CHAPTER 4 Aetiology
In this chapter I shall therefore discuss aetiological factors with specific reference to women and to gynecological problems.
The main aetiological factors are:
Chinese medicine has always emphasized the importance for women to take extra care during the period and after childbirth. All the precautions that apply to the post-partum period also apply, albeit to a lesser degree, to each period time. During the period, the Uterus is in a vulnerable state because it is open; moreover, the loss of blood induces a state of relative Blood deficiency and therefore any aetiological factor at this time easily influences Blood, causing a deficiency or stagnation.
A Qing dynasty text, Most Valuable Treasure of Women and Babies, talks at length about the necessity for women to take care during and immediately after the period:
When the period arrives, new blood has not been produced and old blood is being discharged; at this time women become irritable and they should avoid overstrain, stress and emotional problems. It is also most important that they avoid cold food and sitting or lying in cold and damp places. During the period the pores are open, old blood enters the Penetrating Vessel in order to be discharged. Exposure to cold at this time stops old blood from moving downwards; it will instead accumulate in the body giving rise to stagnant Blood, palpable masses, dysmenorrhoea or short periods. New blood is produced 1–2 days after the end of the period; exposure to cold at this time prevents the production of new blood leading to exhaustion of Blood manifesting with a sallow complexion, lassitude, long cycle and leucorrhoea. This is why women suffer from more diseases that are difficult to cure. Women from rich families are arrogant and often hide their feelings. They cannot stop eating cold fruits if these are delicious; this causes Cold to invade the Stomach. These women cool themselves too much in summertime as they do not know that it is harmful to health. After some time, diseases will occur and they may suffer from infertility. It must be pointed out that women should avoid exposure to wind and cold and eating cold foods during the period. To eliminate Blood stasis, this is the best time to give treatment [during the period]. Tonics should be taken after the end of the period. By following these rules a weak woman can get stronger, she will not suffer from diseases and will be able to give birth to many children.1
The Qing dynasty gynecologist Chen Jia Yuan classified the aetiological factors of women’s diseases into four groups:
He included excessive sexual activity with ‘overwork’ and considered physical overwork as an external cause and excessive sexual activity as an internal cause of disease (within the category of ‘overwork’). He said that ‘mental depression’ is different from the ‘Six Stagnations’ (stagnation of Qi, Blood, Heat, Food, Dampness and Phlegm) and that ‘worry and pensiveness’ are a non-substantial cause of disease while dietary irregularity is a substantial one. Dr Chen’s reference to ‘mental depression’ is interesting and very modern. He specifically says that is not equivalent to the depression caused by the Six Stagnations (defined by Zhu Dan Xi and for which Yue Ju Wan Gardenia-Chuanxiong Pill is used). By ‘mental depression’ he means a general state of unhappiness which may be due to many different patterns rather than purely stagnation; as we shall see below, by ‘depression’ he also means a state of mental frustration due to unfulfilled sexual desire (Fig. 4.1). Dr Chen said that overwork should be treated with the tonification method; emotional depression be treated by moving and opening Qi; pungent herbs be used for worry and pensiveness; dietary irregularities should be treated by digestive herbs that dissolve retained food. Passages from his work will be discussed below.
Exterior pathogenic factors
Exterior pathogenic factors have a deep influence on gynecological problems. The Golden Mirror of Medicine (1742) says:
When the climate is moderate and harmonized, the periods are calm. Cold congeals, Heat boils, Wind makes [the periods] surge; external pathogenic factors enter the Uterus and deplete the Directing and Penetrating Vessels causing menstrual problems.2
Shen Yao Feng, author of the Summary of Gynecology (1850), says: “Warm, harmonious weather makes the periods quiet; cold congeals them; heat makes them overflow; wind makes them surge.”3
The three most common Exterior pathogenic factors in gynecology are Cold, Dampness and Heat.
Cold
Cold may mean either Wind-Cold invading the space between skin and muscles or Cold invading the Uterus directly. During menstruation and especially after labour, the Blood-Connecting (Blood-Luo) channels are open and the space between skin and muscles is especially vulnerable to invasions of Wind-Cold.
Invasion of Wind-Cold during menstruation or after labour may cause aches in the joints and painful periods.
External Cold can also invade the Uterus directly causing painful periods. Again, this happens especially during menstruation or after labour.
Dampness
Dampness is a major pathogenic factor in gynecology. It invades the channels of the legs and creeps upwards to settle in the reproductive system in women, causing leucorrhoea, pain on ovulation or dysmenorrhoea. The invasion of Dampness too is facilitated during the menses or after labour.
Once inside the body, Dampness becomes an internal pathogenic factor which easily combines with Heat to form Damp-Heat: this is a major pathogen in gynecology, usually causing abdominal masses, dysmenorrhoea, ovarian cysts, leucorrhoea, infertility or menorrhagia.
Heat
Heat may be either Wind-Heat or Summer-Heat. After the Exterior stage, both these pathogenic factors can penetrate the Interior and enter the Blood portion causing Blood-Heat. This is a major cause of excessive menstrual bleeding.
Exterior pathogenic factors
Cold
Dampness
Emotional stress
Emotional stress has a profound influence on menstruation, pregnancy, labour and menopause. The Golden Mirror of Medicine (1742), when discussing emotional causes of disease in gynecology, says: “Worry, anger, depression injure the emotional life, Blood flows up rebelling upwards bringing Qi with it.”4
The Uterus Vessel connects the Uterus to the Heart: since the Heart is always affected by emotional problems, this connection explains the profound influence of emotional stress on the menstrual function. For example, Chapter 33 of the Simple Questions says:
When menstruation does not come, this is due to the Uterus Vessel being blocked. The Uterus Vessel pertains to the Heart and connects with the Uterus; when Qi rebels upwards towards the Lungs, Heart-Qi cannot flow downwards and the periods do not come.5
Emotional problems are all the more detrimental in women if they occur around the time of puberty. At this time, a girl’s health is particularly vulnerable and emotional problems will affect her body and mind deeply and with long-lasting effect. In particular, emotional stress at this time will deeply affect the Directing and Penetrating Vessels (Ren and Chong Mai) creating the imbalances that will cause gynecological problems later in life.
Emotional stress influences menstruation by affecting first the movement of Blood by Qi. In fact, the first effect of emotional stress is to impair or alter the circulation of Qi by depleting Qi, making Qi stagnant or making Qi rebellious. Each of these pathologies will affect Blood which follows Qi and becomes deficient, stagnant or rebellious and/or Hot (Fig. 4.2).
The Golden Mirror of Medicine says:
Women cannot control themselves and are frequently affected by worry, pensiveness, anger or depression: these make the Blood move, stop, rebel or conform, which is all due to Qi movement.6
Sadness and grief
Sadness and grief deplete Heart and Lungs and can influence menstruation in two ways. By affecting the Heart, they may deplete Heart-Blood, which may affect the Uterus via the Uterus Vessel (Bao Mai). This may lead to amenorrhoea, scanty periods or delayed cycle. If they deplete Lung-Qi, Qi may fail to move Blood and this may also cause amenorrhoea. Deficient Lung-Qi and Spleen-Qi may also either fail to hold Blood and lead to menorrhagia, or fail to raise Qi, leading to prolapses.
In women, sadness may sometimes affect the Liver directly, causing Liver-Blood deficiency. Chapter 8 of the Spiritual Axis says: “When sadness affects the Liver it injures the Ethereal Soul; this causes mental confusion … the Yin is damaged, the tendons contract and there is hypochondrial discomfort.”7 When sadness affects the Liver (which is fairly common in women), it easily causes gynecological problems such as amenorrhoea, scanty periods or delayed cycle, all associated with depression and a feeling of aimlessness due to the Ethereal Soul not being rooted in Liver-Blood.
Worry
Worry knots the Qi of the Lungs, Heart and Spleen. It leads to stagnation of Qi which may cause delayed periods or painful periods. It is important to note that stagnation of Qi is not always synonymous with Liver-Qi stagnation, as the above-mentioned organs also may suffer from stagnation. In particular, Lung-Qi may stagnate as a result of worry. This will cause a slight breathlessness, a pale complexion, sighing, a feeling of tightness of the chest and, in terms of gynecology, pre-menstrual tensions and distension of the breasts. Since the Lung channel courses through the chest area, stagnation of Lung-Qi, deriving from worry or grief, is often involved in the aetiology of breast lumps.
The Qing dynasty gynecologist Chen Jia Yuan wrote with regard to worry:
Worry injures the Lungs and pensiveness injures the Spleen, when these two organs are injured Qi and Blood stagnate, there is a feeling of indignation, palpitations, a feeling of oppression of the chest and amenorrhoea.8
Moreover, in my opinion, worry also affects the Liver and makes Liver-Yang rising: this may cause menstrual headaches. Indeed, Zhang Jing Yue says that worry affects the Liver:
Anger
Anger includes frustration, resentment, bearing grudges, irritation, hatred, etc. These emotions are a major cause of menstrual problems as they cause stagnation of Liver-Qi, which may lead to irregular periods, pre-menstrual tension and dysmenorrhoea, and which can cause further problems in two ways. First of all it can lead to Liver-Blood stasis which causes a more painful type of dysmenorrhoea or abdominal masses; second, stagnant Qi may develop into Fire which causes Blood-Heat and therefore menorrhagia.
The Great Treatise of Beneficial Formulae for Women (1237) says of anger:
Anger causes Qi to rebel upwards: Blood follows Qi and also rebels upwards. If the lower back and legs are affected, there will be pain and a sensation of heaviness there during the period, which will disappear at the end of the period … If anger damages the Liver, there will be dizziness, hypochondrial pain, spitting of blood, acute skin infections and prolonged uterine bleeding.10
Fear
By ‘fear’ is meant either a sudden fright or a chronic state of anxiety. A sudden fright makes Kidney-Qi descend, but a chronic state of anxiety, especially when the Heart is weak, makes Qi rise. For example, fear (in the sense of chronic anxiety) may cause the Qi of the Penetrating Vessel to rebel upwards. This is a very common factor that aggravates menopausal problems.
The Great Treatise of Beneficial Formulae for Women (1237) says about fear:
Shock
Shock depletes Heart, Spleen and Kidneys. It may cause amenorrhoea or a delayed cycle. Shock typically manifests with a Moving pulse even many years after the event. The Moving pulse is rapid, short and shaped like a bean and it gives the impression of vibrating instead of pulsating.
Guilt
Guilt is an extremely common and damaging emotion in Western patients. It may derive from breaking religious or social taboos or from doing something wrong which weighs on the conscience. Of course, guilt can also arise in those who always tend to blame themselves, even if they have done nothing wrong; for example, someone blaming himself or herself unnecessarily for the breakdown of their marriage. This attitude can sometimes be due to patterns established in childhood if a child is never praised and always reprimanded. Interestingly, there is no modern Chinese word for ‘guilt’ used in its emotional rather than its legal sense. There is, however, an ancient word for it called jiu: this character is based on the ‘disease’ radical and a radical that means ‘long time’, i.e. a feeling harboured for a long time leading to disease. Another old Chinese expression for guilt is xin li you gui, which means ‘an evil spirit harboured in the Heart’.
In some cases, guilt may also arise from repressed and unrecognized anger which turns inwards and causes an attitude of self-punishment and guilt.
Guilt affects the Heart, Liver, Lungs and Kidneys and it causes either stagnation or sinking of Qi, depending on the pre-existing condition of the woman. In gynecology, it is common to see conditions caused by sinking of Qi as a consequence of longstanding guilt. This brings about a sinking of Kidney-Qi with an ensuing bearing-down feeling or an actual prolapse of the uterus or bladder. Very often, urinary problems characterized by frequent urination, a bearing-down sensation and a slight urinary incontinence in women are due to longstanding guilt causing Kidney-Qi to sink. The tongue will have a red tip and the pulse will be vibrating as it pulsates. The eyes will look unstable and often flap shut while the woman is talking. When guilt results from repressed anger, the pulse will be Wiry.
A 42-year-old woman complained of a persistent bearing down, uncomfortable and achy feeling in the hypogastrium (just over the bladder). Her periods were very heavy with bright-red blood without clots. Her complexion was pale, she looked very depressed and her pulse was very Weak on both Kidney positions. I diagnosed sinking of Kidney-Qi with sinking Qi unable to contain Blood. I enquired about her emotional and marital life. After a few sessions, she admitted that she felt very guilty about her second marriage and the impact it had had on her child from the first marriage. This is a clear example of the effect of guilt on the Kidneys and the menstrual function.
Emotional stress
Sadness and grief
Fear
Guilt
Irregular diet
Diet is an important aetiological factor in gynecology. The Golden Mirror of Medicine says: “Blood is the essence refined from food and water, if the Stomach and Spleen are injured, fluids are not regulated, Blood dries up, and the periods become unregulated.”12 The Qing dynasty gynecologist Chen Jia Yuan said:
Food can nourish but can also harm people … if a woman has not enough exercise, the digestion is slow, Cold is generated, the Stomach and Spleen are injured so that they cannot transport [food], stuffiness and fullness develop with accumulations and there may be vomiting and diarrhoea.13
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