加减通瘀煎 Jia Jian Tong Yu Jian Modified Opening Through Stasis Decoction

By way of introduction to this first chapter, I’d like to write a bit about women’s physiology and the tubular quality of the Ren vessel and the Bao Tai.  Though I have not heard of these pathways written or spoken of as “tubular” per se, thinking of them in this way has helped me to visualize and understand women’s physiology, patho-physiology and the use of herbs in formulas.  So, please bear with me…If we think of the Ren vessel/Bao Tai as a tubular pathway extending from the upper body (Heart and chest) to the womb, physiologically, this tube provides the route for the Heart fire to descend to warm the womb and for the Kidney water to ascend to control, moisten and cool the Heart.  This pathway allows the communication and interaction of fire and water between the upper Jiao and womb.  We can also see that what travels within this tube is the interaction of fire and water which is the red blood.  The scenario that requires the use of formulas like Jia Jian Tong Yu Tang (Modified Open Through Stasis Decoction), is characterized by blood in this tube becoming congealed and blocking the tube.  If we think about the Qi mechanism and the necessity for there to be a constant free flow of Qi up and down, we can see that a plug in this tube could cause a disruption in this free flow.  The Heart Qi and fire may be unable to move down to the womb.  This can cause a myriad of upward rebellion symptoms along with the primary pathology of the uterine contents, whether blood, lochia or fetus, failing to move out freely.

Dr. Xia’s Jia Jian Tong Yu Tang (Modified Open Through Stasis Decoction) is his foundational formula to, for lack of a better analogy, sort of blow the plug out like a spit ball out of a straw.

What we want to know how to do in the clinic is to recognize when there is this kind of plug in the tube – i.e. how to diagnose this.  Additionally we want to know which herbs discharge this manifestation of blood stasis and how to modify a formula for the various presentations we will see clinically.  The presentation may vary in terms of aspects such as excess/deficiency or heat/cold and it can also vary in terms of presenting symptoms such as headaches, insomnia or, as I mentioned in the last post, difficulty swallowing.  Main complaints can vary from PMS, dysmenorrhea, PCOS, endometriosis and infertility to amenorrhea.  We also want to know how to administer the purgative therapy safely – this has to do with careful diagnosis and timing of the treatment.

The main signs I use clinically to diagnose the presence of this “plug” is the combination of lack of free flow of the uterine contents with lower abdominal discomfort and fullness.  Lack of free flow by itself can be due to pathologies such deficiency of blood or Yin fluids or cold etc. in which case blowing out the plug would be unsuitable if not detrimental.  Lower abdominal fullness and discomfort could also be due to many pathologies such as uterine infection, simple blood stasis that does not block the menstrual flow or other stasis in the lower abdomen.

Lack of free flow of the uterine contents manifests as amenorrhea, scanty menstruation, menstruation the stops and starts, failure of the lochia to discharge or non progression of labor.  All of these pathologies can come form other disease factors besides this one and so it is very important that the lack of free flow is paired with fullness, pain or up-bearing symptoms.

The primary herbs that Dr. Xia uses for opening through menstruation here are:

Shan Zha

Qing Pi

Chuan Niu Xi

Ze Lan

Hong Hua

Tao Ren

We will see others in future posts.  It is important to notice that these herbs do have this kind of special indication.

Below is Dr. Xia’s writing on the 1st formula in the 7th chapter of his text.

Translated by Sharon Weizenbaum

Jia Jian Tong Yu Jian 加减通瘀煎 Modified Opening Through Stasis Decoction

Formula Name:

Tong 通 means to open the flow and Yu 瘀 is stasis and refers to blood stasis.  Jian refers to the method of cooking which is to boil.  Opening stasis refers to a strong method of transforming stasis.  One should use stronger vitalizing blood herbs when the intention is to open the passageways, free the flow of blood stasis, scatter and transform blood stasis.  Based on the pathological condition of the patients, I have modified Zhang Jing-yue’s Tong Yu Jian (Open Through Stasis Decoction) into my own experiential formula.

Formula Constituents:

Chao Dang Gui Wei     12 gm

Shan Zha                      10 gm

Xiang Fu                       9 gm

Hong Hua                    6-9 gm

Wu Yao                        6 gm

Qing Pi                        5 gm

Chuan Mu Xiang          9 gm

Ze Lan Ye                    10 gm

Chi Shao                      10 gm

Chuan Niu Xi               10 gm

Tao Ren                        6-10 gm

Method of Application

One package is for one day, divided into two doses.

Formula Function:

Regulates Qi and vitalizes the blood, opens through stasis and synchronizes the menstruation.

Formula Application

This formula treats blood stasis type late menstruation, scanty menstruation, prolonged menstruation and dysmenorrhea.

Formula explanation:

This formula treats blood stasis type irregular menstrual pathology.  This includes blood stasis type dysmenorrhea and amenorrhea presentations.  It places Dang Gui Wei in an important position for vitalizing blood and transforming stasis.  However, these days pharmacies do not discriminate between Dang Gui Wei, Dang Gui Tou and Dang Gui Shen.  Consequently we assist the function of Dang Gui to open stasis with Tao Ren and Hong Hua making this a stronger blood vitalizing formula. Zhang Jing-yue’s original formula contains Hong Hua but is without Tao Ren.  Tao Ren must be added.  Generally, because of the demands of opening through stasis, I base my formula on Tong Yu Jian (Open Through Stasis Decoction), though, according to the clinical presentation I also add Ze Lan Ye and Chuan Niu Xi to open the pathways of the menstruation.  The goal is to vitalize the blood while guiding its flow and opening through the menses. Therefore, in addition to using herbs to vitalize blood and transform stasis, one should also assist with herbs to synchronize and regulate Qi and move stasis.  The point is to first give herbs to move the menstrual Qi.  It is said that “When menstrual blood does not move, first move the Qi because when the Qi moves, the blood will move.  When there is Qi stasis, there is blood stasis and when there is blood stasis, the blood obstructs the Qi movement”.  Because of this, I add Xiang Fu, Wu Yao and Mu Xiang.  These 3 herb flavors regulate the Qi and synchronize the Qi of the Liver, Kidney and Spleen Zang.  When regulating Qi and moving stasis it helps to vitalize blood and open the menstruation and so you can add Qing Pi.  This herb helps promote easy flow and discharge and strengthens the regulating and synchronizing of the Liver Qi.  Because the Liver stores the blood and governs free flow and discharge, when you want to help the flow and discharge of the menstrual blood and this will regulate Qi and synchronize the menstruation.  Therefore when regulating the Qi and synchronizing the menstruation, one should lay stress on the Liver.  One can add Shan Zha.  Master Zhang uses this not only to vitalize blood and open the menstruation, but also to synchronize and regulate the Qi mechanism.  Because of all this, Jia Jian Tong Yu Tang (Modified Open Through Stasis Decoction) is frequently used in the clinic.

Clinical Application

According to Jing Yue Quan Shu: Fu Ren Gui (The Complete Works of Jing Yue: Women’s patterns), Tong Yu Jian (Open Through Stasis Decoction) treats Qi stasis, congealed blood, inhibited menstruation and vessels and extreme abdominal pain.  In addition to treating late menstruation, lack of smooth flow of menses and painful menstruation, Jia Jian Tong Yu Jian (Modified Open Through Stasis Decoction) can also treat post partum congealed blood excess pain as well as blood reversal or blood rebellion.

1.Late Menstruation, scanty menstruation and painful menstruation:
This formula can be used when there is scanty menstruate that does not flow smoothly.  This presents with abdominal pain that resists pressure, purple blood with dark with clots, pain and distention in the abdomen, chest oppression and vexation.  The pulse is thin and wiry and the tongue is purple and dark.  In this circumstance you can add herbs such as Rou Gui and Ze Lan Ye.

2.Post partum blood stasis abdominal pain:
During the post partum time, if the lochia stops too soon or does not flow out smoothly and this is accompanied by purple dark blood with clots, lower abdominal distention and pain, low back soreness and weakness with chest oppression, abdominal distention, purple dark tongue and a thin rough pulse, one should add Ze Lan Ye, Yi Mu Cao and Yan Hu Suo to this formula.

3.Blood stasis blood fainting: 
This presentation can be due to trauma from an accident, or it can simply manifest when there is scanty menstruation with abdominal pain.  The patient suffers from dizziness, fainting, cold limbs, nausea and vomiting, abdominal distention, a thin pulse and a purple dark tongue.  In this circumstance you can add herbs such as Shi Chang Pu, Guang Yu Jin, Zhi Mo Yao or Zhi Ru Xiang.

Modifications:

This formula is from the Jing Yue Quan Shu: Fu Ren Gui (The Complete Works of Jing Yue: Women’s patterns and it can be modified as below:

1.If there is cold stasis add Rou Gui and Wu Zhu Yu

2.If there is full fire with inner heat with blood that does not move due to dry blood add Chao Shan Zhi, Dan Pi.

3.With slight heat and blood deficiency add Bai Shao and Gui Shen.

4.With blood stasis with very scanty blood add Su Mu and Chong Wei Zi

5.With dry knotted stool add Da Huang and E Zhu or add Mang Xiao and Tao Ren.

Clinical Experience

Tong Yu Jian(Open Through the Menses Decoction) is really 3 formulas. 

1.Tong Yu Jian (Open Through the Menses Decoction) comes from the (Jing Yue Quan Shu: Fu Ren Gui (The Complete Works of Jing Yue: Women’s patterns).  My Jia Jian Tong Yu Tang (Modified Open through the Menses Decoction) was developed based on this formula and my own clinical experience.

2.The second formula is from the Xian Nian Ji (Immortal Collections): Vol. 4. This formula uses Gui Wei, Da Huang, Hong Hua, Su Mu.  These are strong herbs for dispelling stasis but in this formula the dosages are light.  It is for moving evil blood and is used primarily for dispelling when there is post partum congealed blood and stasis leading to poor flow of the menstruation.  This is considered evil blood.

3.The third formula is from Guang Lue Liu Shu: chapter 25. It uses Pu Huang, Wu Ling Zhi, Chuan Yu Jin, Xiao Zhi Shi, Bai Zhu Tang, Jian Ze Xie, Xi Chi Shao, Tao Ren Ni, Ming Hu Bo.  This formula is used to treat blood stasis in which the abdomen becomes filled with fluid.  The pulse is rough and not smooth.  In the Fang Lun Xuan Lu (Selected Writings on Formula Theory) it is written: “When blood stasis is not dispersed, the Spleen and Stomach loose their ability to be fortified and to transform and transport the minute essences.  The turbid Yin gets stopped up and this leads to abdominal distention and fullness.  This is called Blood Tympanites (Gu 臌).  Pu Huang cracks congealed blood, it opens the channels and collaterals.  Wu Ling Zhi cracks congealed blood and also descends the turbid Yin.  Tao Ren cracks the congealed and also moistens dryness.  Chi Shao cracks the congealed and also discharges fire.  Zhi Shi disperses distention and fullness. [Bai] Zhu Tan fortifies the Spleen Qi.  Yu Jin synchronizes the Qi and opens depressive knotting.  Ze Xie separates the clear Yang.  Hu Bo disperses congealed blood and allows open permeability, allowing the congealed to be transformed and for the Qi to be synchronized.  The result is that the Chong vessel is clear and harmonized, the Spleen and Liver Qi transform and the blockage is immediately opened.  How could abdominal distention not recede”?

What these formulas treat is not the same.  However, the meaning of the formulas is identical.  They can be used together in the clinic and adjusted according to the presentation.  When I use Tong Yu Jian (Open Through Stasis Decoction) in the clinic, I often add Shi Xiao San (Powder for Loss of Smile), Tao Ren, Ze Lan and Chuan Niu Xi.  This strengthens the force of transforming stasis and opening the menstruation.  This is because, when the menstruation is blocked and not flowing smoothly, this is usually related to congealed blood and Qi stasis.  So we can say that if we want to open the menstruation we must transform stasis.  If we want to transform stasis we must assist this by moving the Qi.  Qi and blood movement complement each other.  Therefore, in relation to illnesses of menstruation, the meaning of opening through stasis is to open through the menses and transform stasis.

In my own clinical practice I see patients who have serious endometritis.  This may develop after dilation and curettage surgery and it can give rise to adhesions of the uterine cavity.  The degree of adhesions can vary as can the extent to which it influences the menstruation.  It may give rise to scanty menstruation or even amenorrhea.  In general though, this is due to stasis and obstruction in the uterus with lack of free movement of the blood. Tong Yu Jian (Open Through Stasis Decoction) can treat this but the effect is only good in relatively light cases.  For more serious cases surgery must be used to sever the adhesions and this formula can be used after that.

Detailed analysis of the principle herbs in this formula: Hong Hua and Shan Zha.

There are three principle herbs in this formula: Dang Gui Wei, Hong Hua and Shan Zha.  Dang Gui Wei is represented by Dang Gui and has been discussed in previous chapters so here I will discuss Hong Hua and Shan Zha.

Hong Hua

Hong Hua is also called Hong Lan Hua.  It is pungent and its nature is warm.  It enters the Heart and Liver.  Its function is to vitalize blood and open through menses.  It dispels stasis and stops pain and can be used for congealed blood type amenorrhea and post partum congealed static blood abdominal pain.   The Ben Cao Guang Mu (The Grand Compendium of Materia Medica) considers Hong Hua an herb to “vitalize blood, moisten dryness, stop pain, disperse swelling and open through the menses”.  It also says “Blood is generated in the heart wrapper, stored in the Liver and belongs to the Chong and Ren vessels.  Hong Hua is the likeness of blood and therefore, in men it is able to move the blood vessels and in women it opens through the menstrual water.  In large amounts it moves the blood and in small amounts it nourishes the blood.  The Ben Cao Hui Yan (Treasury of Words on the Materia Medica) says “Hong Hua cracks the blood, moves the blood, vitalizes the blood and synchronizes the blood.  Primarily it is used to treat the 100 diseases of pregnancy and birth in which the blood is damaged.  It is also used to treat blood vexation, blood dizziness, unconsciousness with an inability to speak, the lochia striking the Heart, gripping pain around the umbilicus, difficult birth, uterine lining failing to discharge or expired fetus in the abdomen.  All of these are presentations of birthing which Hong Hua can treat.  If there is post partum blood dizziness, lock jaw with clenched fists or an evil enters the blood chamber with incessant talking to the point of craziness or blood oppression with interior distention and the patient falls over stiffly as if dead.  These are all post partum presentations for which Hong Hua cannot help but calm.  If there is amenorrhea with no opening through with cold and heat mixed together or late menstruation with abdominal pain and dark purple dripping or traumatic injury with Qi and blood congealed and accumulating – these are all due to a lack of harmony of Qi and blood.  How can Hong Hua fail to synchronize”?

Shan Zha

Shan Zha is sweet and sour and its nature is slightly warm.  It enters the Spleen, Stomach and Liver channels.  Its function is to disperse food and fortify the Stomach.  When we analyze the pharmo-dynamics of Shan Zha we see that it increases the secretion of the digestive enzymes and is also able to promote the digestion of fats.  This is accompanied by an ability to strengthen Heart function and lower the blood fat. This can be used for presentations that include indigestion, post partum congealed obstructed abdominal pain, hernia and chest obstruction heart pain. The Shen Nong Ben Cao Jing Shu (Commentary on ‘Shen Nong’s Classic of the Materia Medica) says “Shan Zha enters the foot Yang Ming and Tai Yin channels.  The Ben Jing Classic of Materia Medica says that the flavor is sour and the Qi is cold.  That this is able to disperse the digestion and move congealed blood indicates that it is not cold.  Shan Zha is able to enter the Spleen and Stomach, scatter abiding accumulated stasis and water dysentery with post partum blocked pain in the abdomen. Generally Shan Zha is thought to transform food and fluids, fortify the Spleen and Stomach, move knotted Qi and disperse congealed blood.  Because of this it is a suitable food for children and birthing women.  The Ben Jing Classic of Materia Medica also says that this is cold and so it has a function as a wash for scabies.  We can see that fundamentally Shan Zha fortifies the Spleen and disperses food stasis.  It also functions to vitalize the blood, transform stasis and disperse accumulated stasis.

Practical Experience

Tong Yu Jian (Open Through the Menses Decoction) is a formula I use frequently in the clinic for lack of free flow of the menstruation.  I often use it with Yue Ju Wan or Wu Wei Tiao Jing San (Tang).  The results are quite good.  For acute abdominal pain use Hong Hua Jiu and the pain will stop.  The Jin Gui (Essentials From The Golden Cabinet) discussed early on that the single flavor Dang Gui in Dang Gui Wan (San) is used for painful menstruation.  The Xian Dai Zhong Yao Xue Da Ci Dian (The Modern Great Dictionary of Chinese Herbs) says that as a principle herb, Shan Zha treats functional dysmenorrhea.  Use 30 gm without the pit, Sunflower seed with the husk 15 gm.  After roasting, grind these into a powder and add 60 gm of brown sugar.  Take one package a day divided into 2 doses or decoct.  Every time before the menses take two packages and do this for 2 cycles.  I treated 105 patients: 30 had a cure, 50 improved and 25 were without effect.  The effect was good for those with blood stasis and deficiency cold.

I treated one case of long cycle.  Ms. Zhang was 35 and her menstruation was scanty and did not flow smoothly.  The color was purple red with small clots and there was lower abdominal acute pain.  When she bled this pain lasted for 12-15 days.  She had an IUD.  Her gynecology and bi-manual check-up revealed no abnormalities and the position of the IUD was normal.  It had been there for 5 years.  Her menstruation had lengthened for the last 5 months.  Her pulse was thin and wiry and her tongue body was dark red with a yellow sticky moss.  On the first day of her menstruation, I gave her 7 packages of Jia Jian Tong Yu Jian (Modified Open Through the Menses Decoction). She stopped bleeding after 8 days.  At the next menstruation I again gave her 7 packages of Jia Jian Tong Yu Jian (Modified Open Through the Menses Decoction).  She bled for 7 days and on day 2 and 3 the amount of blood increased.  She then resumed a normal menstrual cycle.

Dr. Xia is the director of the Gynecology Department at the Affiliated Hospital in Nanjing and professor of Gynecology at the Nanjing University of Tradition Chinese Medicine.  Bringing  over 50 years of experience and insight to his writings, he is not only a highly effective practitioner, he is also a clear teacher/writer.  His material is written in a way that guides the student/practitioner through the necessary steps to gain understanding.

He has pioneered the articulation of the theories that direct us to work with the ebb and flow or Yin and Yang in relation to the menstrual cycle.  He applies this understanding to all areas of gynecology in great detail.  It is no surprise, after reading his books, to discover that he has become know as a manifestation of Guan Yin, the Chinese goddess who come to the aide of women and children.  Though he is perhaps best known in the West for his work with modifying formulas according the the timing of the menstrual cycle, Dr. Xia pays such close attention to the details of patho-physiology in combination with the function of formulas and the individual herbs within them that his books are really a treasure trove of useful gems.  In this particular series, I will be paying attention to his work with blood stasis and the idea of “opening through” in relation to women’s physiology, patho-physiology and menstruation.  These ideas have many implications in the treatment of women including but going beyond the treatment of dysmenorrhea and infertility.

Most entry level Chinese herbalists have a very limited idea of gynecological blood stasis, it’s diagnosis and treatment.  This becomes very apparent as the practitioner works with women in the clinic and finds that so much of what was learned in school simply doesn’t work or works in a way that is far from ideal.  Poor clinical results can be frustrating but they can also push us to learn more and can help our diagnosis and treatments become more nuanced. For me, less than excellent results have pushed me to research many topics, including the topic of “opening through” in relation to gynecology.  This topic also brings up the concept of a more nuanced use of individual herbs.  In relation to blood stasis – many of my own students don’t come in with much more of an understanding of blood stasis herbs other than that they all move the blood and that they should therefore not be used when there is heavy bleeding or during pregnancy.  And yet, through experience we learn that sometimes we must strongly move the blood in order to stop heavy bleeding and that sometimes moving the blood can help prevent a miscarriage.  We also learn that all blood vitalizing herbs are not equal to each other nor the same as each other.  They range from strong to weak and from cold to hot.  Some are especially good at stopping pain, others are especially good improving the quality of the blood itself.  Here is a bit of a preliminary list just some of the various functions of some individual blood vitalizing herbs:

Stopping pain

Softening hardness

Cracking stasis

Warming the blood

Regulating the Qi within the blood

Stopping bleeding

Harmonizing the blood

Nourishing the blood

Supplement the Kidneys

Descend the Heart blood to the uterus

Cool the blood

Relieve constipation

Open up the chest and breast area

And finally blood vitalizing herbs that function to “open through” the menstruation…..

I first noticed that there was something going on with this idea of “opening through” when I was working beside my teacher Dr. Sheng Yufeng, in Hang Zhou, PRC.  I was constantly trying to figure out why she would use particular herbs in particular situations.  I noticed that there were times she would give a formula for blood stasis and include herbs like Huai Niu Xi or Chuan Niu Xi along with herbs such as Su Mu, Chong Wei Zi and Shan Zha.  I wanted to know when and why she used these herbs.  It was not until I found the writings of Dr. Xia Guicheng that these ideas were fulling articulated for me.  Since studying these writings, the diagnosis and appropriate treatment methods for of some patients in my clinic has become clearer and the treatment results improved.

So, what is this “opening through”?  I am translating the character 通, tong1. as “opening through”.  The Eastland Press glossary translates this as “unblocks, promotes, pervades”.  Wiseman and Ye’s Practical Dictionary of Chinese Medicine, Second Edition translates this term variously as “free, open, restore flow, unstop and connecting.  Thinking of this as “opening through” just what gets opened through?  This term is used when the Luo vessels, the channels, the Qi, the lactation, the bowels, the nasal passages, the blood vessels, the urination, the Ren vessel and finally, the menstruation are blocked. What I want to point out in relation to all of these functions is that what is being “freed” or “opened” or “connected” all relates to structures in the body that are tubular.  This is why the idea of “opening through” is useful.  It gives us the image, not only of blockage, but of a tube that is blocked up and needs to be opened.  Though the term “unblocking” may suffice, it does not convey the image of a tube that should be open end to end the way that “opening through” does.  I have to admit “opening through” is a rather bulky term though, but at least for now, I’d like to use it to effectively illustrate the physiology, patho-physiology, treatment principles and function of herbs.

A bit more about the character tong1 通. It is made up of two parts. The first is this: 甬 yong3 which carries the meaning of path or corridor.  The second is 辶 chou4, which carries the meaning of walking or going.  So altogether we have the meaning of movement through a corridor or path.   When we take the 甬 yong3 corridor or path part of the character and combine it with the disease radical getting 痛 tong4, meaning pain.  In other words, when the corridor is pathologically effected, there is pain.  The characters 通 and 痛 are the one’s that are in the famous saying 通则不痛，不通则痛,  or when there is opening through there is no pain and when there is no opening through there is pain.

So what is this tube that is related to “opening through” the menstruation?  This tube is related both to the Ren Vessel and to the Bao Tai, which connects the upper body, especially the Heart and chest, to the uterus.  This tube can get blocked up and when it does, it needs to get opened through from end to end.  Various symptoms can arise when this tube gets blocked up including amenorrhea, scanty menstruation, lack of free flow of menstruation, painful menstruation, heavy menstruation and infertility.  Upper Jiao symptoms can involve the breasts, the head, the emotions or even cause bleeding in the upper warmer as the menstrual blood fails to descend.  The blockage can effect the middle Jiao as well.  Recently I successfully treated a woman with Achalasia, which involved difficulty swallowing and esophageal spasming that was worse premenstrually, integrating the method of opening through the menstruation.  In general, when the menstruation is not open through, a failure of the downward movement of the Qi mechanism can lead to a whole variety of upward rebelling symptomatology in addition to the lower warmer issues.

Before moving on to the entries that include the Dr. Xia’s writings on this topic, I want to include a bit about how he organizes his discussions in his book, Gynecology Formluas and Herbs from Clinical Experience and Study in Fifteen Chapters. In this text, Dr. Xia has a whole chapter devoted to the idea of “opening through”.  He divides this chapter into 8 parts, each part being represented by one of his “opening through” experiential formulas.  He begins with a basic formula Jia Yu Tong Yu Jian (modified Opening Through Stasis decoction) which is based on Zhang Jingyue’s formula Tong Yu Jian (Opening Through Stasis decoction). He uses this formula as a jumping off place for the deeper, more detailed discussion of the topic.  The formulas that follow morph off of the original idea in the variety of ways that Dr. Xia sees most often in his clinical work.  By carefully going through each chapter, the practitioner learns, not only about these particular formulas but so much more.  We learn how to modify a formula to suit a variety of clinical realities but more importantly, we learn about women’s physiology and patho-physiology in great depth.  Finally, we learn about the individual herbs and their nuanced and careful use.  It is like looking at an issue through a variety of lenses until we feel we have quite a complete understanding.  I’ve not previously seen texts organized in this manner and have found it to be an excellent way to transmit his valuable information.

So, stay tuned!  Dr. Xia’s writings will soon be posted here!

If the menstruation is late or scanty with dysmenorrhea and mental dysphoria I often use Mei Gui Hua 1 gm, Yi Mu Cao 1 gm, Ji Xue Teng 20 gm, Dan Shen 15 gm, Dang Gui 10 gm, Chuan Xiong 6 gm, Bai Shao 10 gm, Fu Xiao Mai 15 gm, Hong Zao 10 gm decocted in water.

If there is red or white leucorrhea, the color being sometimes dark and sometimes pale, dripping without stopping and accompanied by vaginal itch with a bad smell, whole body fatigue, vexation and easy anger, I often use Mei Gui Hua 10 gm, Dang Gui 10 gm, Chuan xiong 6 gm, Dan Shen 15 gm, Mu Dan Pi 10 gm, Tu Fu Ling 20 gm, Yi Mu Cao 10 gm, Chuan Duan 10 gm, Bai Zhu 10 gm, Ze Xie 10 gm, Gan Cao 6gm decocted in water.

If a woman easily catches colds before her menstruation with whole body fatigue, breast distention and pain, vexation and a tendency to anger, heart palpitations, insomnia, poor appetite and this is accompanied by edema, dysmenorrhea, dark menstruation that is scanty, stagnant and mixed with clots, I often use Mei Gui Hua 15 gm with Fou Shou Hua 10 gm, Bai Shao 10 gm, Dang Gui 10 gm, fu Ling or Fu Shen 6 gm, Dan Shen 15 gm, Zhi Shi 6 gm, Yi Mu Cao 10 gm, He Ye 10 gm and Hong Zao 10 gm, decocted in water.

When a woman is nearing the age of 50, her menstruation decreases and the cycle becomes irregular and the amount varies.  This may be accompanied by vexatious heat, heart palpitations, insomnia and whole body fatigue.  In this kind of case I often use Mei Gui Hua 10 gm with Fu Xiao Mai 20 gm, Hong Zao 15 gm, Yi Mu Cao 10 gm, Chuan Duan 10 gm, Ji Xue Teng 20 gm, Shan Zhu Yu 10 gm, Ze Xie 10 gm and Dan Shen 15 gm, decocted in water.

In short, Mei Gui Hua body is light and it is fragrant and refreshing.  It is able to course the Liver and refresh the Spleen.  It makes the blood sufficient and the Qi full.  It will dispel stasis and generate the new.  It can be combined with either Yin or Yang formulas and either way it will open and smooth the Qi mechanism and harmonize the blood vessels.  The goal of treatment will be attained.

The relationship between the breasts and women’s disharmonies such as amenorrhea, dysmenorrhea and infertility.

Ji Mai San Case Example 4

Ms. Chang was twenty-five when she came for her first visit on December 13, 1976. She had been married for three years without becoming pregnant. Premenstrually she suffered from breast distention and pain each month and her menstruation was early or late without regularity. The amount was profuse and continued for six to seven days. During menstruation her bowels were sticky and each day moved repeatedly. Her pulse was sinking and thin and her tongue moss was sticky. Her pulse and pattern corresponded.

My differential diagnosis of Ms. Chang’s condition was Liver depression and Qi stasis and Spleen vacuity causing the Spleen to lose its ability to transport. The treatment needed to course the Liver and fortify the Spleen. I gave her seven packages of the following prescription:

Chai Hu                     Radix Bupleurum                                9gm.

Bai Ji Li                      Fructus Tribuli                                   9gm.

Ba Yue Zha                Fructus Akebiae                                 9gm.

Bo He                        Herba Mentha                                     4gm.

Qing Pi                      Pericarpium Citri Immaturus                4.5 gm.

Wang Bu Liu Xing     Semen Vacarri                                      9gm.

Ju He                          Semen Citri                                        4.5 gm.

Ju Luo                        Vascularis Citri                                    4.5 gm.

Chao Bian Dou          Stir-fried Semen Dolichoris Lablab     12gm.

Da Mai Ya                 Fructus Hordei Germinatis                   15gm.

Shen Qu                    Massa Fermentata                                 9gm.

Second Visit: December 22, 1976. Ms. Chang’s case presented as before. I continued with the previous method with some additions and subtractions and gave her seven packages of the following prescription:

Chai Hu                     Radix Bupleurum                                    9gm.

Bai Ji Li                      Fructus Tribuli                                       9gm.

Ba Yue Zha                Fructus Akebiae                                     9gm.

Wang Bu Liu Xing     Semen Vacarri                                          9gm.

Ju He                          Semen Citri                                            4.5 gm.

Ju Luo                        Vascularis Citri                                        4.5 gm.

Da Mai Ya                 Fructus Hordei Germinatis                       15gm.

Shen Qu                    Massa Fermentata                                     9gm.

Jiao Dong Zhu            Scorched Rhizoma Atractylodis                4.5 gm.

Chao Chuan Xiong      Stir-fried Rhizoma Ligusticum                4.5 gm.

Zhi Ji Nei Jin                 Honey fried Endothelium Galli Gigerii     9gm.

Hong Hua                   Flos Carthamis                                         9gm.

Chao Shan Zha             Stir-fried Fructus Cratagai                          9gm.

Dang Gui Radix             Angelica Sinensis                                   9gm.

I gave Ms. Chang the above prescription with additions and subtractions according to her pattern for an interval of over two months. Her menstruation became regular and this year she became pregnant.

Discussion:

In terms of infertility and unsynchronized menstruation due to Liver depression and knotting, I use my proven prescription, Ii Mai San Tribulus Germinated Barley Powder. It has great, unsurpassed effectiveness for this category of pathology.

Gui Xian Tang

Herbal Constituents:

Yin Yang Huo15

Xian Mao9

Rou Gui1.5 (stirred into hot liquid)

Rou Cong Rong9

Ba Ji Tian9

Zi Shi Ying15

Decoct in Water

Function: Warm the Yang, warm the womb, fill the Jing and boost the Kidneys.

Principle indications:  Kidney Yang insufficiency, amenorrhea due to vacuity cold in the uterus, infertility.

Formula explanation:  The Chong is the sea of blood and the Ren envelopes the Fetus.  When the sea of blood in empty and the uterine envelope suffers from deficiency cold, just like when the earth is frozen cold, the grasses and trees cannot grow and the abyss of the deep Yin cannot give life to fishes and dragons, in this way how can the uterus give birth to life?  This can cause infertility or amenorrhea.  Yin Yang Huo, Xian Mao, Ba Ji Tian, Rou Gui, Cong Rong and Zi Shi Ying warm the Kidney and the Heart.  When the Heart and Kidney Qi are flourishing, fire is spontaneously generated and the ministerial fire is filled, the Chong and Ren vessels become abundant, the uterus is then warmed and the Bao Tai cold is spontaneously scattered.  This causes the alchemical transformation like the qi of the warm spring days and the menstruation becomes pregnancy.

When the Liver is depressed and qi is stagnant, add Xiang Fu, Xiao Hui, Yan Hu Suo and Mu Xiang.  If the blood is deficient, add Dang Gui and Dan Shen.  If there is Kidney deficiency, add Gou Ji, Xu Duan and Tu Si Zi.

Case 2 from the practice of Dr. Qiu Xiao-mei  The relationship between the breasts and women’s disharmonies such as amenorrhea, dysmenorrhea and infertility.

Ji Mai San Case Example 2

Ms. Wu was twenty-eight years old when she came for her first visit on December 8, 1976. She had been married for four years without becoming pregnant. At a hospital she underwent an iodized oil radiograph which showed that her uterus was crooked and collapsed. Her two fallopian tubes were unobstructed. By her own report she suffered from premenstrual abdominal pain and breast distention. Her pulse was sinking and thin and her tongue was red and moist. For treatment it was appropriate to course the Liver and rectify the Qi while simultaneously boosting the Kidney. I gave her the following prescription:

Ju He and Ju Luo        Semen et Vascularis Citri                    Each 4.5 gm.

Chai Hu                         Radix Bupleurum                                 9 gm.

Bo He Gen                     Herba Menthe                                     4.5 gm.

Bai Ji Li                            Fructus Tribuli                                     9 gm.

Da Mai Ya                     Fructus Hordei Germinatis                 15 gm.

Fu Pen Zi                        Fructus Rubi                                         9 gm.

Tu Si Zi                         Semen Cuscutae                                     9 gm.

Che Qian Zi                 Semen Plantaginis                                     9 gm.

Gou Qi Zi                     Fructus Lyci                                                 9 gm.

Wu Wei Zi                     Fructus Schizandra                                 4.5 gm.

Shu Di                            Prepared Radix Rehmannia                     30 gm.

Zhi Shou Wu                 Prepared Radix Polygoni Multiflorum     15 gm.

I gave Ms. Zhou more than twenty packages of this prescription with additions and subtractions according to her changing signs and symptoms. By February of the next year she had become pregnant.

Discussion:

This example of infertility appeared with premenstrual abdominal pain and breast distention. The pulse was sinking and fine and the tongue was red and moist. These manifestations relate to Liver depression and Kidney vacuity. Therefore I used modified versions of Ji Mai San [Tribulus and Germinated Barley Powder] and Wu Zi Yan Zong Wan[Five Seed Develop Ancestor Pill].  When the Liver and Kidneys were synchronized the result was obtained quickly.

Sharon’s Commentary:

This case shows Dr. Qiu’s ability to treat a mixed presentation by stringing formulas.  The patient was suffering from both Liver Qi stasis and Kidney Qi deficiency.  The symptoms of premenstrual abdominal pain and breast distention show us that there is Liver Qi stasis.  Her thin deep pulse showed deficiency.  The deficiency and stasis both help explain the misplaced and prolapsed uterus.

Often, when I was sitting in clinic with Dr. Qiu, she would mention that she was using a formula and yet just use two or three ingredients from that formula.  At times she would add just the two seeds Tu Si Zi and Gou Qi Zi to a formula and call this Wu Zi Yan Zong Wan. Many times she would add Chai Hu and Bo He to a formula and say she was using Xiao Yao San.  Over time she taught me to see and use the ideas a formula represents rather than simply being strict about using the entire formula.  This is one of the ways to incorporate the flexible use of formulas.

This case also illustrates Dr. Qiu’s use of Ji Mai San in cases in which there is premenstrual breast distention, especially when this is related to infertility.

Comment from Steven Clavey

I don’t remember who said it first, but a very old saying in Chinese gynecology is “If her breasts are sore, and she is trying to get pregnant, fix the sore breasts first.”
Over the years I have found that pretty good advice. Generally, aside even from the qi blockage that sore breasts evidence, there is usually fluid retention. And if the breasts are holding fluid, chances are the fallopian tubes are holding fluid (to some extent) too, and thus no longer moving with the agility a good tube should have. So if I see any signs of fluid retention in cases like this, I will usually add Fu Ling or Che Qian Zi to a qi-moving formula (like Ji Mai San, or Xiao Yao, or Chai Hu Shu Gan) to help things along.

The relationship between the breasts and women’s disharmonies such as amenorrhea, dysmenorrhea and infertility.

Ji Mai San Case Example 1

I treated a woman named Guo who was 35 years old.  She had been married 7 years with no pregnancy.  Her menstruation came regularly but premenstrually she had breast pain and distention for two weeks.  When her breast was palpated, there were many scattered small seed-like lumps.  The pain extended to below her armpit and when she bent and stretched her arm it was uncomfortable.  She had suffered with this for 10 years.  The surgery department diagnosed her with breast lobular hyperplasia.  Her Traditional Chinese diagnosis was breast lump.  Her pulse was deep and thin and her tongue had a thin moss.  I gave her Ji Mai San for two months after which the breast distention, pain and knotting was gone.  She was without discomfort.  I advised her to continue and follow-up in three months.  When I saw her she had not menstruated for 5 days and the urine test came back positive for pregnancy.

Sharon’s commentary:

This case shows not only how Ji Mai San can treat hyperplasia of the breast, it also illustrates the relationship between the presence of breast distention, pain and lumps to infertility.  As Dr. Qiu wrote in the last blog entry, this formula is prescribed to treat the Qi dynamic and, in particular, the Liver Qi.  What is important to see here is that congestion above, in this case in the breasts, indicates stasis and a general lack of receptivity below, in the womb.  In some women this can manifest to the extent that the breasts actually discharge milk while there is amenorrhea below.  The directionality of this formula is downward.  Ji Mai San descends the Qi from the Shao Yang breast area back to the womb.

What I have found in the clinic is that all or parts of Ji Mai San can be used to treat women who are suffering from PMS in which breast distention is a symptom, as well as women suffering from stasis type amenorrhea or infertility.  We will see in some of the cases to come how Dr. Qiu modified and combined Ji Mai San to treat women with combined stasis and phlegm, stasis and congealed blood and stasis and various deficiencies.

Comment from Steven Clavey:

Supplementing Certainty

The Treatment of Premature Rupture of the Placenta

By Dr. Qiu Xiaomei

Translated By Sharon Weizenbaum

Bu Jue Tang, Supplement Certainty Soup

Herbal Constituents:

Ren Shen Radix Ginseng, (or Dang Shen Radix Codonopsis) 30 gm.
Huang Qi Radix Astragalus 24 gm.
Bai Ji Mo Rhizoma Bletillae Striatae Powder 6 gm. (Stir in)

Method: Decoct in water

Function: Consolidate Qi, absorb Blood, “Weeds through the old to bring forth the new”, stops bleeding and engenders flesh.

Principle Use: Early detachment of the placenta

Formula Explanation: This prescription contains Huang Qi Radix Astragalus which has a warm quality and a sweet bland flavor. It is able to raise Yang and supplement Qi, as well as heal wounds and grow flesh. It is also able to absorb blood and stop bleeding, consolidating so that the bleeding spontaneously stops. Ren Shen Radix Ginseng, (or Dang Shen Radix Codonopsis) increases strength, supplements the middle and boosts the Qi. Bai JiRhizoma Bletillae Striatae sticks and pastes, takes in and closes and repairs damage. Therefore this prescription is called supplement certainty soup. It has a very good effect for early detachment of the placenta.
San Qi, Radix Notoginseng is not in the prescription because its warm nature will tend to scatter. Bai Ji Rhizoma Bletillae Striatae is astringent and can cause closure. It also has the ability to rid the rotten, drive out the congealed and generate the new.
Early detachment of the placenta, according to the doctors of previous dynasties is called pregnancy Blood Beng in gynecology. In 1960 I worked in an obstetric practice and had the opportunity to make a careful observation of many patients. I sought the cause and examined the source. The term bo li means to peel and part from. I considered this term deeply and originated Bu Jue Tang, Supplement Certainty Soup and have found if effective in practice.

Case Study

Ms. Ma was a thirty-six-year-old teacher when she came to my clinic on May 18, 1960. She was seven months pregnant with triplets. The day before she had gone out on a spring outing. That evening she experienced pain in her lower left abdomen with simultaneous lower back pain and a dropping down feeling. During her sleep a moderate amount of vaginal bleeding began like a menstrual period. A western medical check up showed that her placenta was prematurely rupturing. She was then admitted into the hospital.

Ms. Ma’s pulse was thin, slippery and without strength, her tongue moss was thin and white and her facial color was dull white and looked as if she was in pain. I gave her Bu Jue Tang, Supplement Certainty Soup.  After three packages of it the vaginal bleeding stopped. She left the hospital after an examination revealed her placenta to be correct and appropriately dense. Thereafter she returned home and later gave birth at term without difficulty. The baby weighed 6.8 lbs.

Discussion: When a woman is six to seven months pregnant and there is a sudden manifestation of bleeding, this is called “pregnancy blood Beng”. The cause is often over work or anger damaging the Liver. This can cause the fetal Qi to be restless and the Chong and Ren Mai to loose their consolidation. In this kind of case it is appropriate to treat the symptoms and manifestation as well as the cause. Ms. Ma was seven months pregnant with early detachment of the placenta. I gave her Bu Jue Tang, Supplement Certainty Soup which is similar to Li Dong Yuan’s method of using Ren Shen Radix Ginseng, (or Dang Shen Radix Codonopsis) and Huang Qi Radix Astragalus to supplement the Qi and raise and lift. I use Bai Ji Rhizoma Bletillae Striatae to remedy the breaking of the placenta from the wall of the uterus and stop bleeding. This relates to this prescriptions ability to mend. Although there are only a few flavors used it has an amazing effect. San Qi Radix Notoginseng is not in the prescription because its warm nature will tend to scatter. Bai Ji Rhizoma Bletillae Striata is astringent and can cause closure. It also has the ability to rid the rotten, drive out the congealed and generate the new.

Dr. Huang Huang writes on Zhi Gan Cao Tang

Formula Constituents

Zhi Gan Cao        12-24 grams

Sheng Jiang            9-18

Ren Shen            6-12

Sheng Di Huang  50-100

Gui Zhi                    9-18

E Jiao                    6-12

Mai Men Dong     12-24

Huo Ma Ren         12-24

Da Zao                 30-60

Formula Cooking Method

For the above 9 ingredients, use seven sheng of clear wine and eight sheng of water.  First boil eight ingredients to get three sheng and remove the dregs.  Add the E Jiao and warm until it is completely dissolved.  Take one sheng warm and drink 3 times a day.

Original Text

1.When there is cold damage, knotted pulse and heart pulsations, Zhi Gan Cao Tang rules (177)

2.The Qian Jin Yi says that Zhi Gan Cao Tang returns the pulse:  It treats deficiency and depletion with sweating and stuffiness with knotted pulsations. This keeps going without cease.

3.The Wai Tai says that Zhi Gan Cao Tang treats Lung wilt with excessive saliva and 温温液液 (?) in the heart. (Jin Gui Yao Lue, chapter 7 appendix)

Formula Presentation

1.Knotted pulse and heart pulsations

2.Emaciation with a wan withered facial complexion and dry skin

3.Cough, chest oppression, shortness of breath and bleeding.

Formula Application

1.Viral carditis

2.Abnormal sinus syndrome

3.Rheumatic heart disease, coronary heart disease and 高心病.  (?)

4.Bleeding illnesses, blood illnesses and trauma with bleeding.

5.Post chemotherapy for cancers in which the body is severely depleted and weak.

6.Pulmonary tuberculosis, bronchial asthma, lung abscess and cardiopulmonary disease.

Considerations

• 1.In ancient times, this formula was used to stop bleeding and to strengthen.  However, in later generations it is often used not only to stop bleeding but also for patients who are emaciated, weak and depleted.
• 2.Presently this formula is used to treat arrhythmias but in relation to this there are two important points to pay attention to.
  • a.This formula does not treat all abnormal heartbeats.  In general it is for people whose physiques are not well developed and who are clearly emaciated.
  • b.The pulse is knotted and at the same time there are palpitations.  These symptoms emerge together.  The first symptom is one that the practitioner feels while the second is one that is felt by the patient subjectively.  This is an internal thumping that happens spontaneously.  If there is a knotted pulse without these pulsations then this formula will not be as effective.
• 3.When this formula is used for serious acute disease presentations, the dosages are important to attain the desired goal.  In these cases Sheng Di, Gan Cao and Gui Zhi should be used in large amounts.  When this formula is used to recuperate from chronic illness, for vegetarians or delicate body types then smaller dosages will do.  One package can be used for two or three days even.  If the dosage is too big it could cause indigestion, distention or diarrhea.
• 4.The amount of Gan Cao in this formula is large.  The cause of the illness differs from person to person.  If it is a serious acute illness with abnormal heart rhythms then it is appropriate to use large amounts.  On the other hand, when one is recuperating from a chronic illness it does not need to be a large dose.  One can take 6-12 grams and that will suffice.  You should pay attention to any adverse reactions to large dosages of Gan Cao such as water swelling, weakness of the four limbs, hypertension and reduced blood potassium.
• 5.Cook this formula a long time and add wine.  This is the classic instruction.  When cooking the formula “clear wine” is to be added and cooked for a long time.  In the past, rice wine was called clear wine.  The alcohol content is not high and after cooking the alcohol volatizes and what is left is a very nutritious substance.  In modern times the process of adding wine and cooking for a long time has shown to have a nutritional effect.  Cooking Di Huang with wine is also the usual practice of Zhang Zhong in his classic formula.
• 6.This formula is richly nutritious.  After decocting and concentrating the liquid, it can be made into syrup and used as a medicine in the winter.  This is quite convenient.
• 7.When determining if this formula has been effective, you will primarily want to observe whether or not the appetite and spirit have returned to normal and also whether or not the bowels are functioning easily.  For the long term you will want to see the body weight go up and if the nourishment is good.  If the formula is not appropriate the response will be diarrhea and abdominal distention.