Principles and Methods of Treatment

CHAPTER 6 Principles and Methods of Treatment



INTRODUCTION 121
When to tonify and when to eliminate 122

Combinations of gynecological and systemic manifestations 124

Relationship among patterns, Chinese diseases and Western diseases 125

PATHOLOGY OF THE INTERNAL ORGANS 127
Kidneys 127

Liver 132

Spleen 144

Heart 149

QI AND BLOOD PATHOLOGY 152
Qi rebellious 152

Blood-Cold 154

The famous doctor of the late Ming dynasty, Zhang Jing Yue (1563–1640) said that “To treat one woman equals treating five men”, which means that treating women is five times more difficult than treating men. The reason for this is presumably that the menstrual function adds complexity to women’s pathology and treatment.


I personally find quite the opposite: I would say that treating one man equals treating five women! This is because I think that the menstrual function, rather than adding complexity to women’s pathology, actually clarifies it. In fact, the additional diagnostic signs deriving from the regularity of the cycle, the amount of bleeding, the colour and consistency of the blood, the pre-menstrual symptoms, the conditions of pregnancy and childbirth, all these factors assist the diagnosis. In many cases, when women are seeking treatment not for gynecological but for other problems, an analysis of the menstrual symptoms is a ‘clinching’ factor. To give a simple example: a woman who presents with Painful Obstruction Syndrome is suffering aches and pain in the joints; if the pain is severe we might suspect stasis of Blood, a diagnosis confirmed if her menstrual blood is dark and clotted.




!


According to Dr Zhang Jing Yue, treating a woman is five times more difficult than to treat a man. My experience shows the opposite is true.


Another example: suppose a woman presents with lower abdominal pain and we are unsure about the diagnosis which may be Dampness, Qi stagnation, Blood stasis or Cold. If her menstrual blood is dark with large, dark clots, then her abdominal pain is due to Blood stasis. In this example, the menstrual symptom made the diagnosis easier, not more difficult.


There are other not-strictly medical reasons why I find treating women easier that treating men. In general, women tend to be more in touch with their bodies than men are; they also tend to be more in touch with their emotions than men are. Some psychotherapists say that men take on average 9 months to reach the point in therapy where women start from.


The discussion of principles of treatment will be carried out according to the following topics:


• Introduction.

• Pathology of the internal organs.

• Qi and Blood pathology.


Introduction


The steps to a successful treatment are as follows:


• Correct identification of the Chinese disease-symptom (bian bing).

• Correct identification of the pattern (bian zheng).

• Appropriate strategy of treatment: this includes whether to tonify the body’s Qi or clear pathogenic factors or both, and timing of treatment.

• Appropriate method of treatment: this includes choosing the proper method for the pattern, the disease, the patient’s condition and other factors.

If acupuncture is used, in addition to the above points, a successful treatment depends on these further factors:


• A correct and harmonious choice of points, including correct location.

• The proper manipulation of the needles according to the methods of reinforcing or reducing (or even).

This chapter will discuss the methods of treatment in herbal medicine and acupuncture for each organ. Before doing so, it is appropriate to discuss the choices facing us when deciding whether to tonify the body’s Qi or eliminate pathogenic factors, whether to heat or cool, and how to approach cases with contradictory symptoms and signs. This discussion will be conducted in three parts:


1. When to tonify and when to eliminate.

2. Combinations of gynecological and systemic manifestations.

3. Relationships among patterns, Chinese diseases and Western diseases.


When to tonify and when to eliminate


The decision whether to tonify the body’s Qi or to eliminate pathogenic factors is absolutely crucial particularly when using herbal medicine. Obviously one should tonify in cases of deficiency and clear in cases where there are pathogenic factors. In practice, however, the choice is not so simple because in the overwhelming majority of cases a deficiency of the body’s Qi and the presence of pathogenic factors occur simultaneously, i.e. the condition is characterized by both Emptiness and Fullness. There are, of course, formulae that can simultaneously tonify and clear but in my experience it is often preferable to address the Fullness first by clearing pathogenic factors.


In gynecology, there are many examples of conditions characterized by both Fullness and Emptiness, e.g. deficiency of the Kidney with Dampness in the genital system (e.g. in ovarian cysts or polycystic ovary syndrome), Liver-Blood deficiency with Liver-Qi stagnation or Liver-Blood stasis (e.g. in pre-menstrual tension), Spleen-Qi deficiency with Dampness (e.g. in 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.



Case history


A 42-year-old woman had been suffering from painful periods for 5 years. Her periods came usually late (every 5 weeks) and the menstrual blood was dark with small clots. The period pain was intense, of a spastic nature and alleviated by the application of a hot-water bottle. She also suffered from backache, dizziness, tiredness, frequent, pale urination and slight depression. Her tongue was Pale and wet and her pulse was Deep, Weak on both Rear positions, and Tight in general.



Diagnosis


This is a clear case of Blood stasis from Cold in the Uterus occurring against a background of Kidney-Yang deficiency.



Treatment principle


Since there is a Full condition (Blood stasis and Cold in the Uterus) and a deficiency one (Kidney-Yang deficiency), the practitioner faces a choice in deciding what to do first: expel pathogenic factors or tonify Kidney-Yang? The decision depends on the clinical manifestations. In this case, the main presenting problem was severely painful periods. Since these are due to Blood stasis (the Manifestation), it is preferable to concentrate on eliminating pathogenic factors first, i.e. invigorating Blood, eliminating stasis and expelling Cold. Another factor that indicates the need to eliminate pathogenic factors first in this case is the Tight quality of the pulse. Although the pulse is Weak on both Rear positions, the Tight quality indicates the presence of pathogenic factors, so it is preferable to concentrate on eliminating them. Had the pulse been Weak in all positions and the periods only slightly painful, then it might have been preferable to concentrate on tonifying Kidney-Yang.



Case history


A 36-year-old woman had been trying to conceive for 4 years. Her menstrual cycle was long (34–35 days) and getting longer, the period lasted 5–7 days, it was painful and the menstrual blood was dark with clots. She also experienced abdominal pain before the period. She had been diagnosed as having endometriosis and a cyst on the right ovary. She had undergone two IVF treatments without success. She had also been suffering from night sweating for 5 years, the sweating occurring for 10 days before the period and also during it. On interrogation, it transpired that she also experienced the following symptoms: dizziness, frequent, pale urination, feeling cold, chilblains, floaters, poor memory, tingling of limbs, tiredness and thrush. Her tongue was very sightly Red on the sides and very slightly peeled in the centre, and had a sticky-yellow coating. Her pulse was Slippery on the right side and Empty at the deep level on the left side.



Diagnosis


This patient presents a complex picture with various patterns, some Empty and some Full in nature. On the Full side, there is Liver-Qi and Liver-Blood stasis (abdominal pain before the period, Red sides of the tongue, painful period with dark, clotted blood), and Dampness (thrush, sticky-yellow coating, ovarian cyst, Slippery pulse). On the Empty side, there is 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:


• Cang Zhu Rhizoma Atractylodis 6 g

• Huang Bo Cortex Phellodendri 4 g

• Yi Yi Ren Semen Coicis 9 g

• Chuan Niu Xi Radix Cyathulae 4 g

• Chen Pi Pericarpium Citri reticulatae 3 g

• Fu Ling Poria 6 g

• Ban Xia Rhizoma Pinelliae preparatum 6 g

• Xiang Fu Rhizoma Cyperi 6 g

• Ze Lan Herba Lycopi 4 g

• Dang Gui Radix Angelicae sinensis 6 g

• Tu Si Zi Semen Cuscutae 4 g


Explanation



• The first four herbs constitute the formula Si Miao San Four Wonderful Powder which drains Damp-Heat from the Lower Burner.

• Chen Pi, Fu Ling and Ban Xia help to resolve Dampness.

• Xiang Fu moves Qi and eliminates stagnation.

• Ze Lan invigorates Blood and eliminates stasis and it also helps to resolve Dampness.

• Dang Gui pacifies the Liver and nourishes Blood.

• Tu Si Zi tonifies Kidney-Yang.

Thus, although this prescription contains a Blood and a Kidney tonic, its main impact is to drain Dampness and move Qi.


After only 15 days of taking this formula, the patient had a period which came 28 days after the previous one; it was already less painful and less dark; her night sweating lasted only 2 nights rather than 10. I continued with a modification of this prescription for 3 months until most of the symptoms of Dampness and stagnation had gone, and then followed it up with a formula to tonify Kidney-Yang and to nourish Blood.



Combinations of gynecological and systemic manifestations


We can distinguish three possible situations: one where the gynecological and systemic signs simply coexist with each other, one where there is a causal interaction between them and another where the gynecological signs contradict each other.



Coexistence 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.

• Liver.

• Spleen.

• Heart.


Kidneys


Since the Kidneys can only be deficient, the methods of treatment for this organ consist only in tonification. They are:


• tonify Kidney-Yang

• strongly tonify Kidney-Yang and stoke up the Fire of the Gate of Life

• nourish Kidney-Yin

• nourish Kidney-Essence

• tonify both Kidney-Yang and Kidney-Yin.


Tonify Kidney-Yang


Tonifying Kidney-Yang is applicable in deficiency of Kidney-Yang which may cause amenorrhoea, infertility, early periods, heavy periods or miscarriage. In pure deficiency of Kidney-Yang there will be chilliness, frequent, pale urination, backache, pale complexion, slight depression, Pale tongue and Deep-Weak pulse.


Typical herbs are Rou Gui Cortex Cinnamomi, Ba Ji Tian Radix Morindae officinalis, Yin Yang Huo Herba Epimedii, Tu Si Zi Semen Cuscutae, Suo Yang Herba Cynomorii, Fu Pen Zi Fructus Rubi, Du Zhong Cortex Eucommiae, Xu Duan Radix Dipsaci, etc.


Representative formulae are You Gui Wan Restoring the Right [Kidney] Pill, You Gui Yin Restoring the Right [Kidney] Decoction and Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill. Among the Three Treasures formulae, Strengthen the Root tonifies Kidney-Yang. Among the Women’s Treasure formulae, Unicorn Pearl, Warm the Palace and Ease the Journey–Yang tonify Kidney-Yang.


The herbs and prescriptions that tonify Kidney-Yang are obviously warm or hot and care must be taken that there is no Heat anywhere. In fact, it would not be unusual for a patient to suffer from Kidney-Yang deficiency and Damp-Heat in the Bladder: in such a case, the use of one of the above formulae would be contraindicated.


There are two methods to tonify Kidney-Yang in gynecology. The first is to tonify Fire from Water, i.e. stoking up Fire by nourishing Water which means obtaining Yang from Yin. As mentioned in Chapter 3 on pathology, Water and Fire are inseparable and mutually nourishing, especially so in women. Thus, in order to tonify Fire it is necessary to nourish Yin as well so that the newly-generated Fire does not consume Water: if we recall the metaphor of the oil lamp (see Figure 3.1), when we increase the flame, the oil is consumed at a speedier rate.


In applying the method of obtaining Fire from Water, relatively large amounts of Yang tonics are added to Yin tonics. This method is clearly reflected in Zhang Zhong Jing’s Jin Gui Shen Qi Wan Golden Chest 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.



Summary



Tonify Kidney-Yang


Gynecological symptoms

Amenorrhoea, infertility, early periods, heavy periods or miscarriage



General manifestations

Chilliness, frequent, pale urination, backache, dizziness, tinnitus, pale complexion, slight depression, Pale tongue and Deep-Weak pulse



Herbs

Rou Gui Cortex Cinnamomi, Ba Ji Tian Radix Morindae officinalis, Yin Yang Huo Herba Epimedii, Tu Si Zi Semen Cuscutae, Suo Yang Herba Cynomorii, Fu Pen Zi Fructus Rubi, Du Zhong Cortex Eucommiae, Xu Duan Radix Dipsaci, etc.



Formulae

Representative formulae are You Gui Wan Restoring the Right [Kidney] Pill, You Gui Yin Restoring the Right [Kidney] Decoction and Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill



Three Treasures or Women’s Treasure formulae

Strengthen the Root, Unicorn Pearl, Warm the Palace and Ease the Journey-Yang tonify Kidney-Yang



Acupuncture

BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, KI-7 Fuliu, Ren-4 Guanyuan, and KI-13 Qixue with moxa



Strongly tonify Kidney-Yang and stoke up the Fire of the Gate of Life


Tonifying Kidney-Yang and stoking up the Fire of the Gate of Life (Ming Men) is used when there is a very pronounced deficiency of Kidney-Yang and decline of the Fire of the Gate of Life without any signs of Kidney-Yin deficiency. The main manifestations are infertility, amenorrhoea, mental depression, feeling cold, cold limbs, very frequent and pale urination, incontinence of urine, nocturia, backache, a feeling of cold in the back and knees, a very Pale and wet tongue and a Deep, Weak and Slow pulse.


In this case, there are very pronounced symptoms and signs of severe Kidney-Yang deficiency and decline of the Fire of the Gate of Life. One therefore adopts the method of tonifying and warming the Fire of the Gate of Life, without nourishing Yin as in the previous case. Obviously, this method should be used only in the complete absence of any Heat signs.


The main herbs that stoke up the Fire of the Gate of Life are Rou Gui Cortex Cinnamomi, Lu Rong Cornu Cervi pantotrichum, Xian Mao Rhizoma Curculiginis and Fu Zi Radix Aconiti lateralis preparata. Any of the other Kidney-Yang tonics mentioned above is also applicable.


Representative formulae are Zan Yu Dan Aiding Fertility Pill and Tu Si Zi Wan Cuscuta Pill. Among the Women’s Treasure formulae, Unicorn Pearl, Warm the Palace and Ease the Journey-Yang tonify Kidney-Yang and the Minister Fire.



Acupuncture


The main points to stoke up the fire of the Gate of Life are basically the same as those that tonify Kidney-Yang: BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, KI-7 Fuliu, Ren-4 Guanyuan, and KI-13 Qixue with moxa. In addition to these, an important point to use is Du-4 Mingmen with moxa: the use of this point with direct moxa (cones) is the closest acupuncture can get to using Rou Gui Cortex Cinnamomi and Fu Zi Radix Aconiti lateralis preparata.



Summary



Strongly Tonify Kidney-Yang and stoke up the fire of the Gate of Life


Gynecological symptoms

Infertility, amenorrhoea



General manifestations

Mental depression, feeling cold, cold limbs, very frequent and pale urination, incontinence of urine, nocturia, backache, a feeling of cold in the back and knees, a very Pale and wet tongue and a Deep, Weak and Slow pulse



Herbs

Rou Gui Cortex Cinnamomi, Lu Rong Cornu Cervi pantotrichum, Xian Mao Rhizoma Curculiginis and Fu Zi Radix Aconiti lateralis preparata



Formulae

Zan Yu Dan Aiding Fertility Pill and Tu Si Zi Wan Cuscuta Pill



Women’s Treasure formulae

Unicorn Pearl, Warm the Palace and Ease the Journey-Yang



Acupuncture

BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, KI-7 Fuliu, Ren-4 Guanyuan, and KI-13 Qixue with moxa



Nourish Kidney-Yin


Nourishing Kidney-Yin is adopted in cases of deficiency of Yin. There are several variations of this method according to the condition. They are:


• mildly nourish Yin

• strongly nourish Yin

• nourish Yin and clear Empty-Heat

• nourish Yin and Blood

• nourish Yin and astringe.

The main manifestations of Kidney-Yin deficiency are infertility, menorrhagia, habitual miscarriage, menopausal problems, backache, dizziness, tinnitus, a feeling of heat, malar flush, night sweating, a 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.



Summary



Nourish Kidney-Yin


Gynecological symptoms

Infertility, menorrhagia, habitual miscarriage, menopausal problems



General manifestations

Backache, dizziness, tinnitus, a feeling of heat, malar flush, night sweating, a Floating-Empty or Fine-Rapid pulse and a Red tongue without coating



Herbs

Sheng Di Huang Radix Rehmanniae, Shu Di Huang Radix Rehmanniae preparata, Gou Qi Zi Fructus Lycii, Nu Zhen Zi Fructus Ligustri lucidi, Tian Men Dong Radix Asparagi and Gui Ban Plastrum Testudinis, Han Lian Cao Herba Ecliptae, Qing Hao Herba Artemisiae annuae, Qin Jiao Radix Gentianae macrophyllae, Di Gu Pi Cortex Lycii, Ze Xie Rhizoma Alismatis, Xuan Shen Radix Scrophulariae, Zhi Mu Radix Anemarrhenae, Mu Dan Pi Cortex Moutan, Wu Wei Zi Fructus Schisandrae, Shan Zhu Yu Fructus Corni, Suan Zao Ren Semen Ziziphi spinosae, Mu Li Concha Ostreae, Long Gu Fossilia Ossis mastodi and Fu Pen Zi Fructus Rubi



Formulae

Liang Di Tang Two ‘Di’ Decoction, Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill, San Jia Fu Mai Tang Three-Shell Restoring the Pulse Decoction and Zuo Gui Wan (Yin) Restoring the Left [Kidney] Pill (Decoction), Qing Hao Bie Jia Tang Artemisia-Amyda Decoction, Qing Gu San Clearing the Bones Powder, Qing Jing San Clearing the Menses Powder, Gui Shao Di Huang Tang Angelica-Paeonia-Rehmannia Decoction, and Yang Jing Zhong Yu Tang Nourishing the Essence and Planting Jade Decoction



Three Treasures or Women’s Treasure formulae

Nourish the Root, Ease the Journey-Yin, Female Treasure and Heavenly Empress, Nourish Yin and Restrain the Flow and Growing Jade



Acupuncture

Ren-4 Guanyuan, KI-6 Zhaohai, KI-3 Taixi, KI-13 Qixue, KI-10 Yingu, KI-9 Zhubin, and SP-6 Sanyinjiao, without moxa



Nourish the Kidney-Essence


The Kidney-Essence has a Yin and a Yang aspect and its deficiency can therefore manifest with symptoms of either Yin or Yang deficiency. Apart from the manifestations pertaining to a background of Yin or Yang deficiency, the main manifestations of Kidney-Essence deficiency are weak knees, poor memory, weak bones, osteoporosis, loose teeth, falling or prematurely greying hair, infertility and primary amenorrhoea.


Herbs that nourish the Essence include Wu Wei Zi Fructus Schisandrae, Tu Si Zi Semen Cuscutae, Huang Jing Rhizoma Polygonati, Lu Rong Cornu Cervi pantotrichum, Gou Qi Zi Fructus Lycii and Zi He Che Placenta hominis.


There is no specific category of formulae that nourish the Essence. However, any of the formulae tonifying Kidney-Yang or nourishing 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.



Summary



Nourish the Kidney-Essence


Gynecological symptoms

Primary infertility, amenorrhoea



General manifestations

Weak knees, poor memory, weak bones, osteoporosis, loose teeth, falling or prematurely greying hair



Herbs

Wu Wei Zi Fructus Schisandrae, Tu Si Zi Semen Cuscutae, Huang Jing Rhizoma Polygonati, Lu Rong Cornu Cervi pantotrichum, Gou Qi Zi Fructus Lycii and Zi He Che Placenta hominis



Formulae

Any of the formulae tonifying Kidney-Yang or nourishing Kidney-Yin with the addition of herbs that nourish Kidney-Essence



Acupuncture

Ren-4 Guanyuan, KI-6 Zhaohai, KI-3 Taixi, SP-6 Sanyinjiao, BL-23 Shenshu, BL-52 Zhishi, KI-13 Qixue and KI-7 Fuliu



Tonify both Kidney-Yang and Kidney-Yin


As explained in Chapter 3 on pathology, a simultaneous deficiency of both Kidney-Yang and Kidney-Yin is very common in women; however, this is never a 50–50 situation and the deficiency of one will always predominate. When treating this condition, therefore, one must make a clear diagnosis of the condition to decide whether there is a predominance of Kidney-Yang or Kidney-Yin deficiency. In the former case, one selects a formula that tonifies Kidney-Yang and modifies it with the addition of some Yin tonics. Vice versa applies in the case of a predominance of Kidney-Yin deficiency.


There is no specific category of formulae to tonify both Kidney-Yang and Kidney-Yin and one would simply add a few Kidney-Yin tonics to a Yang-tonifying prescription or a few Kidney-Yang tonics to a Yin-nourishing prescription. The structure and composition of certain classical formulae, however, are based on the principle of tonifying both Yin and Yang. For example, Jin Gui Shen Qi Wan Golden Chest Kidney-Qi Pill is based on the formula Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill which nourishes Kidney-Yin, with the addition of two Yang tonics, Fu Zi Radix Aconiti lateralis preparata and Rou Gui Cortex Cinnamomi (or Gui Zhi Ramulus Cinnamomi). The modern formula Er Xian Tang Two Immortals Decoction, used for menopausal problems from a deficiency of both Kidney-Yin and Kidney-Yang, also combines herbs that strongly tonify Kidney-Yang with herbs that nourish Yin and clear Empty-Heat.


Among the Women’s Treasure formulae, Ease the Journey-Yin and Ease the Journey-Yang tonify both Yin and Yang when there is a predominance of Kidney-Yin or Kidney-Yang deficiency respectively: they are both used for menopausal problems.



Acupuncture


Any of the points mentioned above for Kidney-Yang and Kidney-Yin deficiency may be used: Ren-4 Guanyuan, KI-13 Qixue, KI-3 Taixi, KI-6 Zhaohai, KI-7 Fuliu, KI-10 Yingu, KI-9 Zhubin, BL-23 Shenshu and BL-52 Zhishi. These points should all be used without moxa.


In complicated cases of deficiency of both Kidney-Yang and 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.



Summary



Tonify both Kidney-Yang and Kidney-Yin


Gynecological symptoms

Infertility, scanty periods, amenorrhoea, irregular periods



General manifestations

Dizziness, tinnitus, backache, night sweating, cold feet, frequent, pale urination, Weak pulse on both Rear positions



Formulae

Er Xian Tang Two Immortals Decoction



Women’s Treasure formulae

Ease the Journey-Yin and Ease the Journey-Yang.



Acupuncture

Ren-4 Guanyuan, KI-13 Qixue, KI-3 Taixi, KI-6 Zhaohai, KI-7 Fuliu, KI-10 Yingu, KI-9 Zhubin, BL-23 Shenshu, and BL-52 Zhishi



Liver


There are six treatment methods related to the Liver:


1. Nourish the Liver.

2. Pacify the Liver and eliminate stagnation of Qi.

3. Pacify the Liver and eliminate stasis of Blood.

4. Clear Liver-Heat by pacifying the Liver.

5. Drain Liver-Fire.

6. Subdue Liver-Yang or extinguish Liver-Wind.

The above treatment methods are extremely important in gynecology given the importance of the Liver in all gynecological functions and pathology.



Nourish the Liver


To nourish the Liver means nourishing Liver-Blood or Liver-Yin. A deficiency of Liver-Blood and/or Liver-Yin may be at the root of amenorrhoea or infertility. Clinical manifestations include poor memory, insomnia, blurred vision, dry eyes, dry hair, tingling of the limbs, a Pale and dry tongue and a Choppy or Fine pulse.


The chief herb to nourish Liver-Blood is of course Dang Gui Radix Angelicae sinensis and others include Shu Di Huang Radix Rehmanniae preparata, Gou Qi Zi Fructus Lycii, Sang Ji Sheng Herba Taxilli, Bai Shao Radix Paeoniae alba and Long Yan Rou Arillus Longan.


Formulae that nourish Liver-Blood include Si Wu Tang Four Substances Decoction, Ba Zhen Tang Eight Precious Decoction, Dang Gui Shao Yao San Angelica-Paeonia Powder and many others, many of which are based on Si Wu Tang. The formula Si Wu Tang Four Substances Decoction forms the basis for endless variations which can treat most menstrual problems. For example, the book Essential Methods of Dan Xi (1347) mentions several variations of this formula:



For late periods with scanty blood use Si Wu Tang plus Dang Shen and Bai Zhu. If there is Phlegm and leucorrhea add Ban Xia and Chen Pi [to Si Wu Tang]

Related posts:

  1. Vaginal Itching (and Trichomonas and Candida Infections and Genital Eczema)
  2. Abdominal Pain after Childbirth
  3. Acupuncture and Herbal Treatment in Midwifery
  4. Endometriosis

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Jun 6, 2016 | Posted by in GYNECOLOGY | Comments Off on Principles and Methods of Treatment

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