CHAPTER 6 Principles and Methods of Treatment
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
The steps to a successful treatment are as follows:
If acupuncture is used, in addition to the above points, a successful treatment depends on these further factors:
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:
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 post-partum 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.
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.
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 Kidney-Yang 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:
Explanation
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 of contradictory gynecological and systemic manifestations
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 Blood-invigorating 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 Liver-Qi 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
Since the Kidneys can only be deficient, the methods of treatment for this organ consist only in tonification. They are:
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 Kidney-Qi Pill which contains the six herbs forming Liu Wei Di Huang Wan Six-Ingredient 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 Ren-4 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 Back-Transporting points is particularly important in chronic diseases.
Tonify Kidney-Yang
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
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.
Strongly Tonify Kidney-Yang and stoke up the fire of the Gate of Life
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
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:
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 Floating-Empty 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.
Nourish Kidney-Yin
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
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 Kidney-Yin can nourish the Essence if it includes one or more of the above-mentioned 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.
Nourish the Kidney-Essence
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
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 Kidney-Yin, 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.
Liver
There are six treatment methods related to the Liver:
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 Liver-Blood 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 Liver-Yang 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 Liver-Blood (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.
Nourish the Liver
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
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.
Pacify the Liver and eliminate stagnation of Qi
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 Pinellia-Magnolia 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 Atractylodes-Cyperus Conducting Phlegm Pill
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:
A different classification of the Blood-invigorating herbs differentiates four groups, listed here in ascending order or strength:
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)
Herbs that invigorate Blood and stop bleeding
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
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 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 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:
It may be useful to classify the Blood-invigorating herbs according to their target area/organ (Fig. 6.1):
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:
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
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 Blood-invigorating 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 Heart-Blood. 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.
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
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.
Clear Liver-Heat by pacifying the Liver
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
Drain Liver-Fire
‘Liver-Fire’ is quite different from Liver-Heat deriving from stagnant Liver-Qi: 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 | Fire | |
|---|---|---|
| Feeling of Heat | Mild | Pronounced |
| Thirst | Mild | Intense |
| Face | Red | Very red |
| Mind | Mild irritability | Severe irritability, agitation, insomnia, slight manic behaviour |
| Urine | Yellow | Dark and scanty |
| Stools | Normal | Dry, constipation |
| Bleeding | None | There may be bleeding |
| Tongue | Red or only sides Red | Dark Red, dry |
| Pulse | Not Rapid or only slightly Rapid, Overflowing | 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.
Drain Liver-Fire
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
Subdue Liver-Yang or extinguish Liver-Wind
Liver-Yang or Liver-Wind may rise from a variety of causes: from Kidney-Yin deficiency, a simultaneous Kidney-Yin and Kidney-Yang deficiency, Liver-Yin deficiency or Liver-Blood deficiency. Whatever the cause, Liver-Yang 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.
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
Spleen
The treatment methods applicable to the Spleen are:
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 Spleen-Qi, 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.
Tonify Spleen-Qi and Spleen-Blood
General manifestations
Tiredness, poor appetite, loose stools, slight abdominal distension, Pale tongue, Weak pulse
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 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
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.
Tonify Spleen-Yang
General manifestations
Tiredness, poor appetite, loose stools, slight abdominal distension, a pronounced feeling of cold, cold arms and legs, Pale and wet tongue, Deep-Weak pulse
Herbs
Huang Qi Radix Astragali, Bai Zhu Rhizoma Atractylodis macrocephalae, Ren Shen Radix Ginseng, Dang Shen Radix Codonopsis, Shan Yao Rhizoma Dioscoreae
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.
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
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 Spleen-Qi 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 Spleen-Qi 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.
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, Ren-12 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.
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 Agastache-Magnolia-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.
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 Spleen-Qi 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, BL-22 Sanjiaoshu, Ren-9 Shuifen, and ST-28 Shuidao, with reducing or even method.
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
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:
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 Heart-Blood. 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 Heart-Blood 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.
Heart-Blood deficiency
Herbs
Dang Gui Radix Angelicae sinensis, Bai Zi Ren Semen Platycladi, Suan Zao Ren Semen Ziziphi spinosae
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 Heart-Yin 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, Ren-14 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.
Heart-Yin deficiency
Gynecological symptoms
Scanty periods, amenorrhoea, infertility, post-natal depression, menopausal problems
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 Heart-Blood.
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, SP-10 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.
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.
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
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.
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:
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 Stomach-Qi. 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 Stomach-Qi 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 Liver-Qi 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. Ren-10 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.
Qi rebellious
Herbs
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
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.
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
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).
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!”.
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..
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..
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..
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..
Journal of Chinese Medicine (Zhong Yi Za Zhi 
) 32(12): 4..
Cited in Discussion about Formulae to Invigorate Blood and Eliminate Stasis, p. 43..
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..
Nanjing College of Traditional Chinese Medicine 1962 Gynaecology in Chinese Medicine(Zhong Yi Fu Ke Xue
), p. 23..