CHAPTER 53 Breast Milk not Flowing (and Acute Mastitis)

This condition consists of scanty or absent breast milk after childbirth. I have preferred the term ‘Breast Milk not Flowing’ to ‘Insufficient Lactation’ or ‘Agalactia’ because the last two terms both imply a deficiency, a lack of a vital substance; lack of breast milk, however, may be due not to a deficiency of milk but to an obstruction or stagnation that prevents the flow of milk.

Pathology

The pathology of insufficient or absent lactation can be clearly differentiated between deficiency and excess: breast milk may be deficient because its source, Blood, is deficient; or there may be enough milk but it does not flow properly due to stagnation of Qi in the breast. Fu Qing Zhu places a special emphasis on distinguishing between the two main causes of insufficient lactation: a deficiency of Qi and Blood; or stagnation of Qi in the breast. He also places special emphasis on the role of Qi in lactation.

To transform breast milk from Blood needs Qi’s action and to express it needs Qi’s power. This situation could be compared with that of water being pumped out of a reservoir: there may be plenty of water (breast milk) in the reservoir, but if the pump (Qi) is inefficient, the water will not flow.

Fu Qing Zhu says:

Breast milk is a product of the transformation of Qi and Blood. Milk cannot be generated without Blood, but it also cannot be generated without Qi … without Qi, breast milk cannot be transformed, without Blood it cannot be generated. Of the two, Blood is transformed into breast milk … In a woman after childbirth, Blood is exhausted … how can it be transformed into breast milk? It is due to the strength of Qi if Blood is transported and transformed into breast milk … if Qi is flourishing, milk is also flourishing, if Qi is depleted, milk is depleted.¹

Breast milk is a product deriving from the transformation of menstrual Blood by the Directing and Penetrating Vessels (Ren and Chong Mai): these two vessels are the source of menstrual blood below, and of breast milk above. Zhang Jing Yue says in his Complete Works of Jing Yue (1624):

Breast milk is a product of the transformation of the Qi and Blood of the Directing and Penetrating Vessels: downward movement of Qi and Blood produces the menses while upward movement produces milk. When there is insufficient lactation after childbirth, it is due to Qi and Blood deficiency … which is due to the depletion of the Directing and Penetrating Vessels.²

The Stomach channel also plays a role in lactation as it controls the breast as a whole, while the Liver channel controls the nipple. Fu Qing Zhu says: “Breast milk is transformed from Yang Ming [channel] which pertains to Earth.”³

While the main Empty cause of insufficient lactation is deficiency of Qi and Blood, the main Full cause of insufficient lactation is stagnation of Liver-Qi. As mentioned above, the Liver controls the nipple and it easily overacts on the Bright-Yang Channels (Wood overacting on Earth). Lactation relies on the power of Qi to transform Blood into milk and to express the milk properly. When Liver-Qi stagnates, it may hinder the flow of Stomach-Qi in the breast and create stagnation there with symptoms of distension, pain and milk not flowing.

Fu Qing Zhu emphasizes the role of stagnant Liver-Qi in hindering Stomach-Qi in the breast and it is significant that Dr Fu mentions “stagnation in the Bright Yang [Yang Ming]” rather than Liver-Qi stagnation. He says:

Distension, fullness and pain in the breast show that [the breast] would like to transform the milk but cannot do so, what else beside stagnant Qi could cause this? The stagnation in Bright Yang is due to shame and resentment.⁴

Thus, Fu Qing Zhu clearly identifies emotional problems as the chief cause of stagnation of Liver-Qi. The Literati’s Care of their Parents (Ru Men Shi Qin) by Zhang Zi He (1156–1228) also says: “Crying, weeping, sadness, anger, depression, may all cause the breast vessels not to flow.”⁵

Thus, we can also see the pathology of Breast Milk not Flowing in terms of Qi and Blood, with the former either deficient or stagnant and the latter only deficient (see Figure 53.1).

Figure 53.1 Pathology of Breast Milk not Flowing.

In terms of differential diagnosis, Breast Milk not Flowing should be distinguished from Breast Carbuncle (Ru Yong) which is also characterized by insufficient lactation but, in addition, by systemic signs such as shivers, fever, joint pain and a feeling of oppression of the chest: Breast Carbuncle corresponds to acute mastitis in Western medicine.

Identification of patterns and treatment

The patterns discussed are:

• Qi and Blood deficiency

• Liver-Qi stagnation.

Qi and Blood deficiency

Clinical manifestations

Insufficient or absent lactation after childbirth, watery milk, no feeling of distension of the breasts, sallow complexion, dry skin, poor appetite, tiredness. Tongue: Pale. Pulse: Choppy.

Treatment principle

Tonify Qi and Blood primarily: secondarily, remove obstructions from the breast Connecting channels.

Herbal treatment

a. Prescription

– TONG RU DAN

– Penetrating the Breast Special Pill

b. Prescription

– EMPIRICAL PRESCRIPTION from Dr Cong Chun Yu

Explanation

This formula is used if there is a condition of mixed deficiency and excess, with deficiency of Qi and Blood and some stasis of Blood, Heat and Phlegm in the breasts. Thus, in such a case, although the main problem is a deficiency of Qi and Blood, the breasts would be swollen, hot and tender. The tongue presentation appropriate to this formula is a Pale body but with slightly Red sides and Swollen with a sticky coating.

– Dang Gui and Huang Qi tonify Blood and Qi respectively; the high dosage indicates that this is the primary aim of the formula.

– Lou Lu resolves Toxic-Heat and promotes lactation.

– Dong Kui Zi drains Dampness and promotes lactation.

– Wang Bu Liu Xing and Chuan Xiong invigorate Blood and eliminate stasis.

– Gua Lou resolves Phlegm and affects the breasts.

– Tian Hua Fen and Bai Shao promote fluids and nourish Blood.

– Tong Cao and Mu Tong remove obstructions from the breast Connecting channels.

Women’s Treasure remedy

– PRECIOUS SEA

This remedy tonifies Qi and nourishes Blood. The tongue presentation appropriate to this remedy is a Pale and Thin body.

Liver-Qi stagnation

Clinical manifestations

Absent or scanty lactation, distension, hardness and pain of breasts, hypochondrial distension, irritability, epigastric distension. Tongue: slightly Red on the sides. Pulse: Wiry.

Treatment principle

Pacify the Liver, eliminate stagnation, move Qi, remove obstructions from the breast Connecting channels, promote lactation.

Acupuncture

T.B.-6 Zhigou, G.B.-41 Zulinqi, ST-18 Rugen, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), G.B.-34 Yanglingquan, LIV-3 Taichong, Ren-17 Shanzhong, S.I.-1 Shaoze, T.B.-3 Zhongzhu, BL-51 Huangmen, LU-9 Taiyuan, LIV-4 Zhongfeng, G.B.-21 Jianjing. All with reducing or even method.

Explanation

– T.B.-6 moves Qi and affects the sides of the breasts.

– G.B.-41 removes obstructions from the breast Connecting channels.

– ST-18 is a local point for the breast.

– SP-4 and P-6 subdue rebellious Qi in the Penetrating Vessel and pacify the Liver. The Penetrating Vessel flows over the breasts.

– G.B.-34 and LIV-3 move Qi, eliminate stagnation and pacify the Liver.

– Ren-17 moves Qi in the chest.

– S.I.-1 is an empirical point to promote lactation.

– T.B.-3 moves Qi and removes obstructions from the Upper Burner.

– BL-51 moves Qi of the Triple Burner in the breast region and removes obstructions from the breast channels.⁷

– LU-9 is recommended for ‘jealous breast’ (also called ‘grudging milk’, see below) with pain in the breast and insufficient milk, by Huang Fu Mi in the ABC of Acupuncture (AD 259).⁸

– LIV-4 is also recommended by the ABC of Acupuncture for insufficient lactation with abdominal distension and a dry throat.⁹

– G.B.-21 moves Liver-Qi, makes Qi descend and affects the breasts.

Herbal treatment

a. Prescription

– XIA RU YONG QUAN SAN

– Promoting Lactation Gushing Spring Powder

External treatment

– Apply a decoction of Pu Gong Ying Herba Taraxaci and Chen Pi Pericarpium Citri reticulatae.

Folk remedy

– A soup made of Wang Bu Liu Xing Semen Vaccariae, Chuan Shan Jia Squama Manitis and Tong Cao Medulla Tetrapanacis.

Three Treasures remedy

– FREEING THE MOON

This remedy is a variation of Xiao Yao San Free and Easy Wanderer Powder which pacifies the Liver, moves Qi and eliminates stagnation. The formula has been modified in such a way (with more herbs that move Qi and affect the breast) that it is more suitable than Xiao Yao San for breast problems. The tongue presentation appropriate to this remedy is a body that is slightly Red on the sides.

Women’s Treasure remedies

– FREEING CONSTRAINT

This remedy is a variation of the formula Yue Ju Wan Gardenia-Ligusticum Pill: it pacifies the Liver, moves Qi, eliminates stagnation, calms the Mind and settles the Ethereal Soul. It differs from the previous remedy in so far as it is for ‘pure’ Liver-Qi stagnation without Liver-Blood deficiency. For this reason, the pulse indicating the use of this remedy is quite Wiry and Full on both right and left. The tongue presentation appropriate to this remedy is a body that is Red on the sides (Liver area).

– PENETRATING VESSEL

This remedy is specific to subdue rebellious Qi in the Penetrating Vessel: it is therefore indicated when there are symptoms and signs of rebellious Qi in this vessel. As the Penetrating Vessel flows over the breasts, a stagnation of Qi in this channel may cause the breast milk not to flow. Other symptoms include abdominal pain, fullness and distension, a feeling of energy rising, a tightness of the chest, slight breathlessness, a feeling of lump in the throat and anxiety. This remedy subdues rebellious Qi in the Penetrating Vessel by nourishing Blood and the Kidneys within this vessel.

Liver-Qi stagnation

Clinical manifestations

Absent or scanty lactation, distension, hardness and pain of breasts, hypochondrial distension, irritability, epigastric distension. Tongue: slightly Red on the sides. Pulse: Wiry.

Treatment principle

Pacify the Liver, eliminate stagnation, move Qi, remove obstructions from the breast Connecting channels, promote lactation.

Acupuncture

T.B.-6 Zhigou, G.B.-41 Zulinqi, ST-18 Rugen, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), G.B.-34 Yanglingquan, LIV-3 Taichong, Ren-17 Shanzhong, S.I.-1 Shaoze, T.B.-3 Zhongzhu, BL-51 Huangmen, LU-9 Taiyuan, LIV-4 Zhongfeng, G.B.-21 Jianjing. All with reducing or even method.

Three Treasures remedy

• FREEING THE MOON

Women’s Treasure remedies

• FREEING CONSTRAINT

• PENETRATING VESSEL

Prognosis and prevention

Both acupuncture and herbs are effective for Breast Milk not Flowing and are the treatment of choice also considering that Western medicine has very little to offer. Herbs are probably more effective than acupuncture especially for treating deficiency of Qi and Blood. In fact, if lactation is insufficient because of a blockage due to Qi stagnation, acupuncture is good at clearing it; but if lactation is deficient because of lack of Blood, herbs are better at supplementing the deficiency.

In deficiency cases, it is important that the nursing mother eats easily digestible but also nourishing foods and especially foods that nourish Blood such as beef or chicken. If the woman is vegetarian she should pay great care and attention to eating enough protein of vegetable origin. As mentioned above, in China, pig’s trotter is considered the best type of food for insufficient lactation from a deficiency of Blood; many women may find this type of food unappealing, but it is eaten quite frequently in Mediterranean countries.

In insufficient lactation from stagnation of Qi, it is of course important that the woman avoids emotional problems and is, as far as possible, isolated from any source of irritation or worry.

Western view

The problem of insufficient lactation from not enough milk (i.e. from a deficiency according to the Chinese perspective) is given only a cursory mention in obstetrics books, perhaps because although there are drugs to inhibit lactation, there is none to increase it. Obstetrics books do give, however, indications as to how to ascertain that there is not enough milk, and that is by weighing the baby before and after every feed for 24 hours. If the mother is not producing at least 60 ml per feed and the baby is not gaining weight, then milk production is insufficient. Western books simply advise that the mother should eat and drink more.

The engorgement of the breast occurring a few days after childbirth roughly corresponds to the Full type of Breast Milk not Flowing from the Chinese point of view. If the baby does not empty the breasts sufficiently, they soon become engorged, distended, tender, hard and knotty. Once this condition is established, the congestion and pressure on the ducts prevent a proper flow of milk and the baby cannot empty the breasts: this clearly corresponds to Breast Milk not Flowing from Liver-Qi stagnation. From the Western point of view, manual expression of milk before each feed may help to relieve the congestion; alternatively, an electric breast pump may be used.

Appendix: acute mastitis

Acute mastitis and breast abscess broadly correspond to the Chinese disease ‘Breast Carbuncle’ (Ru Yong): this is characterized by redness, swelling, heat and pain in the breast and by red nodules which, after some days, rupture with the discharge of sticky pus. Judging from the description of clinical manifestations of Breast Carbuncle, the initial stages correspond to acute mastitis, the later stage, with the discharging nodules, to breast abscess.

Zhu Dan Xi describes the pathology and aetiology of Breast Carbuncle in some detail:

The breast itself pertains to the Bright-Yang channels, while the nipple to the Terminal-Yin channels. If the nursing mother does not know the principles of good nutrition, or if she is affected by indignation and anger, Qi will rebel upwards, her emotions of depression and a feeling of oppression are repressed, heavy-to-digest food brews inside, so that the Qi of the Terminal Yin [Liver] stagnates, the orifices are blocked and milk cannot come out. When the Bright-Yang Heat boils over, it transforms into pus. In some cases the feeding baby might have Phlegm stagnating in the diaphragm and his/her breath is burning hot; when this is blown on to the mother’s breast, hot Qi is blown which gives rises to nodules. Right at the beginning, one should overcome the pain and massage the nodules to soften them, thus when the baby sucks the milk flows and the nodules will be dispersed.¹⁴

Apart from the above-mentioned emotional causes, the ancient Chinese doctors differentiated two stages of breast problems after childbirth; the first, ‘Blow Breast’ (Chui Ru), was caused by the baby ‘blowing’ onto the breast and transmitting Heat to it; the second, Breast Carbuncle, developed from the first. The idea of the baby blowing onto the breast and transmitting its own Heat to the mother ties in remarkably well with modern medicine’s pathology of puerperal mastitis because, in most cases, this problem is due to infection with Staphylococcus aureus, with the baby being the most frequent source of infection. Very often breast infections occur in association with skin infections or umbilical cord infections which the baby has. Bacteriological investigations carried out during epidemics of breast infection with S. aureus have shown that if one baby in a nursery has the organism in its nose or mouth, almost all the other babies will be affected and so spread infection to their mothers.¹⁵

Fu Qing Zhu gives a similar interpretation of Breast Carbuncle:

The nipples pertain to the Terminal-Yin channels [Liver] and the breast itself to the Bright-Yang channels. A swelling of the breast with red nodules that after some days rupture and ooze a sticky pus which then heal, is due to Toxic Heat in Stomach and Gall-Bladder with stagnation of Qi and Blood and is called Breast Carbuncle which is easy to treat.¹⁶

There is yet another breast condition occurring after childbirth called ‘jealous breast’ or ‘envious breast’ (du ru), which could also be translated as ‘begrudging milk’ characterized by milk not flowing due to the baby’s inability to suck properly: the breast becomes engorged, hot, painful and hard, the milk does not flow, Qi and Blood stagnate, and the mother is thirsty and cannot bear the breasts being touched. According to the ancient doctors, this condition should be treated as soon as it appears by gently kneading the breast to disperse accumulation so that the milk flows and the baby can suck: if this is not done, Heat and pus may form and the condition develops into Breast Carbuncle.

Figure 53.2 illustrates the various types of breast conditions after childbirth and their relationship with Western puerperal diseases.

Figure 53.2 Breast conditions occurring after childbirth and their modern equivalent.

Fu Qing Zhu then gives detailed treatment principles for Breast Carbuncle according to clinical manifestations. He says:

If the breast is painful and hot and the woman feels hot and shivery, release the Exterior and expel pathogenic factors. If there is pain, pacify the Liver and clear the Stomach. If there is pus that does not flow out, expel it from within. If the flesh does not heal and watery pus flows continuously, tonify Stomach and Spleen. If pus flows and there are shivers and fever, tonify Qi and Blood. If there is inability to eat and vomiting, tonify Stomach-Qi.¹⁷

Treatment

The pathology of Breast Carbuncle after childbirth is always one of Heat and Toxic-Heat affecting the Liver, Stomach and Gall Bladder channels. Thus, the treatment principle is to clear Heat, resolve toxins, pacify the Liver, clear Stomach-Heat and resolve pus.

Acupuncture

G.B.-41 Zulinqi, ST-44 Neiting, LIV-2 Xingjian, L.I.-11 Quchi, SP-9 Yinlingquan, SP-6 Sanyinjiao, ST-40 Fenglong, ST-18 Rugen, P-6 Neiguan, T.B.-6 Zhigou. All with reducing or even method. No moxa.

Prescription from the Great Compendium of Acupuncture (1601)¹⁸

L.I.-8 Xialian, ST-36 Zusanli, G.B.-43 Xiaxi, LU-10 Yuji, BL-40 Weizhong, G.B.-41 Zulinqi, S.I.-1 Shaoze.

Prescription from Dr Wang Feng Jin ¹⁹

This prescription is for acute mastitis and, interestingly, places the emphasis of treatment on the Liver and Heart channels: Du-14 Dazhui, Du-12 Shenzhu, BL-15 Xinshu, BL-18 Ganshu, BL-17 Geshu, ST-15 Wuyi, G.B.-21 Jianjing, HE-1 Jiquan, P-6 Neiguan.

Herbal treatment

Folk remedies

– The mother should eat a gruel made from Yi Yi Ren Semen Coicis every day.

– To stop the milk production, two treatments may be applied, one external, the other internal. Externally, the mother should apply powdered Mang Xiao to the breasts, tightly wrapped in gauze. This should be renewed every day and she should also drink less. Internally, she should take a decoction of 60 g of (Chao) Mai Ya Fructus Hordei germinatus (fried) and 60 g of Shan Zha Fructus Crataegi daily for 3 days.

External use

– Apply a wash decocted from the following herbs: Dan Nan Xing Rhizoma Arisaematis preparatum, Ban Xia Rhizoma Pinelliae preparatum, Jiang Can Bombyx batryticatus, Bai Zhi Radix Angelicae dahuricae, Zao Jiao Ci Spina Gleditsiae. After decocting and straining, add fresh juice from 20 spring onions.

Fu Qing Zhu 1973 Fu Qing Zhu’s Gynaecology (Fu Qing Zhu Nu Ke ), Shanghai People’s Publishing House, Shanghai, pp 67–68. First published in 1827. Fu Qing Zhu was born in 1607 and died in 1684..

Zhang Jing Yue 1986 The Complete Works of Jing Yue (Jing Yue Quan Shu ), Shanghai Science and Technology Press, Shanghai, p. 678. First published in 1624..

Fu Qing Zhu’s Gynaecology, p. 68..

Ibid., pp 68–69..

Zhang Zi He 1217 The Literati’s Care of Their Parents (Ru Men Shi Qin), cited in Cong Chun Yu 1989 Chinese Medicine Gynaecology (Zhong Yi Fu Ke Xue ), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 192..

Wu Qian 1977 The Golden Mirror of Medicine (Yi Zong Jin Jian ), People’s Health Publishing House, Beijing, Vol. 3, p. 104. First published in 1742..

The action of this point can be explained by reference to the Triple Burner’s function of being the ‘ambassador’ or ‘avenue’ of the Original Qi (Yuan Qi) as it emerges from between the Kidneys: this is described in Chapter 66 of the Classic of Difficulties (Nan Jing). The Classic of Difficulties says that the Original Qi spreads to the five Yin and six Yang Organs through the Triple Burner, it enters the twelve channels and emerges at the Source points. From this point of view, therefore, the Triple Burner is the agent through which the Original Qi performs its functions in different parts of the body, and a proper, smooth flow of Qi of the Triple Burner is essential to this function. Clavey (in Fluid Physiology and Pathology in Traditional Chinese Medicine, Churchill Livingstone, Edinburgh, 1995, p. 21) gives an interesting, slightly different interpretation of the role of the Triple Burner in relation to the Original Qi. He says that the Triple Burner separates the initially undifferentiated Original Qi and directs it into different channels and organs to perform its various functions. Thus, the point BL-51, level with BL-22 Sanjiaoshu which is the Back-Transporting point of the Triple Burner, is situated in the area of the Kidneys, from where the Original Qi emerges. Gaohuang in the name of BL-51 indicates the Gaohuang region between the heart and diaphragm, including the breast, while the character men, meaning ‘door’, indicates that Qi comes and goes through this point or that this point is a crucial gateway for the passage of Qi. Thus, this point controls the entering and exiting of Qi of the Triple Burner in the breast region, hence its use to remove stagnation of Qi in this area. This point’s name should be seen in conjunction with that of BL-53 Baohuang; in fact, the Triple Burner penetrates upwards to the Gaohuang region (through the point BL-51 Huangmen) and downwards to the Baohuang region (through the point BL-52 Baohuang). ‘Baohuang’ indicates both the uterus and bladder..

Shandong College of Traditional Chinese Medicine 1980 An Explanation of the ABC of Acupuncture (Zhen Jiu Jia Yi Jing Jiao Shi ), People’s Health Publishing House, Beijing, p. 1478. The ABC of Acupuncture was written by Huang Fu Mi c. AD 259..

Ibid., p. 1480..

The Golden Mirror of Medicine, p. 104..

Hu Xi Ming 1990 Great Treatise of Secret Formulae in Chinese Medicine (Zhong Guo Zhong Yi Mi Fang Da Quan ), Culture Publishing House, Shanghai, Vol. 2, p. 74..

Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong ), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 26. Chen’s book, written during the Qing dynasty (1644–1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang) and published in 1729..

Wang Xue Tai 1995 Great Treatise of Chinese Acupuncture (Zhong Guo Zhen Jiu Da Quan ), Henan Science and Technology Publishing House, p. 496..

Han Bai Ling 1983 Bai Ling’s Gynaecology (Bai Ling Fu Ke ), Heilongjiang People’s Publishing House, pp 140–141..

Lewis T L T, Chamberlain G V P 1994 Obstetrics by Ten Teachers, Edward Arnold, London, p. 261..

Fu Qing Zhu’s Gynaecology, p. 120..

Ibid., p. 120..

Heilongjiang Province National Medical Research Group 1984 An Explanation of the Great Compendium of Acupuncture (Zhen Jiu Da Cheng Jiao Shi ), People’s Health Publishing House, Beijing, p. 1108. The Great Compendium of Acupuncture itself was published in 1601..

Wang Xue Tai (chief ed.) 1991 Medical Records of Famous Contemporary Chinese Acupuncturists (Zhong Guo Dang Dai Zhen Jiu Ming Jia Yi An ), Jilin Science and Technology Press, Jilin, p. 24..