also Shao Yao Gan Cao Tang skin eruptions, 441–442 substitutions for herbs, 1009–1010 suffocation, feeling of, 520, 521 Sweating afer Childbirth, 626–628 target areas/organs, 137, 137f
Tokishakuyakusan, 284, 317, 732–733 See also prescriptions See also Dang Gui Shao Yao San Trichomonas vaginalis, 832 Unkeito, 921 See also prescriptions See also Wen Jing Tang urinary problems after childbirth, 616–617, 618, 619, 620, 621, 622–623 retention during pregnancy, 534, 535, 536–537 urinary syndrome, 530, 531 vaginal discharge, excessive, 816, 817–818, 819, 820–821, 822–823, 824 external treatment, 821–822, 823 vaginal itching, 828–829, 830, 831 Candida albicans, 832 eczema, genital, 833, 834 external treatment, 829, 832, 834 Trichomonas vaginalis, 832 Vulvar Sores, 842, 844–845 Yang Linking Vessel, 192, 193 Yang Stepping Vessel, 192 Yin Linking Vessel, 192, 193 Yin Stepping Vessel, 192 See also prescriptions herpes, genital, 845b Herpes simplex, 846–847 hirsutism, 890–891, 896 treatment, 895 history, 3–6 acupuncture in labour, 559–561 Hollow pulse, 108 hormones and Directing Vessel, 180 and Extraordinary Vessels, 34–35 hormone replacement therapy (HRT), 753–755 clinical trials, 755, 759, 760, 763, 765–767
hormone therapy, 925t Hot and Cold symptoms contradictory, 65–66, 65f, 67, 161 Qi, rebellious, of Penetrating Vessel, 66f, 67, 68–70 Qi stagnation, 66f simultaneous, 50, 51 Hot and Cold syndromes, 65 hot flushes, 753 acupuncture, 169b, 757–760 hot foods, 83 hygiene rules, 94–95 in pregnancy, 453–455 hyperthyroidism, 725 hypothalamus–pituitary–ovarian axis, 17–18, 17f disruption, 891 Governing and Directing Vessels, 40, 41f in infertility, 722–723, 722f hypothalamus–pituitary–testis axis, 18, 19f hypothyroidism, 725 hysterectomy, 93–94, 925t
I
illness, chronic body aches, 415–416 dizziness at period time, 445 early periods, 202 fever at period time, 421–422 late periods, 211–212 painful periods, 256 prolapse of uterus, 835 scanty periods, 239–240 skin eruptions, 439 threatened miscarriage, 478 infection Fever after Childbirth, 649 lochial discharge, 612 pulse, 108 urinary tract, 532, 532f, 649 vaginal discharge, excessive, 825, 826 vulval sores, 846–847 infertility, 685–734 acupuncture, 188b aetiology, 685–686, 688f anovulation, 720 case histories Blood deficiency, 696b, 700b Blood stasis, 713b Cold in Uterus, 703b Dampness, 708b Kidney-Yang deficiency, 696b, 697b Qi deficiency, 700b clinical trials acupuncture, 725–728
endocrine failure, 726 Fallopian tube problems, 728–730 herbal treatments, 726–727, 728–733, 885 hypoestrogenemia, 730 immune infertility, 729, 730–732 luteal insufficiency, 732–733 oviduct obstruction, 732 ovulatory failure, 725–726, 727, 728–733 Combined patterns, 690–691, 715 corpus luteum defects, 720 Empty conditions, 686–688, 688f, 690–699 Fallopian tube problems, 718, 720–721, 722 Full conditions, 686–688, 688f, 690, 701–715 male sterility, 733–734 and myomas, 924 ovulatory failure, 722–723, 725–726 modern literature, 908–909, 910 pathology, 686–689 pattern identification/treatment, 689–693 Blood deficiency, 699 Blood-Heat, 708–709 Blood stasis, 689, 712–713 Cold-Dampness, 689 Cold in Uterus, 701–702 Combined patterns, 715–716 Damp-Phlegm, 714–715 Dampness in Lower Burner, 704–707 Empty conditions, 693–699 Full conditions, 701–715 Kidney-Yang deficiency, 689, 693–696 with Blood stasis, 716 with Blood stasis and Dampness, 716 with Damp-Phlegm in Uterus, 715 with Dampness, 715–716 Kidney-Yin deficiency, 689, 697–698 Kidney-Yin deficiency with Empty-Heat, 689 Liver- and Kidney-Yin deficiency, 689
Liver-Qi stagnation, 689 Phlegm, 689 Qi stagnation, 709–712 Spleen- and Kidney-Yang deficiency, 689 and PCOS, 894–895 physiology, 9 prognosis/prevention, 721–722 treatment by four phases, 689–690 underdeveloped uterus, 720 Western view, 689, 722–725 insomnia, 101, 765 insulin, 894 internal organs interrelationship, 43f and menstruation, 34f pathology, 49–64, 64f treatment, 127–152, 160 See also specific organs interrogation, 98–104 abdominal pain, 102 childbirth, 103 fertility/infertility, 103 menstruation, 98–101 miscarriage/abortion, 103–104 pregnancy, 103 vaginal discharge, 102 intra-uterine devices (IUDs) age of onset, 98 in endometriosis, 850, 854 side effects, 854 irregular periods, 225–230 aetiology, 225–226 pathology, 226
pattern identification/treatment, 226–230 Kidney-Yang deficiency, 227–228 Kidney-Yin deficiency, 228–230 Liver-Qi stagnation, 226–227 prognosis/prevention, 230 isoflavones, 752, 753
J
Japanese herbal medicine, 281–282, 317 Shakuyakukanzoto, 284, 921–922 Tokishakuyakusan, 284 See also prescriptions See also Dang Gui Shao Yao San Unkeito, 921 See also prescriptions See also Wen Jing Tang Japanese-style acupuncture, 882–883 jealous breast, 664 joint pain after childbirth, 651–656 aetiology, 651 pathology, 651–652 pattern identification/treatment, 652–655 Blood deficiency, 652–653 Blood stasis, 654 Liver-Blood and Kidney-Yang deficiency, 655 Wind invasion, 653–654 prognosis/prevention, 656
K
kampo medicine, 281–282, 317 Kidney(s), 24–28 Governing Vessel connections, 73f hereditary weakness, 211 historical writings, 5 in menstrual cycle, 19, 19f menstruation, 15 not harmonized with Heart, 748 nourishing, 71 pathology, 49–52, 64f treatment, 127–131 physiology, 9, 9f tonifying, 24, 28, 29, 78, 199 clinical trial, 733 Kidney channel acupuncture, 459 Kidney deficiency, 22, 49–52, 109 abdomen in, 109 endometriosis, 859 Flooding and Trickling, 321, 326 infertility, 686 menstrual cycle, 99, 101 miscarriage, 104 painful periods, 257 polycystic ovary syndrome, 897, 912 pulse, 105 after surgery, 93 threatened miscarriage, 480 urinary retention after delivery, 567 Kidney deficiency and Blood deficiency with Qi stagnation, 521
Kidney deficiency and Liver deficiency, 296–300 Kidney divergent channel, 40–41 Kidney-Essence, 25 menopause, 737 menstruation, 9 nourishing, 130–131 herbs, 691, 691t Kidney-Fire, 27 Kidney-Qi early periods, 201 in menorrhagia, 31 not firm, 204 in pregnancy, 44 sinking, 31, 31f, 82 Kidney-Qi deficiency, 535, 618 Kidney-Qi deficiency and Spleen-Qi deficiency, 329 Kidney-Qi sinking, 535 Kidney-Water in menstrual blood, 27–28 Kidney-Yang menstrual cycle, 12, 15–16, 17, 19 tonifying, 127–128 moxa, 128, 129 tonifying strongly and stoking up Fire of Gate of Life, 128–129 Kidney-Yang deficiency, 56, 65f, 72 ankles, swollen, 108 with Blood stasis, 716 constipation after childbirth, 630–631 constipation during pregnancy, 541 and Damp-Heat in Bladder, 127
and Damp-Phlegm, 905, 910–911 with Damp-Phlegm in Uterus, 715 and Damp-Phlegm with Blood stasis, 905–906 with Dampness, 715–716 and Dampness with Blood stasis, 907–908 diarrhoea at period time, 413–414 endometriosis, 869–870, 870f, 873, 875–877 Flooding and Trickling, 346–347 habitual miscarriage, 546–547 infertility, 689, 693–696, 715–716 irregular periods, 227–228 late periods, 217–219 and Liver-Blood deficiency, 655 male sterility, 734 menopause, 737, 740–741, 744 menstrual cycle, 101 oedema during pregnancy, 497–498 polycystic ovary syndrome, 913 scanty periods, 241–242 vaginal discharge, 103 vaginal discharge, excessive, 817–818 water retention, 101 Kidney-Yang deficiency and Kidney-Yin deficiency See Kidney-Yin deficiency and Kidney-Yang deficiency Kidney-Yang deficiency and Spleen-Yang deficiency, 290–291 amenorrhoea, 303–304 Fetus not Growing, 492–493 infertility, 689 oedema during menstruation, 405–406 polycystic ovary syndrome, 901–902 pre-menstrual syndrome, 373 Kidney-Yin menstrual cycle, 17, 19, 21 menstruation, 11, 12, 25 ovulation, 15, 21
nourishing, 129–130 Kidney-Yin and Kidney-Yang, tonifying, 131 Kidney-Yin deficiency, 71 aphonia, 523–524 complexion, 110 constipation after childbirth, 631–632 constipation during pregnancy, 542 endometriosis, 871, 874 Flooding and Trickling, 349–350 habitual miscarriage, 548–549 infertility, 689, 697–698 irregular periods, 228–230 menopause, 737, 738–740, 745, 751 scanty periods, 243 vaginal discharge, excessive, 818–819 Kidney-Yin deficiency and Bladder-Heat, 621–622 Kidney-Yin deficiency and Empty-Heat, 108, 115, 208–209 infertility, 689 long periods, 253–254 urinary syndrome, 531 Kidney-Yin deficiency and Heart-Yin deficiency, 307 Kidney-Yin deficiency and Heart-Yin deficiency and Empty-Heat, 434–435 Kidney-Yin deficiency and Kidney-Yang deficiency, 27, 27f, 49–52, 51f, 52t age, 50 diagnosis, 116 Hot and Cold symptoms, 51, 51f interdependency, 52 menopause, 737–738, 741–743, 747 oil lamp analogy, 50, 50f predominance Yang, 50f, 52t predominance Yin, 50f, 52t tongue, 116
treatment, 131 Kidney-Yin deficiency and Liver-Blood deficiency, 56 Kidney-Yin deficiency and Liver-Yin deficiency amenorrhoea, 304–305 breast distension, pre-menstrual, 382, 392–393 breast lumps, 786–787 infertility, 689 with Liver-Yang rising, 745–747 menopause, 745–747 painful periods, 273 pre-menstrual syndrome, 371–372 vaginal itching, 830–831 Kidney-Yin deficiency and Liver-Yin deficiency with Empty-Heat, 423–425 Kidney-Yin deficiency and Liver-Yin deficiency with Liver-Yang rising, 446–447, 510–511 Kidney-Yin deficiency and Lung-Yin deficiency, 431 Klebsiella (Calymmatobacterium) granulomatis, 847 knees, 136 Korean herbal medicine, 281–284
L
labour acupressure, 561–562 acupuncture, 557–564 analgesia, 558–559, 578–580, 581, 583 difficult labour, 562–564 history, 559–561 induction, 558, 568b, 577–578 testimonials, 569b, 570b case histories, 568b clinical trials acupuncture, 575–583 herbal treatments, 583–584 delayed labour, 559 difficult Qi and Blood deficiency, 564, 571–572 Qi and Blood stagnation, 564–565, 572 duration, 583 Half Labour (Ban Chan), 477, 478 herbal treatments difficult labour, 571–572 long/excessive strain during breast milk flow, 669 Breast Milk not Flowing, 657 Persistent Lochial Discharge, 607 Sweating afer Childbirth, 625 urinary problems, 615 physiology, 557–564 pulses in, 108 Small Labour (Xiao Chan), 477, 478 laparoscopic ovarian diathermy, 895 laser acupuncture point stimulation, 576
late periods aetiology, 211–212 case histories, 214b, 219b pathology, 212 pattern identification/treatment, 211–223 Blood deficiency, 212–213 Cold in the Uterus, 213–216 Kidney-Yang deficiency, 217–219 Liver-Qi stagnation, 220–221 prognosis/prevention, 222 leucorrhoea, 72–73, 103 pulse, 106 leukoderma, 846 leuprorelin/leuprolide, 856t lifting, 95, 495, 533 limbs, palpation of, 108 lipomas, 790 lips, 111 Liver, 28–30 harmonizing, 199–200 harmonizing with Spleen, 146–147 nourishing, 132–133 pacifying and Blood stasis elimination, 134–140 clearing Liver-Heat, 141 and Qi stagnation elimination, 133–134 pathology, 52–59, 64f in PCOS, 892f tongue in, 111 treatment, 132–143 patterns, overlapping, 53f
sadness, effects of, 80 tonifying, 25, 28 Liver-Blood, 28 and Liver-Qi, 29, 29f and menstrual blood, 29–30, 30f in menstrual cycle, 14, 15–16 nourishing, 29 and Uterus, 29f Liver-Blood deficiency, 29–30, 52, 53, 55–57, 60t complexion in, 110 consequences, 55–57, 55f headaches, 101 menopause, 744 pre-menstrual syndrome, 369–370 symptoms, 55 tongue in diagnosis, 116, 116f Liver-Blood deficiency and Kidney-Yang deficiency, 655 Liver-Blood deficiency with Liver-Yang rising, 116, 117f, 509–510 Liver-Blood Heat, 58, 205–206 Liver-Blood stasis, 56, 57, 60t breast distension, pre-menstrual, 382, 388–389 consequences, 57, 57f endometriosis, 862–864, 864f long periods, 252–253 menstrual cycle, 99 miscarriage, 104 painful periods, 257 symptoms, 57 tongue, 116 Liver channel and breast, 383 Damp-Heat, 59, 60t
Liver deficiency, 103 painful periods, 257 Liver deficiency and Kidney deficiency, 296–300 Liver Empty-Heat, 111 Liver-Fire anxiety during pregnancy, 504 blazing, 101, 398 breast milk flow, 670–671 draining, 142 menstrual cycle, 101 polycystic ovary syndrome, 897, 903–904 tongue, 111, 113–114 Liver-Fire with Damp-Heat and Toxic-Heat, 842 Liver-Heat, 52, 53 clearing by pacifying Liver, 141 pre-menstrual syndrome, 362–363 Liver-Qi and Liver-Blood, 29, 29f in menstrual cycle, 15–16 in menstruation, 29 rebellious, 153 Liver-Qi stagnant and invading Spleen, 412–413 Liver-Qi stagnation, 29, 52, 53–54, 60t, 108 abdominal masses, 795–796 anxiety during pregnancy, 503 breast distension, pre-menstrual, 382 breast lumps, 771, 772, 777–780 Breast Milk not Flowing, 660–663 complexion in, 110 consequences, 53, 53f, 54
constipation during pregnancy, 543 emotional origin, 54 infertility, 688, 689 invading Stomach, 101, 463–464 irregular periods, 226–227 late periods, 220–221 long periods, 252–253 menstrual cycle, 99, 101 overdiagnosis, 54 painful periods, 256, 257 with Phlegm breast lumps, 776t, 788 pre-menstrual syndrome, 363–364 pre-menstrual symptoms, 101 pre-menstrual syndrome, 358–360 primary/secondary, 54, 54t symptoms, 53 tongue, 111, 116 treatment, 56–57, 133 turning into Fire, 206–207 epistaxis/haemoptysis, 430–431 painful periods, 269–270 turning into Heat, 332–336 urinary problems after childbirth, 619–620 vaginal discharge, excessive, 823–824 Liver-Qi stagnation and Heat, 776t, 788 Liver-Qi stagnation turned into Fire, 784 Liver stagnation turning to Heat, 60t Liver-Wind, 59, 60t agitating within, 513–514 extinguishing, 143 tongue, 114 Liver-Yang rising, 52, 53, 55–56, 59, 60t, 101, 116
dizziness at period time, 446–447 headaches during menstruation, 398–399 Liver-Blood deficiency, 509–510 Spleen deficiency and Phlegm, 511 tongue in diagnosis, 116, 116f Liver-Yang subduing, 143 Liver-Yin deficiency and Empty-Heat, 208–209, 286–287 Liver-Yin deficiency and Kidney-Yin deficiency amenorrhoea, 304–305 bleeding between periods, 286–287 breast distension, pre-menstrual, 382, 392–393 breast lumps, 786–787 infertility, 689 menopause, 745–747 painful periods, 273 pre-menstrual syndrome, 371–372 vaginal itching, 830–831 Liver-Yin deficiency and Kidney-Yin deficiency with Empty-Heat, 423–425 Liver-Yin deficiency and Kidney-Yin deficiency with Liver-Yang rising, 446–447, 510–511 lochia Persistent Lochial Discharge aetiology/pathology, 607–608 pattern identification/treatment, 608–612 Blood-Heat, 610–611 Blood stasis, 609–610 Qi deficiency, 608–609 prognosis/prevention, 612 Western view, 612 retention of lochia, 612 long periods, 249–254 aetiology, 249
pathology, 249 pattern identification/treatment, 249–254 Blood-Heat, 251–252 Kidney-Yin deficiency with Empty-Heat, 253–254 Liver-Qi and Liver-Blood stasis, 252–253 Qi deficiency, 249–250 prognosis/prevention, 254 lower back, 136 Lower Burner Damp-Heat, 115 diet, 83 excess patterns, 73 stagnation, 84–85 lumps See abdominal masses See also breast lumps Lung channel, 383 Lung-Qi deficiency, 525–526 Lung-Qi deficiency and Spleen-Qi deficiency, 622–623 Lung-Qi stagnation, 64 breast distension, pre-menstrual, 382, 386–387 breast lumps, 771, 788 worry, effects of, 80 Lung-Qi stagnation and Heart-Qi stagnation, 502 Lung-Qi stagnation and Phlegm, 364 Lung-Yin deficiency, 526–527 Lung-Yin deficiency and Blood deficiency, 306–307 Lung-Yin deficiency and Kidney-Yin deficiency, 431 Lungs, 32
pathology, 64, 64f luteal phase Chinese medicine, 15–16 Western medicine, 15–17 luteinizing hormone (LH) and acupuncture, 916 follicular phase, 14 in infertility, 722–723, 723f luteal phase, 16, 17 ovulation, 15, 21
M
malar flush, 110 male sterility, 733–734 mastitis, 366, 790 acute, 664–665 menarche age of onset, 98 and endometriosis, 850 interrogation, 98–99 physiology, 10 menopause/menopausal syndrome, 45–46 acupuncture, 171 aetiology, 736–737 age of onset, 10, 46, 735 case histories, 744b, 747b clinical trials acupuncture, 755–761 herbal treatments, 761–766 moxibustion, 756–757 Western medicine, 766–767 definition, 45–46 early/premature, 735, 736 nourishing Yin after, 71 pathology, 46f, 737–738 pattern identification/treatment, 738–751 Blood stasis, 750–751 Kidney- and Liver-Yin deficiency with Liver-Yang rising, 745–747 Kidney-Yang deficiency, 740–741 Kidney-Yin deficiency, 738–740 Kidney-Yin and Kidney-Yang deficiency, 741–743 Kidneys and Heart not harmonized, 748
Qi stagnation and Phlegm accumulation, 749 prognosis/prevention, 751–753 pulses in, 106 symptoms, 736, 753 Western view, 753–755 Menoprogen, 761 menorrhagia, 31, 353 Liver-Blood Heat, 58 pulses in, 105, 108 menses retention of, 859 warming, 138–139 menstrual blood, 19, 20 formation, 24, 25, 25f, 55 and Liver-Blood, 29–30, 30f smell in diagnosis, 117 transformation into breast milk, 30, 33f menstrual cycle Chinese medicine, 15–17, 19–23 duration, 10 follicular phase, 14, 15, 16–17, 16t four phases, 12–13, 13f, 14f, 19–23, 255 phase 1 (menstrual), 19–20, 23 phase 2 (post-menstrual), 20–21, 24 phase 3 (ovulation), 21–22, 24 phase 4 (pre-menstrual), 23, 24 in treatment, 122 treatment principles, 23–24 hormonal/endometrial changes, 16f interrogation, 99 Liver-Qi stagnation, 53 luteal phase, 15–17, 16t menstrual phase, 14, 15, 16–17, 16t
problems at period time, 379 Western medicine, 14–17, 16t menstrual irregularities, 197, 198f aetiology/pathology, 197 treatment principles, 198–200 harmonizing Liver, 199–200 harmonizing Qi and Blood, 199 strengthening Spleen, 199 tonifying Kidneys, 199 menstrual pain in diagnosis, 100 Penetrating Vessel, 34 menstruation, 14 Blood invigoration, 136 blood loss, 99, 100 and Blood stasis, 78 and breast cancer, 86 care during, 77 care during/after, 77 emotional stress, 80, 80f excessive exercise, 85 hygiene rules, 94–95 intercourse during, 858 and internal organs, 24–33, 34f interrogation, 98–101 blood loss, 99, 100 cycle details, 99 pain, 100 and ovarian cancer, 87 Penetrating Vessel, 35 physiology, 7, 9, 10–24 pulses in, 108 retrograde, 850 treatments contraindicated, 127 Western medicine, 14
mental-emotional problems See emotional problems metrorrhagia, 353 midwifery, Chinese medicine in, 555–585 Mind-calming herbs, 136–137 Mind Obstructed, 57 Minister Fire (Fire of the Gate of Life), 25, 26–27, 27f at conception, 27f in conception, 43 deficiency, 72 and Essence, 88, 89f exhaustion, 88 and Extraordinary Vessels, 26f and luteal phase, 15–16 ovulation, 21 pathology, 27, 27f, 58, 58f, 59f and sexual activity, 91–92 stoking up, and strongly tonifying Kidney-Yang, 128–129 and Tian Gui, 27–28 Mirena IUD, 854 miscarriage Chinese view, 477, 478, 478f early, 104, 553 excessive childbirth, 88 and Girdle Vessel, 41 habitual (Hua Tai), 477, 478, 545–554 aetiology/pathology, 545 case history, 547b early, 553 mid-term, 554 pattern identification/treatment, 546–552 Blood deficiency, 551 Blood-Heat, 549–550
Blood stasis, 552 Kidney-Yang deficiency, 546–547 Kidney-Yin deficiency, 548–549 Spleen-Qi deficiency, 550–551 prognosis/prevention, 553 Western view, 553–554 historical treatment, 5 inevitable, 477, 488 interrogation, 103–104 pulse diagnosing, 107, 108 threatened, 477–489 aetiology/pathology, 478–479 pattern identification/treatment, 479–487 Blood-Heat, 484–485 falls/traumas, 486–487 Kidney deficiency, 480 Qi and Blood deficiency, 483–484 prognosis/prevention, 487–488 Western view, 488 Western view, 474, 477 See also abortion See also abortion, complete See also abortion, incomplete See also abortion, missed mittleschmertz, 276 morning sickness, 32, 44, 65, 69–70, 457–468 case histories, 462b, 464b, 466b pathology, 457–458 pattern identification/treatment, 460 Heart-Fire, 467–468 Heart-Qi deficiency, 467 Liver-Qi stagnation invading Stomach, 463–464 Phlegm accumulation, 465–466 Stomach-Heat, 465 Stomach-Qi deficiency with Empty-Cold, 461–462 Stomach-Yin deficiency, 462–463 prognosis/prevention, 468 Motive Force (Dong Qi), 25, 26, 105
mouth ulcers, 433–437 aetiology, 433 pathology, 433 pattern identification/treatment Blood-Heat, 442–443 Heart-and Kidney-Yin deficiency with Empty-Heat, 434–435 Heart-Fire, 433–434 Stomach Damp-Heat, 435–436 Stomach Damp-Heat with Spleen deficiency, 436 Stomach-Fire, 435–436 prognosis/prevention, 437, 444 moving downwards, 139, 142 moxibustion breech presentation, 556, 557, 575–577 exclusion criteria, 557 postulated action, 557f cervical intra-epithelial neoplasia (CIN), 809 clinical trials, 575–577, 882–884 endometriosis, 882–884 ginger-partitioned, for painful periods, 277 infertility, 694 menopause, 756–757 modern literature, 910 polycystic ovary syndrome, 910 See also acupuncture, with moxa muscle channels in breasts, 777 myomas (fibroids), 71, 275–276, 340b, 804–805, 923–934 acupuncture, 180b case histories, 801b, 928b Chinese view, 924 aetiology, 924–929 Damp-Phlegm, 928 Full- /Empty-Cold, 926 modern literature, 933 pathology, 926–927, 927f
Root/Manifestation, 926, 927f treatment principles, 927–928, 927f Western diagnostic tests, 927–928, 927b clinical trials, 933–934, 934t complications, 924 in infertility, 724 pattern identification/treatment, 929–932 Blood stasis from Cold, 930 Blood stasis from Qi stagnantion, 929–930 Blood stasis with Kidney-Yang deficiency, 932 Blood stasis with Phlegm, 931 Blood stasis with Qi and Blood deficiency, 931–932 in pregnancy, 924 types, 804, 804f, 923, 924f Western view, 353–354, 923–924 treatment, 925t myomectomy, 925t
N
naferelin, 856t neurological problems, 161 nevi, 846 no periods See amenorrhoea nodules, breast, 770, 790, 791t Nutritive Qi, 642, 643t
O
obesity, 896 observation, 109–116 complexion, 109–110 lips, 111 tongue, 111–116 oedema during menstruation, 405–410 aetiology, 405 case histories, 407b, 408b pathology, 405 pattern identification/treatment, 405–409 Qi stagnation, 408–409 Spleen- and Kidney-Yang deficiency, 405–406 prognosis/prevention, 410 during pregnancy, 495–499 aetiology/pathology, 495 pattern identification/treatment, 495–499 Kidney-Yang deficiency, 497–498 Qi stagnation, 498–499 Spleen-Yang deficiency, 496–497 prognosis/prevention, 499 Western view, 499 oestradiol, 15, 17 oestrogen in menopause, 753 in menstrual cycle, 14, 15, 18 and phytoestrogens, 752 in pregnancy, 44 oestrogen therapy, 753, 754, 765–766
clinical trials, 760 See also hormone replacement therapy oral contraceptives See contraceptive pill orifices, opening, 140 Original Qi (Yuan Qi), 25, 26 deficiency, 65 osteoporosis and HRT, 755 ova, 9, 11 ovarian cancer, 87 ovarian stimulation, 895 ovarian tumour torsion, 474 ovaries in menopause, 46, 735, 736 in PCOS, 892 physiology, 9 polycystic, 894 overwork, 63, 78, 86, 95 amenorrhoea, 296 anxiety during pregnancy, 501 bleeding between periods, 285–286 breast distension, pre-menstrual, 381 breast lumps, 772 constipation during pregnancy, 540 convulsions during pregnancy, 513 cough, 525 diarrhoea at period time, 411 dizziness at period time, 445 dizziness during pregnancy, 509 early periods, 201, 202 epistaxis/haemoptysis, 429
fever at period time, 421 Flooding and Trickling, 320 infertility, 686 irregular periods, 226 late periods, 211 long periods, 249 menopause, 737 mouth ulcers, 433 myomas, 926 painful periods, 256 pre-menstrual syndrome, 358 scanty periods, 239, 240 skin eruptions, 439 suffocation, feeling of, 519 threatened miscarriage, 478–479 urinary syndrome, 529 vaginal discharge, excessive, 814 vaginal itching, 828 ovulation cervical secretions, 22 cervix in, 21–22, 22f Directing Vessel, 15, 22 failure, 722–723 clinical trials, 725–726, 727, 728–733 modern literature, 908–909, 910 See also anovulation Governing Vessel, 22 Kidney-Yin, 15, 21 luteinizing hormone in, 15, 21 Minister Fire, 21 Penetrating Vessel, 15, 22 Western medicine, 15 See also under menstrual cycle, four phases
P
pain See abdominal pain See also menstrual pain Painful Periods (dysmenorrhia), 255–284 acupuncture, 169b aetiology, 255–256 case histories Empty conditions, 274b Full conditions, 260b, 262b, 266b clinical trials, 276–284 acupressure by seed-pressure, 276–277, 279–280 acupuncture, 276–281 herbal treatments, 281–284, 884–885 diagnosis, 257–258, 260 Empty conditions, 258, 270–274 endometriosis treated as, 860 Full conditions, 258, 259–270 Liver-Blood stasis, 57 pattern identification/treatment, 259 Blood stasis, 261–262 Cold stagnation, 264–266 Damp-Heat, 268 Kidney- and Liver-Yin deficiency, 273 Qi and Blood deficiency, 270–271 Qi stagnation, 259–260 Stagnant Liver-Qi turning into Fire, 269–270 Yang and Blood deficiency, 271–272 prognosis/prevention, 274–275 tongue, 112 treatment principles, 258–259 Western view, 275–276 Painful Urination Syndrome, 165 palpation, 104–109
abdomen, 108–109 pulses, 104–108 skin, 108 pancreas pathology in PCOS, 892f papilloma, 790 parasites, 841–842 pathogenic factors abdominal masses, 794 elimination vs tonification, 122–123 expulsion, 23 external, 78–79 PCOS See polycystic ovary syndrome Penetrating Vessel (Chong Mai), 33–35, 162f and abdomen temperature, 108 acupuncture, 158–159, 160, 162–168, 459 areas of influence, 160, 160t case histories, 169b, 170b in endometriosis, 861–862, 862f opening points, 158, 162, 163f and breast, 383 breast lumps, 772, 772f, 773–774, 774f, 776–777 breast milk formation, 33f connecting Stomach and Uterus, 64, 69–70 course, 32, 34, 36f disharmony, 519 with Directing Vessel, 449–450, 771–772, 782–783 Emptiness, 35, 110, 162 energetic sphere, 37f exhaustion, 103 Flooding and Trickling, 322 herbal treatments, 191–192, 193–196 Damp-Heat, 195
Damp/stasis, 195–196 deficient/Cold, 194 Empty, 193–196 Empty-Heat, 194–195 Full-Cold, 194 Full-Heat, 195 stagnant Heat, 195 unstable, 194 historical writings, 3 infertility, 688–689 menstrual cycle, 15–16, 19, 21, 70 menstruation, 14, 24, 200 ovulation, 15, 22 pre-menstrual phase, 23 treatment of irregularities, 23 pathology, 67–70, 168 polycystic ovary syndrome, 896, 897 treatment, 898 in pregnancy, 449–450 pulse, 106 Qi rebelling upwards, 153 Qi rebellious, 65–66, 66f, 67, 68–70, 109 skin eruptions, 440 spinal branch, 34 in threatened miscarriage, 478 Pericardium muscle channel, 383, 777 Phlegm breast lumps, 776t and food retention, 796–797 infertility, 689 obstructing Uterus, 22 infertility, 688 scanty periods, 245–246 resolving, 139–140 tongue, 113
Phlegm accumulation, 465–466, 749 Phlegm and Blood stasis, 931 Phlegm and Liver-Blood deficiency, 55 Phlegm and Qi stagnation, 101, 382, 390 Phlegm and Spleen deficiency with Liver-Yang rising, 511 Phlegm and Spleen-Qi deficiency, 447–448 Phlegm-Fire harassing the Mind, 506–507 harassing upwards, 365–367, 515 Phlegm-Heat in Lungs, 527–528 Phlegm with Liver-Qi stagnation, 363–364 Phlegm with Lung-Qi stagnation, 364 physical work/exercise after childbirth, 590–591 excessive, 84–85 amenorrhoea, 296 bleeding between periods, 286 body aches, 415–416 case history, 85b diarrhoea at period time, 411 dizziness at period time, 445 dizziness during pregnancy, 509 early periods, 201–202 endometriosis, 858 excessive vaginal discharge, 814–815 fever at period time, 421–422 Flooding and Trickling, 320 headaches during menstruation, 395 heavy periods, 231
infertility, 686 late periods, 211–212 long periods, 249 menstruation, 85 myomas, 926 oedema during menstruation, 405 oedema during pregnancy, 495 prolapse of uterus, 835 scanty periods, 240 threatened miscarriage, 478–479 urinary retention, 533 vaginal itching, 827 inadequate, 85, 540 physiology, 7–47 of labour, 557–564 phytoestrogens, 751–753 pigmentation, 44 Pinyin–English glossary, 1011–1019 placenta, retained, 612, 676t Blood Stasis and Cold, 574 Cold leading to Blood stasis, 566 Qi and Blood deficiency, 573–574 Qi deficiency, 565–566 polycystic ovary syndrome (PCOS), 805, 889–922 anovulatory, 892 case histories, 910b, 911b, 912b, 913b Chinese view, 896–898 clinical manifestations, 896–898 modern literature, 908–910 acupuncture, 908–910 herbal treatments, 909, 910 moxibustion, 910
pattern identification/treatment Blood deficiency, 904 Blood stasis, 902–903 combined patterns, 905–908 Damp-Heat in Uterus and Liver channel, 912 Damp-Phlegm and Kidney-Yang deficiency, 905, 910–911 Damp-Phlegm and Kidney-Yang deficiency with Blood stasis, 905– 906 Damp-Phlegm and Kidney-Yin deficiency with Blood stasis, 906 Damp-Phlegm in Uterus, 899–900, 910–911 Dampness and Kidney-Yang deficiency, 907 Dampness and Kidney-Yin deficiency with Blood stasis, 907–908 Dampness or Damp-Heat, 900–901 Kidney deficiency, 912 Kidney-Yang deficiency, 913 Liver-Fire and Damp-Heat in Liver channel, 903–904 Spleen- and Kidney-Yang deficiency, 901–902 patterns, 897 clinical trials, 914–922 endometriosis, compared with, 897–898 and polycystic ovaries, 894 risks associated, 894 Western view, 889–895 aetiology/pathology, 892–893 clinical manifestations, 893–894, 894f description, 889–895 description/definitions, 889–895 diagnosis, 893 endocrinology, 890–892, 891f symptoms, 889 treatment, 894–895 post-natal depression, 87, 593–600 aetiology, 594 case history, 596b mild, 600 old Chinese conditions, 593–594
pathology, 594–595 pattern identification/treatment Heart-Blood deficiency, 595 Heart-Blood stasis, 598–599 Heart-Yin deficiency, 597–598 prognosis/prevention, 600 Western view, 600 post-natal psychosis, 32, 87, 140 Post-Natal Qi, 28, 144 and breastfeeding, 32 in conception, 43 in menstruation, 11, 25 post-partum conditions and heavy periods, 231 pre-eclampsia, 499, 512 pre-menstrual breast distension See breast distension, pre-menstrual pre-menstrual symptoms, 23 in diagnosis, 101 pre-menstrual syndrome, 65, 357–378 acupuncture, 170b, 187b aetiology, 357–358 case histories, 372b Empty conditions, 370b, 371b, 374b, 375b Full conditions, 360b, 361b, 362b, 367b, 368b Empty conditions, 357–358, 369–376 Full conditions, 357–367 Liver-Qi stagnation, 53 pathology, 358 pattern identification/treatment, 358 Heart-Heat, 365 Liver- and Kidney-Yin deficiency, 371–372 Liver-Blood deficiency, 369–370 Liver-Heat, 362–363
Liver-Qi stagnation, 358–360 Liver-Qi stagnation with Phlegm, 363–364 Lung-Qi stagnation with Phlegm, 364 Phlegm-Fire harassing upwards, 365–367 Spleen- and Kidney-Yang deficiency, 373 prognosis/prevention, 376 Western view, 376–377 treatment, 14, 377 Pre-Natal Qi, 43, 167 pregnancy, 44–45 amenorrhoea, differentiating from, 298, 298t Blood invigoration, 135 and breast cancer, 86 delayed, and endometriosis, 850 diet, 83, 84t excessive, 88 close-succession, 574–575 fetus calming herbs, 450–451 frequent, 87 interrogation, 103 multiple, 107 and ovarian cancer, 87 as pathogenic factor, 86–87 pathological conditions, 450 problems, 107 pulse diagnosing, 107 pulses in, 107 recommendations, 451–452, 453–455 sex of fetus, diagnosis of, 107 stages, 7, 45 pregnancy testing, 451 prescriptions Ai Fu Nuan Gong Wan, 154, 216, 216t, 264–265, 265t, 267, 348, 701, 702t An Chong Tang, 194, 234, 251
An Dian Er Tian Tang, 482 An Tai Yin, 481 An Xin Tang, 598 Ba Wei Di Huang Wan, 56 variation, 531 Ba Wu Tang variation, 408–409 Ba Zhen Tang, 56, 122–123, 132, 144, 241, 301, 491, 670, 699, 802–803, 904 variation, 300–301, 302, 303, 396, 397, 416–417, 446, 645, 701 variations, 144 Ba Zhen Yi Mu Tang, 270–271 variation, 691t, 694 Ba Zheng Tang variation, 288 Bai He Gu Jin Tang, 306–307, 526–527 Bai Zhu San, 496 variation, 511 Bai Zi Ren Wan, 149, 151 Bai Zi Yang Xin Wan, 149, 371 Ban Xia Bai Zhu Tian Ma Tang, 448, 511 Ban Xia Hou Po Tang, 133, 387–388, 464, 502 variation, 386–387, 788 Ban Xia Hu Po Tang variation, 364 Ban Xia Tang, 192 Bao Chan Wu You San, 573 Bao He Wan, 648 Bao Sheng Tang, 462 Bao Sheng Wu You San, 573 Bao Tai An, 483–484 Bao Yin Jian, 195, 251, 338t, 484–485, 549, 611 variation, 234, 251, 336–337, 352 Bi Xie Fen Qing Yin, 830 Bi Xie Shen Shi Tang, 820, 821t, 832 variation, 828 Bu Fei Tang, 526 Bu Gan Tang, 55–56 Bu Gan Yi Shen Tang, 819 Bu Pi An Tai Yin, 492
Bu Qi Gu Jing Wan, 146 Bu Shen Di Huang Tang, 305, 305t, 871 Bu Shen Fang, 350 Bu Shen Gu Chong Wan, 546 Bu Shen Hua Yu Qu Tan, 917–918 Bu Shen Huo Xue, 728–729, 916–917 Bu Shen Tiao Gan Qing Xin, 766 Bu Yang Huan Wu Tang, 138 Bu Zhong Yi Qi Tang, 145, 192, 193, 203, 232–233, 250, 425, 836 variation, 608–609, 616 Cang Fu Dao Tan Wan, 133, 196, 246, 312, 313 variation, 797, 869 Chai Hu Gui Zhi Gan Jiang Tang, 765 Chai Hu Shu Gan Tang, 220, 222t, 359–360, 362, 384, 779, 780t Chan Li Bao, 583–584 Chang Ning Tang, 602 Chen Tong San variation, 418 Chen Xiang San, 620 Cheng Qi Tang, 193 Chiljeh Yangbuh Wan, 281–284 Chuan Shan Jia San, 929 Chun Gen Hong Hua Tang, 635 Cong Rong Tu Si Zi Wan, 218, 218t Cu Huang Ti Tang, 303 Cui Sheng Yin, 572 Da Bu Yin Wan, 191 Da Bu Yuan Jian, 194, 212, 213t, 214–215, 837 Da Huang Bie Chong Wan, 139, 929 Da Huang Mu Dan Tang, 139–140 variation, 641–642, 642t Da Qi Qi Tang, 798, 863–864, 929 Da Tiao Jing Wan, 301 Da Ying Jian, 216, 216t Dan Gui Huo Xue Tang, 646 Dan Gui Long Hui Wan, 903 Dan Shen Yin, 137 Dan Zhi Xiao Yao San, 141, 195, 206, 270, 386, 611, 671, 788
variation, 361, 363, 423 Dan’e decoction, 888 Dang Gui Bu Xue Tang, 326, 344, 761–762 Dang Gui Di Huang Yin, 56, 242, 299 Dang Gui Jian Zhong Tang, 194, 271–272, 603 Dang Gui San, 3 Dang Gui Shao Yao San, 132, 192, 284, 317, 470, 471, 732–733 in clinical trials, 284, 317, 933–934 Dang Gui Sheng Jiang Yang Rou Tang, 602–603 Dang Gui Si Ni Tang, 56, 193 Dang Gui Yin Zi variation, 441 Dao Chi San, 152, 434–435, 468, 530 variation, 365, 434 Dao Gong Tang variation, 605 Dao Jing Tang, 153 Dao Tan Zhong Zi Tang, 900 Dao Zhi Tong Jing Tang, 409 Di Gu Pi Yin, 209, 424 Di Shen Zi Yin Fang, 514 Di Tan Tang, 515 Di Yu Huang Bo Fang, 636 Ding Jing Tang, 221, 227 variation, 221, 222t Dong Kui Zi San variation, 536 Du Huo Ji Sheng Tang, 653–654 Du Shen Tang, 674 Duo Ming Wan, 574, 675–676 E Jiao Yang Xue Tang, 521 E Zhu San, 929 empirical prescriptions, 268, 800, 800t, 832 Dr Chen Jia Yuan, 485, 520, 521, 572, 655, 661–662, 662t Dr Cong Chun Yu, 659 Dr Huang Tao Qiang, 806–807, 807t Dr J H F Shen, 571 Dr Lian Fang, 718–719 Dr Liu Geng Wu, 288–289, 901 Dr Meng Jing Chun, 739, 740t, 742, 743t
Dr Shan Dao Wei, 698, 705–706, 707t, 708, 720 Dr Shang Xian Min, 691t, 694, 701–702, 702t, 705, 707t, 710, 711t, 712–713 Dr Sun Ning Quan, 718–719 Dr Tian Jin Feng, 810 Dr Xia Gui Cheng, 515, 717 Dr Yao Shi An, 806, 807t Dr Zhang Jian Zhai, 207, 215–216, 301, 310–311, 311t, 461–462, 484, 818, 819 Dr Zhu Nan Sun, 698, 706–707, 707t, 710, 711, 711t, 713, 719–720 Shanghai College of Traditional Chinese Medicine, 720–721 Er Miao San, 147–148 variation, 268, 867 Er Xian Tang, 131, 742, 743t, 762, 783 Er Zhi Wan, 253, 287, 350, 742, 743t variation, 349, 549 Fang Ji Huang Qi Tang, 734 Fo Shou San, 313, 675–676 variation, 312 formulae, 935–1008 Fu Fang Huang Qi Jian, 572 Fu Geng Yin, 743, 743t Fu Ke Zhu Xian Dan, 303 Fu Ling Dao Shui Tang, 496–497 Fu Shen San, 595 Fu Yuan Huo Xue Tang, 139 Fu Zheng Zi Beng Tang, 345 Gan Jiang Ling Zhu Tang, 192 Gan Jiang Ren Shen Ban Xia Wan, 3 Gan Lu Xiao Du Yin, 436 Ge Xia Zhu Yu Tang, 137, 244, 245t, 261, 716, 738, 750, 799, 800t, 902 variation, 263 Geng Nian An, 739, 740t Geng Nian Fang, 739, 740t, 742 Formula I, 742, 743t Formula II, 742, 743t Geng Nian Le, 742, 743t
Gong Wai Yun No.1 formula, 475 No.2 formula, 475 Gong Zheng Tang, 929 Gu Ben Zhi Beng Tang, 344 variation, 290–291, 550–551 variations, 328 Gu Chong Tang, 194 Gu Chong Zhi Xue, 354 Gu Jin Jian, 303–304 Gu Yin Jian, 218, 218t, 228, 870 Gua Lou San, 665, 666t Gua Lou Xiao Yao San, 787, 788 Gui Pi Tang, 56, 144, 146, 149, 203, 232–233, 250, 308, 341–342, 344, 346, 467, 502 variation, 595 Gui Rong Bu Chong Tang, 204 Gui Shao Di Huang Tang, 130, 273 variation, 369–370 Gui Shen Wan, 194, 242, 299 Gui Zhi Chai Hu Tang, 644 Gui Zhi Fu Ling Tang, 276 Gui Zhi Fu Ling Wan, 3, 139, 765–766, 799–800, 800t, 929, 930, 931, 932 variation, 341, 806–807, 807t Gui Zhi Tang, 127 Guo Qi Yin, 252–253 He Xue Zhi Yang Tang, 834 Hu Po San, 339 Hua Gan Jian, 195, 520 Hua Ji Wan, 802–803 Hua Shui Zhong Zi Tang, 128 Hua Yu Ding Tong Tang, 262, 864 Hua Yu Liao Zhi Tang, 635 Huan-an powder, 355 Huang Lian E Jiao Tang, 748 Huang Lian Jie Du Tang, 151 Huang Qi Dang Gui San, 619
Huang Qi Gui Zhi Wu Wu Tang variation, 652 Huang Qi Jian Zhong Tang, 193 Huang Qi Tang, 626 Hui Mai San, 665–666, 666t Huo Po Xia Ling Tang, 147–148 Ji Chuan Jian, 541, 631 Ji Sheng Shen Qi Wan, 406 Jia Jian Si Wu Tang, 233 Jia Jian Xiao Yao San, 825 Jia Wei Liu Jun Zi Tang, 466 Jia Wei Wu Lin San, 530–531 Jia Wei Xiao Yao San, 141, 390, 778–779, 780t variation, 391–392 Jia Wei Yang He Tang, 783 Jian Gu Tang, 128, 413–414 Jian Pi Shu Yu Tang, 390 Jiao Ai Tang, 3, 472 variation, 470–471 Jie Du Huo Xue Tang, 195 variation, 641, 642t Jie Du Si Wu Tang variation, 234, 251 Jin Gi Shen, 127 Jin Gui Shen Qi Wan, 131, 217–218, 218t, 291, 618, 738, 902 variation, 535 Jin Ling Zi San, 133, 252, 798 Jin Ling Zi Wan, 193 Jin Qi Jiang Tang, 918–919 Jing Fang Si Wu Tang, 644 Jing Qin Si Wu Tang, 332 Ju He Wan, 701, 702t Ju Pi Zhu Ru Tang, 148 Ju Yuan Jian, 232–233, 250, 483–484 variation, 203 Kai Yu Zheng Yuan San, 797 Kai Yu Zong Yu Tang, 710, 711t Kang Yi Zhong Yu, 885 Kun Bao Tang, 746, 746t
Lang Shou Tang, 192 Li Huo Tang, 825 Li Qi San Yu Tang, 486 Li Qi Xie Huo Tang, 485 Li Yu Tang, 496 Li Zhong Tang, 193 Li Zhong Wan, 145, 147–148, 741 variation, 461 Liang Di Tang, 130, 195, 208, 253, 287, 337, 338t, 350, 424 Liang Ge San, 435–436 Liang Xue Chu Shi Tang, 443 Ling Gui Zhu Gan Tang, 466 variation, 406, 407 Ling Jiao Gou Teng Tang, 153, 514 Ling Jiao Gou Teng Yin, 143 Liu Jun Zi Tang, 122–123 variation, 830 Liu Mo Tang, 543, 797 Liu Wei Di Huang Wan, 127–128, 130, 131, 229, 287, 748 variation, 523 Liu Wei Hi Huang Wan variations, 56 Long Dan Xie Gan Tang, 122–123, 142, 195, 671, 734, 820–821, 821t, 828–829, 842, 903, 918–919 variation, 398 Lou Ju Ci Gu Tang, 787 Lu Pu Tang, 783 Mai Men Dong Tang, 463 Mie Di Zhi Yang Tang, 820 Mu Xiang Liu Qi Yin, 387 Nan Cheng Fang, 571–572 Nei Bu Wan, 817 Nei Yi Fang, 261–262, 864 Nei Yi pill/enema, 887 Ou Jing Tang, 139–140 Pai Luan Tang, 310–311, 311t Pen Qiang Jie Du Tang, 822–823 Pen Qiang Ling, 823
Ping Gan Kai Yu Zhi Xue Tang, 336 Qi Gong Wan, 705, 707t, 715, 900, 911, 931 variation, 715 Qi Ju Di Huang Wan, 447, 510–511, 738, 746, 746t, 786 variation, 399, 510 Qi Zhen San, 614 Qi Zhi Xiang Fu Wan, 221, 222t Qiang Gui Si Wu Tang, 417 Qin Jiao Niu Bang Tang, 441 Qin Jiao Si Wu Tang, 417 variation, 237 Qin Lian Si Wu Tang, 56, 205, 422 Qing Dai San, 834 Qing Gan Bu Shen Tang, 310–311, 311t Qing Gan Da Yu Tang, 206 Qing Gan Hua Shi Tang, 833 Qing Gan Jie Yu Tang, 779, 780t variation, 784 Qing Gan Yin Jing Tang, 195, 430 Qing Gan Zhi Lin Tang, 825, 901 variation, 288 Qing Gu San, 130 Qing Hao Bie Jia Tang, 130 Qing Hun San, 674–675 Qing Jin Jiang Huo Tang variation, 527 Qing Jing San, 130, 195, 205, 331, 422 variation, 208–209, 709 Qing Re Gu Jing Tang, 195, 332, 337, 338t, 550 Qing Re Li Shi Tang variation, 343 Qing Re Tiao Xue Tang, 196, 268, 867 Qing Re Yang Yin Tang, 485 Qing Re Zhi Beng Tang, 331, 333–335 Qing Wen Bai Du Yin variation, 681 Qing Xin Ping Gan Tang, 746, 746t variation, 208 Qing Zhi Si Wu Tang, 788 Qu Yu Ding Tong Tang, 636
Qu Yu Jie Du, 886 Quan Sheng Bai Zhu San, 145, 148 variation, 406 Ren Shen Dang Gui Tang, 597 Ren Shen Mai Dong San, 505–506 Ren Shen Tang, 308–309 Ren Shen Yang Rong Tang, 212, 213t, 301, 670, 872 Ren Shen Zi Xue Tang, 240–241 Rou Gan Zhi Tong Tang, 392–393 Ru He Nei Xiao Tang, 778, 780t Ruan Jian Hua Tan Fang, 900 San Cu Tang, 299 San Huang San, 810 San Jia Fu Mai Tang, 130, 516, 680 San Miao San, 147–148 San Qi Hong Teng Tang, 706, 707t prescription I, 706 prescription II, 706 prescription III, 706 San Ren Tang, 389 Sha Xiang San, 599 Shao Fu Zhu Yu Tang, 138, 154, 194, 196, 266, 310–311, 311t, 712, 877, 903 variation, 244, 245t, 552 Shao Tai Wan, 194 Shao Yao Gan Cao Tang, 284, 921–922 She Hua Tang, 832 Shen Fu Tang, 475, 674 Shen Gui Yin Chan Fang, 572 Shen Ling Bai Zhu San, 148, 412 Shen Tong Zhu Yu Tang, 654 Shen Xiao Gua Lou San, 779, 780t Sheng Hua Tang, 138, 610 variation, 486–487, 604, 646 Sheng Mai San, 475, 627–628 Sheng Ti Gu Tuo Jian, 837 Sheng Tie Luo Yin, 366–367
Sheng Yu Tang, 270, 486 variation, 481–482 Shi Quan Da Bu Tang, 271, 674 variation, 609, 666, 666t Shi Wei Liu Qi Yin, 781–782 Shi Xiao San, 193, 551, 610, 641, 642t, 798 variation, 235, 338–339, 352 Shou Tai Wan, 192, 481 Shu Gan Jiang Ni Tang, 430 Shu Gan Tong Ru Tang, 661 Shu Qi Huo Luo Tang, 388–389 Shun Jing Fang variation, 431 Si Jun Zi Tang, 144, 147–148 Si Ling San, 498–499 Si Miao San, 124, 147–148, 706, 707t, 716, 734, 738, 901 variation, 263, 876, 878, 912, 914, 928 Si Ni San, 108, 133 Si Ni Tang, 193 Si Qi Tang, 133 Si Wu Tang, 132, 138, 192, 199, 235, 252, 551 clinical trial, 282 variation, 132, 199, 304–305, 305t, 409, 540, 630, 659–660 Song Bao Tang, 573–574 Su Ye Huang Lian Tang, 464 Tai Shan Pan Shi San, 481 Tai Yuan Yin variation, 483–484 Tang Shi Shu Jie Fang, 207 Tang Yang Fang, 832 Tao He Cheng Qi Tang, 138, 139, 140 Tao Hong Si Wu Tang, 56, 196, 244, 245t, 338–339, 418 variation, 261, 309–311, 311t, 426 Tao Hong Yin, 418 Tao Ren San, 929 Tao Ren Wan, 929 Tian Gui Fang, 920–921 Tian Ma Gou Teng Yin, 55–56, 143, 153, 399 Tian Wang Bu Xin Dan, 150, 307, 598, 748
Tiao Gan Tang, 273 Tiao Mian Hua Yu, 885–886 Tokishakuyakusan See also prescriptions See also Dang Gui Shao Yao San Tong Gan Sheng Ru Tang, 661, 662t Tong Guan II Hao Fang, 721 Tong Guan Tang, 721 Tong Jing Huo Luo Tang, 647–648 Tong Jing Ning in clinical trial, 283–284 Tong Jing Yin, 261 Tong Pao Yin, 622–623 Tong Qiao Huo Xue Tang, 140 variation, 402 Tong Ru Dan, 659 Tong Xie Yao Fang, 413 Tong You Tang, 542, 632 Tong Yu Jian, 388 Tu Gua Gen Powder, 255 Tuo Li Xiao Du San, 844–845 Wan Dai Tang, 148, 816, 825 Wen Bao Yin, 128 Wen Dan Tang variation, 363–364, 366–367, 368 Wen Jing Tang, 3, 56, 138, 194, 215, 264, 265, 265t, 267–268, 310–311, 311t, 702, 702t, 750–751, 764–765, 865–866, 877, 921 clinical trials, 317, 921 variation, 703, 704, 876, 878 Wen Qi Hua Shi Tang, 265, 265t Wen Shen Fu Yang Tang, 265, 265t Wen Tu Yu Lin Tang, 492 Wu Wei Xiao Du Yin, 641, 785, 842 variation, 822 Wu Xiang Wan, 388 Wu Yao San, 310–311, 311t Wu Yao Tang variation, 221, 222t Wu Zi Yan Zong Wan, 734 variation, 817–818 Xia Ru Yong Quan San, 661, 662t Xian Fang Huo Ming Yin, 666, 666t
Xiang Ai Xiong Dang Yin, 613 Xiang Bei Yang Rong Tang, 786 Xiang Leng Wan, 796, 929 Xiang Ling Wan, 884–885 Xiang Sha Liu Jun Zi Tang, 461 Xiao Ban Xia Tang, 148, 466 Xiao Chai Hu Tang, 193 Xiao Du Yin, 666, 666t Xiao Feng San variation, 442–443 Xiao Kang Wan, 729 Xiao Lui Fang, 929 Xiao Tiao Jing Tang, 599 Xiao Xian Xiong Tang variation, 527 Xiao Yan Zhi Xue, 354–355 Xiao Yao San, 29, 54, 56–57, 133, 147, 199–200, 220, 222t, 226, 359–360, 359t, 374, 375, 376, 384, 471, 498–499, 503, 795–796 variation, 783, 824 variations, 141, 259, 369, 779, 780, 780t Xiao Yao Wan, 371 Xiao Zhang Shu Yu Tang, 384 Xiao Zhi Tang, 634 Xie Gan An Shan Wan, 504 Xie Xin Tang, 151 Xuan Fu Dai Zhe Tang, 153 Xuan Yu Tong Jing Tang, 269–270 Xue Fu Zhu Yu Tang, 138, 139, 140, 426, 785 Yang Jing decoction, 316 Yang Jing Zhong Yu Tang, 130, 157 variation, 698 Yang Rong Tang, 149 Yang Rong Zhuang Shen Tang, 655 Yang Xin Tang, 149 Yang Xue Ding Feng Tang, 56, 441 Yang Xue Run Fu Yin, 56 Yang Xue Xi Feng Fang, 516 Ye Guan Jian, 392 Yi Gan He Wei Yin, 153
Yi Guan Jian, 132 variation, 372, 645 Yi Huang Tang, 816, 821, 821t, 825 Yi Mu Xiong Gui Tang, 572 Yi Pi Wen Shen Tang, 216, 216t Yi Qi Dao Ni Tang, 534 Yi Qi Gu Chong Tang, 194, 323, 344–345 Yi Qi Li Shui Tang, 534 Yi Qi Yang Xue Tang, 483–484 Yi Shen Fu Yang Tang, 228 Yi Shen Jian Pi Yang Xue Tong Li, 920 Yi Shen Tong Jing Tang, 157, 272 Yi Wei Ning, 886–887 Yi Yin Jian, 195, 305t variation, 212–213, 213t, 305 Yin Dao 1 Hao Pian, 832 Yin Qiao San variation, 644 Yong Quan San, 661, 662t You Gui Wan, 52, 56, 127–128, 263, 347, 373, 375, 391–392, 738, 741, 870, 902 variation, 314, 375–376, 547, 877, 878, 919–920 You Gui Yin, 127 Yu Lin Zhu variation, 691t, 694, 715, 716 Yu Nu Jian, 434–435, 465 Yu Ping Feng San variation, 626–627 Yu Shen Hua Yu Tang, 272 Yu Shen Jian Pi An Tai Tang, 547 Yu Tai Jian Zi Tang, 491–492 Yu Yin Tang variation, 482 Yu Yin Zhi Ben Tang, 350 Yuan Tu Gu Tai Tang, 128 Yue Ju Wan, 133, 141, 359–360, 359t, 426, 749 variation, 788 Zan Yu Dan, 56, 129 Tu Si Zi Wan, 129 Ze Lan Tang, 153 Zeng Ye Tang, 542, 632
Zhen Gan Xi Feng Tang, 143, 153 Zhen Qi Zhuan Yin, 731–732 Zhen Wu Tang, 128, 497–498 Zhi Bo Di Huang Wan, 622, 844 variation, 531, 819, 831 Zhi Bo Si Wu Tang, 332 Zhi Dai Wan, 820, 821t Zhi Han San, 627–628 Zhi Jie Er Chen Tang, 527–528 Zhi Ling Wan, 633 Zhi Mei Jing Yin Sai Ji, 822 Zhi Mei Xi Ji, 832 Zhi Mu San variation, 505–506 Zhi Zi Chi Tang, 844 Zhong Yao Ren Cong Tiao Qi Zu Fang, 299–300 Zhu Li Tang, 506–507 Zhu Yu Zhi Xue Tang, 289–290 Zhu Yun Tang, 710, 711t Zhu Yun Yu Lin Fang, 691t, 694–695 Formula I, 694 Formula II, 695 Zi Shen Tang, 536–537 Zi Shui Qing Gan Yin, 143 Zou Gui Wan, 52 Zu Su Yin variation, 520 Zuo Gui Wan, 229, 243, 349, 549, 738, 819, 871 Zuo Gui Wan (Yin), 130 Zuo Gui Yin, 304–305, 305t variation, 739, 740t Zuo Jin Wan, 464 progesterone, 21 in early miscarriage, 553 in menstrual cycle, 14, 15, 16–17, 18 in pre-menstrual syndrome, 376–377 in pregnancy, 44 therapy, 754
progesterone supplementation, 16–17 progestins in endometriosis, 853–854, 855t side effects, 853–854 prolactin, 18f, 377 prolapse See Bladder, prolapse See also uterine prolapse prostaglandin synthetase inhibitors, 377 prostaglandins, 377 psoriasis, 846 psychosis, 140 psychotic neurosis, 600 puberty, 80, 84t puerperium, 591 pulse(s) Blood-Cold, 65 Blood pathology, 67t emotional problems after childbirth, 87 Extraordinary Vessels, 161–162 historical writings, 3–4 Hollow, 108 Leather, 107 Liver-Blood deficiency, 55 Liver-Blood Heat, 58 Liver-Blood stasis, 57 Liver pathology, 60t Liver-Qi stagnation, 54 palpation, 104–108 Dr Chen Jia Yuan’s pulses, 106
gender differences, 104 in labour, 108 levels of pulse, 104–105 Li Shi Zhen’s pulses, 106 in menorrhagia, 108 during menstruation, 108 in pregnancy, 107 Rear (Chi) position, 105–106 in pregnancy, 451 pregnancy diagnosis, 107 multiple pregnancy, 107 problems, 107 Qi pathology, 67t in shock, 81 Slippery, 107 Slowed Down, 106 Spleen pathology, 60, 61, 61t Triple Burner position, 105 Uterus position, 105, 105f pyelonephritis, 532f
Q
Qi descending, 20 disharmony of nutritive and defensive Qi, 424 exhaustion, 103 Fever after Childbirth, 642, 643t Food-Qi, 144 harmonizing Qi and Blood, 199 moving, 24, 137–138 Nutritive Qi, 642, 643t Original Qi (Yuan Qi), 25, 26, 65 pathology, 64–67, 67f, 67t Post-Natal, 28, 144 and breastfeeding, 32 in conception, 43 in menstruation, 11, 25 Pre-Natal, 43, 167 tonifying, 122–123, 138 True Qi (Zhen Qi), 25 upright Qi deficiency, 802–803 Qi collapse with Blood deficiency, 674–675 Qi deficiency, 56, 67t diet, 83 early periods, 202–204 Flooding and Trickling, 321, 326 heavy periods, 232–233 infertility, 700b labour, 108 long periods, 249–250 menstrual cycle, 99 painful periods, 257 Persistent Lochial Discharge, 608–609
retained placenta, 565–566 Sweating afer Childbirth, 626–627 urinary retention, 566–567 Qi deficiency and Blood deficiency amenorrhoea, 297 Breast Milk not Flowing, 658–660 difficult labour, 564, 571–572 Fetus not Growing, 491–492 fever at period time, 424 painful periods, 270–271 retained placenta, 573–574 threatened miscarriage, 483–484 Qi deficiency and Blood deficiency with Blood stasis, 931–932 Qi deficiency and Blood stasis, 475 Qi deficiency and Yin deficiency, 352 Qi deficiency and Yin deficiency and Blood stasis, 352 Qi masses, 793, 795–797 Qi of the Upper Burner, 71 Qi-Painful Urinary Syndrome (Qi Lin), 94 Qi rebelling upwards feeling of suffocation, 519 Penetrating Vessel, 153 Qi rebellious, 44, 65, 67t abdomen in, 109 attacking Heart, 106 menstrual problems, 79–80 of Penetrating Vessel, 65–66, 66f, 67, 68–70, 109, 110, 162–163, 164f treatment, 152–154, 193
Qi sinking, 67t, 82 Flooding and Trickling, 323 treatment, 193 Qi stagnation, 65, 66f, 67t abdomen in, 109 abdominal pain in pregnancy, 469, 471 ankles, swollen, 108 breast lumps, 771, 772, 788 with disharmony of Liver and Spleen, 519–520 elimination and Liver pacification, 133–134 haemorrhoids, 635–636 infertility, 709–712 oedema during menstruation, 408–409 oedema during pregnancy, 498–499 painful periods, 258, 256–257, 259–260 with Phlegm, 101 and Phlegm accumulation, 749 in pregnancy, 449 and surgery, 93–94 tongue, 112 and tongue colour, 112 treatment, 788 Qi stagnation and Blood deficiency and Kidney deficiency, 521 Qi stagnation and Blood stasis abdominal masses, 798 amenorrhoea, 297, 309–311 difficult labour, 564–565, 572 myomas, 929–930 retention of lochia, 612–613
R
rectocele, 839, 839f respiratory tract infection, 649 Restless Fetus (Tai Dong Bu An), 477, 478 See also miscarriage, threatened retrograde menstruation, 850
S
sacral pain, 488 sadness, 62, 64, 79–80 Lungs, 32 in miscarriage, 103 as pathogenic factor, 80 salpingitis, 723–724 salpingostomy, 728–730 scanty periods, 239–247 aetiology, 239–240 pathology, 240 pattern identification/treatment, 240–246 Blood deficiency, 240–241, 246–247 Blood stasis, 244–245 Kidney-Yang deficiency, 241–242 Kidney-Yin deficiency, 243 Phlegm obstructing Uterus, 245–246 and PCOS, 896 prognosis/prevention, 246–247 Sea of 12 Channels See Penetrating Vessel Sea of Blood, 162 See also Penetrating Vessel Sea of Channels See Penetrating Vessel Sea of Food, 162 Sea of Marrow, 162 Sea of Qi, 162
Sea of Yin channels See Directing Vessel sexual activity, 88–92 beneficial effects, 92 causing disease, 90, 91 early, 89–90 endometriosis, 858 Flooding and Trickling, 320 infertility, 686 and Essence, 89–90 excessive, 78, 85, 88, 89–90, 90f painful periods, 256 in pregnancy, 529 threatened miscarriage, 479 urinary retention, 533 urinary syndrome, 529 Governing/Directing Vessels interaction, 92f insufficient, 91–92 and menstruation, 90, 91 endometriosis, 858 in pregnancy, 91 sexual frustration, 91 shock, 81 skin eruptions, 439–444 aetiology, 439 on face, 440 pathology, 439 pattern identification/treatment, 440–443 Wind-Heat with Blood deficiency, 440–442 skin palpation, 108 Slippery Fetus (Hua Tai) See miscarriage, habitual Small Intestine channel, 31, 32, 61
Small Labour (Xiao Chan), 477, 478 smell in diagnosis, 103, 117 smoking, 737 sperm, 89 Spleen, 30–31 diet, 83 harmonizing with Liver, 146–147 pathology, 60–61, 64f, 144–148 strengthening, 199 tonifying, 28 to hold blood, 146 to resolve Dampness, 147–148 Spleen-Blood deficiency, 61 Spleen-Blood deficiency and Heart-Blood deficiency, 308–309 Spleen-Blood deficiency with Dampness, 61t Spleen-Blood, tonifying, 144 Spleen deficiency, 99 lip colour, 111 with Liver-Yang rising and Phlegm, 511 with Stomach Damp-Heat, 436 tongue, 113–114 vaginal discharge, excessive, 815–816 Spleen-Heat, 111 Spleen not gathering Blood, 61t Spleen-Qi in menorrhagia, 31 tonifying/raising, 144, 145
Spleen-Qi deficiency, 60, 148 and Dampness, 829–830 diarrhoea at period time, 411–412 early periods, 202–203 habitual miscarriage, 550–551 tongue, 114 tongue shape, 115–116 urinary problems, 534, 616–617 Spleen-Qi deficiency and Blood deficiency, 61t Spleen-Qi deficiency and Kidney-Qi deficiency, 329 Spleen-Qi deficiency and Lung-Qi deficiency, 622–623 Spleen-Qi deficiency and Phlegm, 447–448 Spleen-Qi deficiency and Stomach-Qi deficiency, 669–670 Spleen-Qi sinking, 30–31, 31f, 61, 61t, 145 miscarriage, 104 prolapse of uterus, 836 urinary retention, 534 Spleen-Yang deficiency, 148 ankles, swollen, 108 menstrual cycle, 101 oedema during pregnancy, 496–497 vaginal discharge, 103 water retention, 101 Spleen-Yang deficiency and Blood-Heat, 124–125 Spleen-Yang deficiency and Kidney-Yang deficiency amenorrhoea, 303–304 bleeding between periods, 290–291 Fetus not Growing, 492–493 infertility, 689 oedema during menstruation, 405–406
polycystic ovary syndrome, 901–902 pre-menstrual syndrome, 373 Spleen-Yang deficiency and Phlegm, 781–782 Spleen-Yang, tonifying, 145 Spleen-Yin, 106 Spleen-Yin deficiency, 111, 148, 148f spontaneous abortion See miscarriage standing, excessive, 533 steaming breast, 647–648 sterility female See infertility male, 733–734 Stomach, 32–33 and Heart-Qi, 32 Liver-Qi stagnation invading, 463–464 pathology, 64, 64f, 148 Stomach channel, 383 acupuncture, 458–460 breast milk formation, 658 Stomach Damp-Heat, 435–436 Stomach Damp-Heat with Spleen deficiency, 436 Stomach Empty-Heat, 115 Stomach-Fire, 435–436 Stomach-Heat, 465
Stomach-Qi pulse, 106 rebelling upwards, 64, 153 Stomach-Qi deficiency, 115 Stomach-Qi deficiency and Empty-Cold, 461–462 Stomach-Qi deficiency and Spleen-Qi deficiency, 669–670 Stomach-Yin deficiency, 114, 115, 462–463 suffocation, feeling of (zi xuan), 519–522 surgery, abdominal, 93–94 bleeding between periods, 286 Fever after Childbirth, 640 fever at period time, 422 heavy periods, 231 scanty periods, 239 Surging Periods, 479 Sweating afer Childbirth, 625–628 aetiology/pathology, 625–626 pattern identification/treatment Qi deficiency, 626–627 Yin deficiency, 627–628 prognosis/prevention, 628 sweet food, 83 Swimming Menses (You Jing), 477, 478 syphilis, 847 systemic and gynecological manifestations, 124–125 coexistence, 124–125 contradiction, 125
interaction, 125
T
tampons in endometriosis, 850, 858 temperature See basal body temperature Tense Syndrome, 673, 675–676 Three Treasures remedies Bend Bamboo, 55–56, 132, 143, 399, 400, 401, 510, 747 Break into a Smile, 134 Brighten the Eyes, 56, 132, 396, 446, 645, 647–648 Brocade Sinews, 132, 417, 652–653 Calm the Shen, 56, 144, 146, 149, 203, 467, 502, 595, 609 Calm the Spirit, 309 Central Mansion, 148, 412 Clear the Soul, 507, 749 Clear Yang, 448, 511 Drain Fire, 142, 151, 398, 423, 431, 671, 822, 829, 842 Ease the Journey-Yang, 191, 204 Ease the Journey-Yin, 191, 435, 747 Ease the Muscles, 436 Expel Wind-Cold, 644 Freeing the Moon, 132, 503, 543, 662, 711 Freeing the Sun, 336 Glorious Sea, 56, 441 Invigorate Blood and Stem the Flow, 552 Jade Spring, 431, 435, 463, 524 Nourish the Root, 130, 229, 243, 305, 372, 392–393, 441–442, 523–524, 549, 819 Nourish the Root and Clear Wind, 655 Open the Heart, 364, 387, 388, 502 Red Stirring, 140, 151, 389, 402, 426, 599 Release Constraint, 134, 141, 711, 749 Root the Spirit, 132, 645, 647 Separate Clear and Turbid, 406, 534, 617, 618, 829, 830
Settling the Soul, 142, 504 Soothe the Centre, 148, 413, 436, 462, 464, 830 Stir Field of Elixir, 235, 419, 604, 610, 613, 647 Strengthen the Root, 127, 218–219, 228, 291, 300, 346, 362, 373, 406, 414, 492–493, 535, 547, 618, 654, 818 Tonify Qi and Ease the Muscles, 145, 203, 233, 425, 534, 551, 609, 816, 836 Unicorn Pearl, 219, 228 Water Passages, 622 throat disorders, 71 thrombophlebitis, 649 Tian Gui See Heavenly Gui tongue Blood-Cold, 65 Blood pathology, 68t chest/breast area, 112–113 coated, 114, 116 cracked, 114, 115f, 148f deviated, 114 emotional problems, 594–595 emotional problems after childbirth, 87 Empty-/Full-Heat, 111, 112 Liver-Blood deficiency, 55 Liver-Blood stasis, 57 Liver pathology, 60t Liver-Qi stagnation, 54 long, 114 moving, 114 observation, 111–116 coating, 114, 116 in gynaecology, 115–116 tongue-body colour, 111–113, 116 tongue-body shape, 113–114 Pale, 111, 116
peeled, 115, 116 Purple, 112–113, 116 Qi pathology, 68t quivering, 114 Red/Dark Red, 111–112, 116 short, 114 Spleen pathology, 60, 61, 61t stiff, 114 swollen, 113–114, 114f teethmarks, 113, 114 thin, 114 tonification vs elimination, 122–123 Toxic-Heat, 103, 116 breast lumps, 776t, 785 haemorrhoids, 634 vaginal discharge, 813, 814 vaginal discharge, excessive, 822–823 Toxic-Heat with Liver-Fire and Damp-Heat, 842 toxins convulsions after childbirth, 679, 681 Fever after Childbirth, 639–642 traumas bleeding between periods, 286 scanty periods, 239 threatened miscarriage, 478–479, 486–487 treatment, 121–155 gynecological and systemic manifestations, 124–125 coexistence, 124–125 contradiction, 125 interaction, 125 patterns and Chinese/Western diseases, 125–127 principles, 121–127
case histories, 123b steps for success, 121–122 tonification vs elimination, 122–123 Treponema pallidum, 847 Trichomonas vaginalis, 826, 832 Triple Burner, 105 pulse position, 105 triptorelin, 856t True Qi (Zhen Qi), 25
U
upright Qi deficiency, 802–803 ureters, 93f urinary problems after childbirth, 615–623 aetiology, 615 case histories, 617b, 620b pathology, 615–616 pattern identification/treatment Bladder-Heat and Kidney-Yin deficiency, 621–622 bladder injury, 619 Kidney-Qi deficiency, 618 Liver-Qi stagnation, 619–620 Lung- and Spleen-Qi deficiency, 622–623 Spleen-Qi deficiency, 616–617 after hysterectomy, 93–94 urinary retention after delivery pattern identification/treatment, 566–567 Kidney deficiency, 567 Qi deficiency, 566–567 during pregnancy, 533–537 aetiology/pathology, 533–534 pattern identification/treatment Damp-Heat in Bladder, 536–537 Kidney-Qi deficient and sinking, 535 Spleen-Qi deficient and sinking, 534 prognosis/prevention, 537 urinary syndrome, 529–532 Damp-Heat in Bladder, 530–531 Heart-Fire, 529–530
Kidney-Yin deficiency and Empty-Heat, 531 prognosis/prevention, 532 Western view, 532 urinary tract infection, 532, 532f, 649 uterine artery, 93f uterine artery embolization, 925t uterine carcinoma, 353 uterine myomas See myomas uterine prolapse, 30–31, 32, 41, 70, 85 aetiology/pathology, 835 case history, 347 degrees of prolapse, 838, 838f pattern identification/treatment, 835–837 Kidney-Qi deficient and sinking, 836–837 Spleen-Qi sinking, 836 prognosis/prevention, 838 treatment, 145 Western view, 838 Uterus anatomy, 93f Blood-Heat, 111 Blood stasis, 103 Cold in, 56, 65, 108 connection to Stomach, 64 Damp-Phlegm obstructing, 297–298 Dampness or Phlegm obstructing, 22 delayed involution, 612 emotional stress, 80f and Extraordinary Vessels, 35f as Extraordinary Yang organ, 9f and internal organs, 9, 10f, 43f and Liver-Blood, 29f
physiology, 7, 8–9, 9f pulse position, 105, 105f tongue in diagnosis, 111, 116 underdeveloped, 720 vulnerability, 77 warming, 24 Uterus Channel (Bao Luo) historical writings, 3, 8 physiology, 9 Uterus channel severance, 62 Uterus Vessel (Bao Mai), 61 historical writings, 3, 8 menstruation, 12, 79
V
Vaginal Bleeding during Pregnancy (Tai Lou), 477, 478 See also miscarriage, threatened vaginal discharge, 103 channels, 814–815 excessive, 813–826 aetiology/pathology, 814–815 pathological discharge, 814–815 pattern identification/treatment, 815–825 Damp-Heat, 820–822 Kidney-Yang deficiency, 817–818 Kidney-Yin deficiency, 818–819 Liver-Qi stagnation, 823–824 Spleen deficiency, 815–816 Toxic-Heat, 822–823 prognosis/prevention, 825 Western view, 825 pathological, 814–815 physiological, 825 smell in diagnosis, 117, 814–815 vaginal disorders, 62 vaginal itching, 827–834 aetiology, 827–828 external treatment, 829, 832 pathology, 828 pattern identification/treatment Damp-Heat in Liver channel, 828–829 Dampness and Spleen-Qi deficiency, 829–830 Liver- and Kidney-Yin deficiency, 830–831 prognosis/prevention, 831 Western view, 831–832
vascular endothelial growth factor, 886 vestibular adenitis, 846 vitamin B6 , 377 deficiency, 377 vitiligo, 846 voice in diagnosis, 117 Vulvar Sores (Yin Chuang), 841–847 aetiology/pathology, 841–842 case histories, 843b, 845b neoplastic, 846, 847 pattern identification/treatment, 842–845 Cold retention, 844–845 Toxic-Heat with Liver-Fire and Damp-Heat, 842 prognosis/prevention, 846–847 ulcerative, 846–847 Western view, 846–847 vulvitis, 846
W
water retention, 101 Water, transforming, 139–140 weakness constitutional breast milk flow, 669 infertility, 685–686 joint pain after childbirth, 651 hereditary amenorrhoea, 296 scanty periods, 239 Kidney, 211 Western diseases cross-refered to Chinese disease-symptoms, 1033–1034 diagnosis, 98f Wind external, 643–644, 651 invasion of, 653–654 Wind-Heat, 56, 639 Wind-Heat and Blood deficiency, 440–442 Wind-stroke, 680 Women’s Treasure remedies, 304 Clear Empty-Heat and Cool the Menses, 209, 337, 611 Clear the Moon, 364, 367 Clear the Palace, 312, 715, 869, 900 Cool the Menses, 206, 234, 252, 332, 343, 550, 611, 709, 912 Drain Fire, 903 Drain Redness, 268, 707, 868
Drain the Jade Valley, 289, 821, 823, 833, 901, 904 Ease the Journey-Yang, 127, 129, 131, 242, 738, 741, 743 Ease the Journey-Yin, 130, 131, 209, 254, 287, 424, 738, 740, 743 Female Treasure, 130, 143, 447, 511, 746–747 Free Flow, 134, 147, 259–260 Free-Flowing Sea, 132, 242, 370 Freeing Constraint, 134, 141, 360, 662, 711–712, 780, 798 Freeing the Moon, 56–57, 134, 147, 221, 227, 360, 371, 385, 409, 780, 796, 824, 913 Freeing the Sun, 363 Growing Jade, 56, 130, 229–230, 243, 698, 871, 912 Harmonizing the Moon, 800, 864, 903 Heavenly Empress, 130, 150, 435, 506, 598, 748 Invigorate Blood and Stem the Flow, 23, 140, 235, 290, 328, 339, 912, 914 Nourish the Root, 871 Nourish Yin, 130 Nourish Yin and Restrain the Flow, 350 Penetrating Vessel, 153, 521, 662, 783 Planting Seeds, 132, 482 Precious Sea, 56, 132, 144, 213, 241, 271, 301, 396, 417, 442, 446, 492, 540, 551, 603, 630, 645–646, 660, 670, 699, 802, 872, 904 Restrain the Flow, 130, 146, 233, 250, 345, 912 Stir Field of Elixir, 56, 140, 244–245, 253, 262, 290, 311, 713, 751, 864, 903 Strengthen the Root, 347, 870 Unicorn Pearl, 56, 127, 129, 291, 493, 695–696, 870, 902, 911, 914 Warm the Mansion, 56, 154, 216, 702 Warm the Menses, 56, 154, 266, 866 Warm the Palace, 56, 127, 129, 132, 154, 272 worry, 63, 64, 79–81
471,
903,
471,
802,
Y
Yang collapse, 475 constitution, 439 in labour, 557 Yang deficiency complexion, 110 tongue, 111, 114 Yang deficiency and Blood deficiency, 271–272 Yang deficiency and Cold, 326 Yang Linking Vessel (Yang Wei Mai), 19 acupuncture, 160 areas of influence, 160, 160t opening point, 158 herbal treatments, 192, 193 pulse, 106 Yang Stepping Vessel (Yang Qiao Mai) acupuncture, 159, 160 areas of influence, 160, 160t opening point, 158 herbal treatments, 192 Yang tonics, excessive use of, 841 Yang–Yin balance See Yin–Yang balance Yang–Yin transformation, 12 Yin deficiency anxiety during pregnancy, 501 Blood dried up, 297
after menopause, 71 in pregnancy, 449 Sweating afer Childbirth, 627–628 tongue, 111, 114, 115 Yin deficiency and Blood deficiency and Empty-Wind, 680 Yin deficiency and Qi deficiency, 352 Yin deficiency and Qi deficiency and Blood stasis, 352 Yin Fire, 66f Yin Linking Vessel (Yin Wei Mai) acupuncture, 160, 189 areas of influence, 160, 160t case history, 189b opening point, 158 opening points, 189 herbal treatments, 192, 193 menstrual cycle, 19 pathology, 74 pulse, 106 Yin Stepping Vessel (Yin Qiao Mai), 42–43 acupuncture, 160, 188 areas of influence, 160, 160t case histories, 188b, 189b opening point, 158 opening points, 188 course, 42, 42f herbal treatments, 192 pathology, 73 pulse, 106 Yin–Yang balance, 12–13, 13f, 14f Yin–Yang disharmony, 193
Yin–Yang transformation, 12
Z
zong muscles, 70
Colour Plate
Plate 65.1 Endometriomas.
Plate 65.2 Endometriosis lesions.
Plate 65.3 Laparoscopy in endometriosis.
Plate 66.1 Ultrasound scan of polycystic ovary.
Plate 66.2 Polycystic ovary.
