Jin Gui Yao Lue Am6gqp [PDF]

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JIN GUI YAO LUE Copyright Giovanni Maciocia

金 贵 要 略

CHINESE DYNASTIES XIA 2200-1600 BC (also called “Yin”) SHANG 1600-1100 BC ZHOU 1100-771 BC SPRING AND AUTUMN PERIOD 770-476 BC WARRING STATE PERIOD 475-221 BC QIN 221-206 BC HAN 206 BC-AD 220 THREE KINGDOMS AD 200-AD 280 JIN 265-420 NORTHERN AND SOUTHERN DYNASTIES 420-581 SUI 581-618

TANG 618-907 FIVE DYNASTIES 907-960 SONG 960-1279 (LIAO) 906 1125 (JIN) 1115-1234 YUAN 1279-1368 MING 1368-1644 QING 1644-1911 REPUBLIC OF CHINA 1911-1949 PEOPLE’S REPUBLIC OF CHINA 1949-

The Jin Gui Yao Lue was originally part of the Shang Han Za Bing Lun 伤 寒 杂 病 论 written by Zhang Zhong Jing during the Han dynasty. His real name was Zhang Ji. The Shang Han Za Bing Lun was composed of two sections with sixteen volumes: ten discussed diseases from external invasion of Wind and six discussed general diseases. It was during the Jin dynasty that Wang Shu He separated these two sections with the one on external diseases called Shang Han Lun and the one on general diseases was called Jin Gui Yao Lue. However, this edition of the work has been lost and the edition that we use was published in the Song dynasty (960-1279 AD).

During the Song dynasty the government established the medical literature editing bureau to collect, edit and publish medical works under the guidance of Ling Yi. Since Wang Shu He had already reorganized the section on external diseases, creating the Shang Han Lun, Yi deleted this section and retained the middle and lower sections on general diseases and gynecological diseases, respectively. He also reorganized the gynecological section into three chapters. He named this text Jin Gui Yao Lue Fang Lun 金 贵 要 略 方 论

Shang Han Lun

Shang Han Za Bing Lun Jin Gui Yao Lue

Jin Gui Yao Lue

(Lost) Zhang Ji – Han dynasty

Wang Shu He – Jin dynasty

Ling Yi - Song dynasty

THE AUTHOR Zhang Ji lived approximately from 150-219 AD (Eastern Han dynasty). He was born in Nan Yang in Henan province. During Zhang Ji’s lifetime there were numerous wars and epidemics in China. His own preface to the Shang Han Za Bing Lun stated that among his 200 relatives, two-thirds died from epidemic diseases. These were probably typhoid fever. It was from this experience that he dedicated himself to the study of external diseases.

CONTENTS OF THE TEXT The Jin Gui Yao Lue comprises of 25 chapters discussing general and gynecological diseases. With few exceptions, a feature of this book is that, compared to the Nei Jing, it has very few chapters on philosophy. Most of the chapters are about clinical syndromes and their treatment. Chapter 1 deals with the principle of treatment, pathology and diagnosis. Chapters 2-17 deal with a wide range of internal diseases of the Zang Fu such as consumption, breathlessness, phlegm, vomiting, diarrhea, abdominal pain, constipation, anxiety, chest pain, jaundice, stroke and malaria. Chapter 18 discusses external diseases such as sores and abscesses. Chapter 19 discusses miscellaneous diseases including worm diseases.

Chapters 20-22 deal with gynecological diseases. Chapters 23-25 deal with miscellaneous remedies, food contraindications and first aid methods. These three chapters are not considered to be the work of Zhang Zhong Jing. Overall, the Jin Gui Yao Lue mentions 40 different diseases and 255 herbal formulae. Acupuncture and moxibustion are also mentioned.

CHAPTER ONE - CLAUSE ONE Question: Superior practitioners 上工 treat diseases before they arise. Why is this? Treating diseases before they arise means that when one sees a Liver condition for example, one will know that the Liver will invade the Spleen, and therefore one must tonify the Spleen. When the Spleen is strong at the end of each of the four seasons, pathogenic factors cannot invade the body and the Spleen will not need to be tonified. The middle doctors 中 工 do not know about the transmission of diseases, and when they see a Liver condition they do not understand the need to tonify the Spleen and they treat just the Liver. To treat Liver conditions, tonify with the sour taste and assist additionally with the burnt bitter taste; in addition, tonify with sweet taste medicines. The sour taste enters the Liver, the burnt bitter taste enters the Heart and the sweet taste enters the Spleen.

The Spleen can damage the Kidneys and when these are weak water does not move. When water fails to move, Heart-Fire becomes excessive and damages the Lungs. When the Lungs are damaged, the Qi of Metal fails to move and this leads to exuberance of Liver-Qi. Therefore, by tonifying the Spleen the Liver will be automatically pacified. This describes the subtle and profound 要 妙 method of treating the Liver by tonifying the Spleen. Apply this method for Liver deficiency, not for Full conditions of the Liver. COMMENTS This chapter contains several interesting concepts. 1) Interestingly, this paragraph might be the source of the misconception that in ancient China the so-called “superior doctor” treated before diseases arose. By contrast, what this chapter is saying is that the doctor should be aware of the transmission of disease along the Ke cycle, e.g. from Wood to Earth.

What this chapter is simply saying is that, when the Liver is affected, one must bear in mind the possibility that the Spleen is also affected (Wood overacting on Earth). That is why the chapter advises to tonify the Spleen in such a case. That is why there is a disparaging reference to the so-called “inferior doctor” (zhong gong) who, in such a case, would treat only the Liver and not the Spleen. 2) There is a very interesting reference to the energy of the Spleen being predominant at the end of each of the four seasons. By contrast, if we look at the normal Five Elements diagram, the Earth comes after Fire (Summer) and, for this reason, some people connect Earth to late Summer.

This chapter seems to imply clearly that there is a “Spleen season” at the end of every season.

This means that the Earth does not actually correspond to a particular season in the same way that the four Elements do. The Earth is at the center of the other four, the neutral term of reference around which the seasons and the other elements revolve.

The Lei Jing (1624) by Zhang Jie Bin says: “The Spleen belongs to the Earth, which pertains to the center. Its influence manifests for 18 days at the end of each season, and it does not pertain to any season on its own.” 3) This chapter establishes the correspondence between organs and tastes, assigning the sour to the Liver, bitter and “burnt” to the Heart and sweet to the Spleen. 4) This chapter justifies tonification of the Spleen with a rather complicated and contrived reference to the Ke cycle relationships among the 5 Elements. It says that a disease of the Kidneys can affect the Heart, making Heart-Fire excessive; this can injure the Lungs; when the Lungs are injured, Liver-Qi becomes exuberant.

5) Another interesting aspect of this chapter is the clear reference to Xu and Shi, i.e. Deficiency and Excess. These are two of the 8 Principles. As various other chapters clearly refer to Heat and Cold, Yin and Yang, and Exterior and Interior, it is clear that the Jin Gui Yao Lue has already an embryonic concept of the 8 Principles contrary to what some people say that it is a modern Chinese concept. In fact, the text says “Do not drain a Deficiency or replenish an Excess. Supplement the Deficiency and reduce the Excess”

CHAPTER ONE – CLAUSE TWO Partial translation All diseases fall within three categories. The first are invasion of external pathogenic factors in the channels, then entering the internal organs; these are endogenous causes of disease. The second is obstruction of Blood in the four limbs and the nine orifices, which is due to external pathogenic factors striking the skin. The third includes excessive sexual activity, wounds and animal and insect bites. If a person can nourish themselves carefully (yang zhen 养 慎)(yang sheng 养 生 ) their channels will not be invaded by external Wind; or, in case of invasion of the channels, the treatment can prevent the pathogenic factor from being transmitted to the internal organs; or, when there is heaviness and stagnation in the four limbs, he can apply conduction exercises (?), regulate breathing, apply acupuncture, or massage with medicinal ointments, then the nine orifices will not be blocked.

Furthermore, one should obey the laws, avoid harm from animals, restrain sexual activity, regulate heat, cold, bitter, sour, pungent and sweet with clothing and diet so as not to let the body become debilitated; thus, diseases will not penetrate the Cou Li space. Cou is the place where the Triple Burner connects with the Original Qi [yuan zhen 元 真] and whence Qi and Blood spring. Li is the striae of the skin and of the internal organs.

THE COU LI 腠 理 COU means “space”, “cavity” LI means “texture” or “pattern”, similar to the “veins” and “grain” of wood

ZANGFU

COULI

Zhen Qi

Wei Qi TRIPLE BURNER Yuan Qi

COMMENTS: 1) Classification of 3 causes of disease, even though not the same as the one we know 2) The concept of Yang Sheng 养 生. Yang Sheng literally means “nourishing life” and it includes various practices aimed at insuring health and lengthening life. These include diet, avoidance of pathogenic factors, emotional balance, sexual restraint, exercises, breathing, etc. Yang Sheng is an important feature of the Nei Jing. Yang Sheng has traditionally been influenced by Daoist thinking and techniques, and some people think that Chinese medicine was developed as an off-shoot of Yang Sheng techniques

3) The concept of prevention. This is a logical consequence of the Yang Sheng ideas and techniques. Again, very many chapters of the Nei Jing discuss prevention of disease. 4) The concept of Cou Li and its relationship to the Three Burners and the Yuan Qi. The Cou are a system of cavities, some large and some small. The 3 Burners are three large cavities with the Upper Burner being the chest cavity, the Middle Burner the abdominal cavity, and the Lower Burner the pelvic cavity. In each of these cavities, Qi ascends, descends, enters and exits, and by so doing, it regulates the transformation, transportation and excretion of fluids in the Triple Burner. One of the small Cou cavities is the space between skin and muscles where the Wei Qi circulates and where sweat comes from. This is the space that is invaded by Wind in initial stages of external invasions. The important implication of the Jin Gui Yao Lue passage is that this space is energetically related to the Yuan Qi, and therefore the Kidneys.

Cou Li

Sweating

Ling Shu: “The Triple Burner responds to the Cou Li above and the Bladder below”

Triple Burner

Bladder

Urination

CHAPTER ONE – CLAUSE NINE A patient with a floating pulse in the front position indicates that the disease is on the Exterior; a floating pulse in the rear position indicates that the disease is in the Interior that manifests with backache, rigidity of the back, and inability to walk. There will be shortness of breath and exhaustion.

COMMENTS 1) This passage has some interesting pulse diagnosis concepts. First of all, it uses the word “floating” which we commonly use to indicate a specific pulse quality. “Front” in this case refers to the Cun and “rear” to the Chi position. It correctly correlates a floating quality on the Cun position with an exterior invasion of Wind. It also presents the interesting correlation between Cun and the Exterior and Chi and the Interior. Finally, it correlates a floating quality on the Chi position with backache because that position correlates to Kidneys and Bladder.

CHAPTER ONE – CLAUSE THIRTEEN This clause mentions the 5 Exhaustions (Wu Lao 五 劳) and the 7 Injuries (Qi Shang 七 伤) without listing them. The 5 Exhaustions are mentioned in chapter 23 of the Su Wen and the 7 Injuries are mentioned in the Zhu Bing Yuan Hou Lun 诸 病 源 候 论 (640 AD). 5 Exhaustions - Excessive use of the eyes injures Blood (Heart) - Excessive lying down injures Qi (Lungs) - Excessive sitting injures the muscles (Spleen) - Excessive standing injures the bones (Kidneys) - Excessive walking injures the sinews (Liver)

7 Injuries - Overeating injures the Spleen - Excessive anger injures the Liver - Excessive lifting and sitting on wet ground injures the Kidneys - Excessive cold injures the Lungs - Excessive worry and pensiveness injure the Heart - Excessive wind, rain, cold and summer-heat injure the body - Fright injures the Mind (Zhi 志)

CHAPTER TWO – CLAUSE FOURTEEN A Tai Yang disease manifesting with pain in the joints and mental restlessness with a deep and fine pulse is called Damp Bi. In Damp Bi, urination is inhibited but the stools are by contrast free. The treatment must be based on promoting urination. COMMENTS 1) This short clause makes the important point of treating Dampness by promoting the transformation of fluids and promoting diuresis. 2) This clause also confirms that external Dampness invades and settles in the joints, causing chronic ache. 3) This clause uses the term Bi that we commonly use in Bi Syndrome.

CHAPTER ONE – CLAUSE FIFTEEN For an intractable illness accompanied by a sudden disease, one should first treat the sudden disease and then the intractable illness.

COMMENTS This short clause makes the important point that is adhered to in modern times, i.e. when a chronic disease has an acute episode the acute episode must be treated first.

CHAPTER THREE – CLAUSE ONE In Bai He disease, the hundred vessels [channels] belong to one ancestor, and all are acting together to cause this disease [or any of them can cause this disease]. Manifestations include: the patient wants to eat but cannot; wants to lie down but cannot; wants to walk but cannot. She occasionally enjoys eating tasty foods and sometimes has aversion to the smell of food. Sometimes she feels cold, sometimes hot; has a bitter taste, the urine is dark: all medicinals are ineffective, with severe vomiting and diarrhea following treatment. The patient looks as if possessed by spirits [shen ling 神灵], although the physical appearance is normal. The pulse is slightly rapid.

If there is headache during urination, recovery can be expected in sixty days. If there are chills during urination but with no headache, recovery can be expected in forty days. If there is smooth urination but with dizziness, recovery can be expected in twenty days. The patterns may appear well before the onset of disease, or four or five days after the onset, or even with a vague appearance after twenty days or one month of the onset. Apply treatment in accordance with the presenting pattern. COMMENTS 1) The reference to the hundred channels or vessels is ambiguous. It probably refers to the Lung’s function of controlling all the blood vessels. This interpretation may be reinforced by the use of the word “ancestor” (zong 宗) which is the same zong as in Zong Qi of the chest, which is under the control of Lungs and Heart. This confirms that this disease affects Lungs and Heart. There is a further ambiguity in the use of the word bai which means hundred in so far as Bai He is the name of the herb used for this disease, but it also means “hundreds meeting” i.e. the meeting of all channels and vessels.

2) Bai He disease may have two different etiologies. It may be caused by an external Heat disease injuring the Yin of Lungs and Heart; or, it may be due to emotional stress which is a far more common case in the patients we see. In particular, the Bai He disease is due to sadness, grief, worry, or guilt. 3) Considering the symptoms of the Bai He disease, (wants to eat but cannot eat, wants to speak but cannot speak, wants to lie in bed but is restless, looks haunted, etc.) we may simply say that this patient is suffering from depression and anxiety. Modern Chinese books say that the patient is “as if in a trance” (huang hu 恍 惚).

4) The reference to the patient looking as if being possessed by spirits is interesting because of the terms used. Normally when there are references to spirits and possession in Chinese medicine books they mention gui 鬼. In this passage, however, the book mentions shen ling 神灵. This is interesting because it is not a case of so called demonic medicine, i.e. the patient being actually invaded by evil spirits. On the contrary, it is a case of the patient being haunted by their own psychological distress.

CHAPTER THREE – CLAUSE TWO For Bai He disease occurring after [wrongly] promoting sweating, use Bai He Zhi Mu Tang. COMMENTS 1) The original text mentions the use of Bai He Zhi Mu Tang to restore Yin that has been injured by the wrong application of sweating. However, the modern clinical application of this formula is far broader. It is used for deep mentalemotional distress occurring against the background of Lung- and Heart-Yin deficiency. 2) Zhi Mu in the formula nourishes Yin and clears Heat. Bai He also nourishes Yin, moistens the Lungs and treats the Po. 3) I use this formula for depression and anxiety occurring against the background of Qi and Yin deficiency of Heart and Lungs from emotional stress such as sadness, grief, worry and guilt.

4) The formula mentioned in Clause Two refers to the treatment of Bai He disease caused by the wrong application of sweating. Clauses Three and Four mention the formula for Bai He disease caused by the wrong application of purgation and emesis. If the Bai He disease occurs by itself and is not caused by the wrong treatment, then Clause Five recommends the formula Bai He Di Huang Tang, i.e. Bai He and Sheng Di Huang. 5) I use the above formula if the Bai He disease occurs against the background of Lung- and Kidney-Yin deficiency. This is often caused by different emotions and especially fear, anxiety, worry and guilt. The two formulae may be combined with the use of Bai He, Zhi Mu and Sheng Di Huang.

CHAPTER THREE – CLAUSE FIVE When Bai He disease has not been caused by vomiting, purgation or sweating and it remains the same as at the initial stage, use Bai He Di Huang Tang. COMMENTS 1) Modern Chinese books mention the use of this formula for menopausal depression, anxiety and insomnia, and they also mention combining this formula with Gan Mai Da Zao Tang. I personally frequently combine not this formula but Bai He Zhi Mu Tang with Gan Mai Da Zao Tang for depression and anxiety occurring against a background of Qi and Yin deficiency.

CHAPTER THREE – CLAUSE TEN Hu Huo disease is a type of injury from cold [shang han]. The patient wants to sleep but cannot close his eyes; lies down but then gets up and is restless. Erosion of the throat indicates Huo disease whilst erosion of the genitals [and anus] indicates Hu disease. There is no desire to drink or eat, aversion to the smell of food and the facial complexion that alternates between red, black and white. Erosion of the upper part is accompanied by a hoarse voice. Gan Cao Xie Xin Tang Gan Cao 9g Huang Qin 6g Ren Shen 6g Gan Jiang 6g Huang Lian 3g Da Zao 4 dates Ban Xia 9g Hu Huo 狐惑 Hu means “fox”. Huo means “bewildered, puzzled, deluded, confused”.

COMMENTS 1)This is a complex clause. First of all its name: in my opinion its name can only be understood in the context of ancient Chinese beliefs about spirits (gui) and foxes. According to these ancient beliefs the fox was always identified with negative evil influences and fox spirits wandering at night were particularly dangerous. Therefore the presence of the word fox in the name of this disease, in my opinion, indicates the possibility that this disease is due to possession by fox spirits. Translated into modern terms, in my opinion, this indicates a relatively serious mental-emotional condition characterized by a certain obstruction of the Shen with a state of confusion, bewilderment and delusion. It is interesting to compare this disease with the previous one (Bai He disease): in the Hu Huo disease the Shen is relatively obstructed; in the Bai He disease the Shen is weakened and unsettled (depression and anxiety).

The fox spirit has also been used as an explanatory factor in the incidence of attacks of koro or ethnic psychosis found in Southern China and Malaysia in particular. There is mention of the fox-spirit in Chinese Chan-Buddhism. Linji Yixuan (866 AD) said: "The immature young monks, not understanding this, believe in these fox-spirits ..." The "fox-spirits" here are voices that speak of The Way, and/or Dharma. They are perceived to be malicious influences that lead the innocent astray. (Source: The Record of Linji, Honolulu 2008, p.218)

The most famous example is the Fox Spirit. A fox with superpower traditionally changes its body to a woman of an extreme beauty. The woman/fox will then seduce men and take their power in order to get more superpower to achieve the ultimate immortality. This story is so common in Chinese culture, that if you describe a girl as "Fox Spirit ("狐狸精"), that would mean: "Very beautiful girl but she will take your energy.." or "a gold digger woman"

2) The Hu Huo disease is characterized by the presence of both Heat and Cold. There is Heat above and below causing erosion of the throat and of the genitals, respectively. However there is also Cold in the Middle Burner. In this case, the mental-emotional state is caused not by a deficiency but by the mixture of Heat and Cold. 3) The formula Gan Cao Xie Xin Tang is essentially the same as Ban Xia Xie Xin Tang, with the only difference being a larger dose of Gan Cao. This is a harmonizing formula for Heat above and Cold below. However, as we have just said, in the Hu Huo disease there is erosion of both the throat and genitals. 4) The tongue associated with this formula will be red with a yellow coating and the pulse would be rapid and possibly slippery. 5) Modern Chinese books say that Hu Huo disease corresponds to a condition of Damp-Heat, but I personally do not agree with this view. I think that the Hu Huo disease corresponds to a mixed condition of Heat and Cold caused by severe mental-emotional stress. The fact that when there is erosion of the throat the patient develops a hoarse voice would rule out Damp-Heat.

6) In terms of patterns, I would say that the Hu Huo disease is characterized by Heart-Heat flaring upwards and causing the throat erosion as well as Liver-Heat infusing downwards causing the genital erosion. At the same time, there is Cold in the Middle Burner which causes the aversion to eating and also the desire to sleep (but the Heat causes the inability to close the eyes). The mixture of Heat and Cold explains the alternating facial colors (red, black, white). 7) Modern Chinese books also say that the Hu Huo disease may correspond to Behcet’s syndrome. Although it is true to say that some cases of Behcet’s disease may manifest with the symptoms of Hu Huo disease, there is absolutely no unilateral correspondence between the two. 8) Gan Cao Xie Xin Tang is a variation of Ban Xia Xie Xin Tang, which itself is a variation of Xiao Chai Hu Tang.

9) Modern Chinese books state unequivocally that the Hu Huo disease is a Shang Han disease. I disagree with this view as there is no evidence of it in the original text. Moreover, a modern book says that it is the Shao Yin Syndrome of a Shang Han diseases. To prove this, it explains the erosion of throat and genitals as being due in both cases to the Liver channel and Liver-Heat. Whilst the Liver channel may explain the erosion of genitals (although not anus), the book also explain erosion of the throat as being due to the Liver channel (which is possible but rather far fetched). Indeed, if we look at the formula used for Hu Huo disease, it contains Huang Qin and Huang Lian which enter the Lungs and Heart: Heat in the Lungs and Heart is therefore the most likely explanation of erosion of the throat and Lung-Heat of hoarse voice. 10) If we compare Hu Huo disease with Bai He disease we can say that the former is a case of Shen Obstructed, while the latter is a case of Shen Weakened and Unsettled.

SHEN

SHEN UNSETTLED

WEAKENED

Tiredness, listlessness, apathy, lack of will-power, lack of enthusiasm and drive, depression

Anxiety, mental restlessness, insomnia, agitation, panic, anger

SHEN OBSTRUCTED

Loss of insight, mental confusion, obsessive behaviour, erratic, hallucinations. “Neurotics build castles in the sky, psychotics live in them”

SHEN WEAKENED

Tonify Qi, nourish Blood and/or Yin

Sweet taste

SHEN UNSETTLED

Clear Heat, drain Fire, nourish Blood and/or Yin, clear Empty Heat

Bitter-cold taste to drain Fire, or sweet-cold to nourish Yin together with cold to clear Empty Heat

SHEN OBSTRUCTED

Resolve Phlegm, invigorate Blood, move Qi, open the Shen’s orifices

Pungent taste

SHEN OBSTRUCTED

PHLEGM

BLOOD STASIS

SHEN OBSTRUCTED

Loss of insight, slight, manic behaviour, depression, in the severest degree, psychosis

QI STAGNATION TREATMENT Open the Shen orifices with pungent herbs

SHEN UNSETTLED

HEAT EMPTY HEAT BLOOD STASIS QI STAGNATION

SHEN UNSETTLED

Anxiety, agitation, insomnia, mental restlessness

BLOOD DEFICIENCY

TREATMENT

YIN DEFICIENCY

Calm the Shen with sinking herbs. Bitter if Heat, sour if Yin Xu, sweet if Blood Xu

SHEN UNSETTLED

BLOOD OR YIN XU Shen and Hun deprived or residence become unsettled. Mild anxiety. Sweet to nourish Blood or sweet-cool to nourish Yin. Sinking herbs.

YIN XU WITH EMPTY HEAT Shen and Hun deprived or residence become unsettled. Severe anxiety. Empty Heat Sweet-cold to nourish Yin with cool to clear Empty Heat. Sinking herbs.

HEAT OR FIRE Shen and Hun agitated by Heat become unsettled. Severe anxiety. Pungent-cold to clear Heat or bitter-cold to drain Fire. Sinking herbs.

CHAPTER THREE – CLAUSE ELEVEN Erosion of the lower parts causes dryness in the throat. Use Ku Shen Tang as an external wash. COMMENTS 1) By “lower parts” is meant here external genitals. 2) Modern Chinese books again explain the erosion of the external genitals with dry throat with reference to the Liver channel and again to Damp-Heat. They say that Damp-Heat in the Liver channel infuses downwards causing ulcers and, because it impairs the proper transformation of fluids, it causes dryness of the throat. I personally think this explanation is far-fetched, and in my opinion, the connection between erosion of the genitals and dry throat must be found within the Ren Mai. 3) Whatever the cause of the genital ulcers, this clause establishes the use of Ku Shen as an external wash for such problems, which is widely followed today.

4) Modern Chinese books say that a decoction of Ku Shen can be used as a mouthwash in Behcet’s disease. They also say that it can be used for vaginal itching and discharge together with Huang Bo, Long Dan Cao and She Chuang Zi. Autoimmune disease characterized by inflammation of blood vessels. It may affect eyes, mouth, skin, lungs, joints, brain, genitals.

CHAPTER THREE – CLAUSE FORTEEN In Yang Toxin 阳 毒 disease the face has red macules like brocade. There is pain in the throat, spitting of blood and pus. In can be cured if treated within five days, but incurable after seven days. Use Sheng Ma Bie Jia Tang. COMMENTS 1) Sheng Ma Bie Jia Tang: Sheng Ma, Dang Gui, Hua Jiao, Gan Cao, Xiong Huang, Bie Jia. In this formula Sheng Ma and Gan Cao resolve Toxic Heat. 2) “Yang Toxin” here indicates Toxic Heat at the Qi Level. It may correspond, for example, to severe throat infections with tonsillitis.

CHAPTER THREE – CLAUSE FIFTEEN In Yin Toxin 阴 毒 disease there is a bluish-greenish 青 face, body aches as if one had been beaten by a cane and pain in the throat. In can be cured if treated within five days, but incurable after seven days. Use Sheng Ma Bie Jia Tang minus Xiong Huang and Hua Jiao. COMMENTS 1) “Yin Toxin” here indicates Toxic Heat at the Blood Level with Blood stasis. 2) This condition could correspond also to a severe throat infection with tonsillitis but with an underlying Yin deficiency and probably Blood stasis. Modern Chinese books say that this formula could be used for lupus, thrombocytopenic purpura and septicemia.

CHAPTER NINE – CLAUSE ONE When taking the pulse we should appraise Fullness and Deficiency. If the Yang is feeble and the Yin wiry, it indicates pain from Chest Bi: this is caused by extreme deficiency. Empty Yang reflects [a deficiency of] the Upper Burner, as a result of which, Chest Bi and heart pain are associated with a wiry pulse in the Yin. [Therefore, Chest Bi and heart pain are associated with a wiry pulse in the Yin] [As a result of which, Chest Bi and heart pain are associated with a wiry pulse in the Yin] COMMENTS 1) There are at least two ways of interpreting “Yang” and “Yin” in the pulse. Most modern Chinese commentaries say that Yang refers to the Cun position, while Yin refers to the Chi position. I tend to think that Yang refers to the superficial pulse and Yin to the deep pulse. In fact, I do not see how a disease that is located in the chest is reflected by a wiry pulse in the Chi position.

2) The last sentence is difficult to interpret and I have given three alternative translations. 3) The reference to Empty Yang reflecting the Upper Burner does give legitimacy to the interpretation of “Yang” as the Cun position. However, there is a further complication, and that is that the internal organs on the pulse are reflected not only in the positions but also in the levels. From this point of view, the superficial level (“Yang”) corresponds to Heart and Lungs (the middle level to Stomach and Spleen and the deep level to Liver and Kidneys). Therefore, the above reference to the Empty Yang reflecting the Upper Burner is not in contradiction to the interpretation of “Yang” as the superficial level of the pulse.

Level

Energy

Yin or Yang

Organ

Superficial

Qi/Yang

Yang organs

Lungs and Heart

Middle

Blood

Deep

Yin

Stomach and Spleen Yin organs Liver and Kidneys

CHAPTER NINE – CLAUSE THREE In Chest Bi with breathlessness, cough, expectoration, pain in the chest and back, shortness of breath, deep and slow pulse at the Cun position and small, rapid and tight at the Guan position, use Gua Lou Xie Bai Bai Jiu Tang. COMMENTS 1) This is a good description of the clinical manifestations of Chest Bi with Phlegm. 2) It is difficult to interpret the reference to slow pulse at the Cun position and rapid at the Guan position, as this cannot be. Some modern commentaries say that “slow” and “rapid” should not be interpreted literally and that, rather than referring to the rate of the pulse, they refer to a certain quality. 3) The formula mentioned in this clause is the basis for many variations that are used for Chest Bi. Bai Jiu is rice wine.

CHAPTER NINE – CLAUSE FOUR In Chest Bi with inability to lie down, heart pain extending to the upper back, use Gua Lou Xie Bai Ban Xia Tang. COMMENTS 1) This is a variation of the formula from the previous Clause. This formula is used also when there is Phlegm but accompanied by Yang deficiency and Cold. 2) The inability to lie down is a key symptom of Phlegm obstructing the chest. 3) Besides Gua Lou, Xie Bai and Ban Xia, the formula also has Bai Jiu (rice wine).

CHAPTER NINE – CLAUSE FIVE In Chest Bi with a feeling of stuffiness in the center of the chest, stagnant Qi in the chest, a feeling of fullness in the chest, Qi rebelling from below the ribs to the heart, use Zhi Shi Xie Bai Gui Zhi Tang or Ren Shen Tang. COMMENTS 1) “Stagnant Qi in the chest” is how Chinese books translate this sentence. I think that, in this context, “Qi” may also refer to breath and breathing, and that therefore that symptom could be translated as “breathlessness”. 1) “Feeling of stuffiness” is a translation of Pi 痞. The term Pi has various different meanings. One of its meanings is that it is one of the Five Accumulations Wu Ji 五 积 (one for each Yin organ) related to the Spleen usually indicating a condition of Spleen deficiency with some Qi stagnation. The feeling of stuffiness is a subjective feeling of slight oppression or distention, but with a soft feeling on palpation.

3) Ren Shen Tang: Ren Shen, Gan Cao, Gan Jiang, Bai Zhu. The suggestion that Ren Shen Tang is also applicable suggests a deficiency of the Spleen causing the Pi condition. 4) The formula Zhi Shi Xie Bai Gui Zhi Tang is for Chest Bi from Yang deficiency, Cold and Qi stagnation in the chest. Zhi Shi has a downward movement and it therefore treats the Qi rebelling from below the ribs to the heart. 5) From an acupuncture perspective, this condition may be treated with the Chong Mai. In fact, the reference to “rebellious Qi” Ni Qi 逆 气 suggests a pathology of the Chong Mai. 6) Some modern commentaries say that the symptom of Pi in the heart refers to a feeling below the heart, i.e. the epigastrium. However, there is no evidence of this, as the text clearly says “Pi” in the center of the heart/chest. 7) Zhi Shi Xie Bai Gui Zhi Tang: Zhi Shi, Xie Bai, Gui Zhi, Hou Po, Gua Lou.

CHAPTER NINE – CLAUSE SIX For Chest Bi with stagnation in the center of the chest and shortness of breath, use Fu Ling Xing Ren Gan Cao Tang or Ju Zhi Jiang Tang. COMMENTS 1) Ju Zhi Jiang Tang: Ju Pi, Zhi Shi, Sheng Jiang. 2) There are two formulae suggested for this condition: the former is used if there is Phlegm and the latter if there is Qi stagnation. 3) Compared to the former patterns, this is a milder case of Phlegm and Qi stagnation.

CHAPTER NINE – CLAUSE EIGHT For a feeling of stuffiness in the center of the chest [lit. heart] and rebellious Qi that causes a suspended heart pain, use Gui Zhi Sheng Jiang Zhi Shi Tang. COMMENTS 1) This Clause again refers to rebellious Qi which, from the acupuncture perspective, suggests a pathology of the Chong Mai. 2) This pattern is caused by Cold, Qi stagnation and rebellious Qi in the chest. 3) Again, a modern Chinese commentary says that this Clause refers to the epigastrium because the term “below the heart” indicates the epigastrium. Although this is true and I entirely agree with it, there is no evidence from the original text that it refers to this area: in fact, it clearly says “in the center of the heart”.

4) The term “suspended” xuan 悬 heart pain suggests also rising of Qi from the abdomen to the heart. The term xuan is evocative of both a rising of Qi towards the heart and also of the anxiety associated with it. In fact, the term xuan itself may also mean “anxiety”. The term xuan also means “to hang” and the character is composed of two parts with the top one depicting a man hanging upside down from a rope (with the head therefore down) and the heart below. The heart radical below suggests the mental-emotional aspect of this symptom, i.e. anxiety and worry.

悬

CHAPTER 22 – CLAUSE 5 When a woman feels as if there was a piece of grilled meat in her throat, Ban Xia Hou Po Tang (Pinellia-Magnolia Decoction) is indicated. COMMENTS 1) This clause is the origin of the famous formula Ban Xia Hou Po Tang. The clause is very succinct and it does not explain the pathology of the syndrome, nor the action of the formula. Modern Chinese books always say that this formula is for plum-pit Qi (Mei He Qi) syndrome due to Liver-Qi stagnation. However, there is little evidence of this from the source. If we analyze the ingredients of the formula none of the constituent herbs even enters the Liver. Ban Xia Rhizoma Pinelliae preparatum Hou Po Cortex Magnoliae Zi Su Ye Folium Perillae Fu Ling Poria Sheng Jiang Rhizoma Zingiberis recens

In my opinion, this formula acts primarily on the Lungs, Stomach and Heart: it makes their Qi descend and the primary focus of the formula is the throat and chest. The formula does treat Qi stagnation but it is primarily Qi stagnation of the Lungs, Stomach and Heart; the formula also restores the descending of Qi of these three organs.

Lung

Heart

Besides Qi stagnation, there is also Phlegm but this is Qi-Phlegm, i.e. the most non-substantial type of Phlegm. Ban Xia in the formula makes Qi descend and resolves Phlegm. Hou Po also makes Qi descend and opens the chest. Fu Ling helps Ban Xia to resolve Phlegm. Zi Su Ye makes Lung-Qi descend and also acts on the throat. 2) The formula Ban Xia Hou Po Tang is also mentioned in Sun Si Miao’s Qian Jin Yao Fang with slightly different symptoms: fullness of the chest, a hardness below the heart, a feeling of obstruction of the throat as if there was a piece of grilled meat that cannot be ejected nor swallowed. 3) Although this syndrome and formula are in a chapter on gynaecology, it does not mean it applies to women only: men can get this syndrome too and the same formula is applicable.

CHAPTER 22 - CLAUSE 6 For women with agitation (Zang Zao 脏 躁 ), suffering from sadness and a desire to weep, appearing as though possessed by a spirit (Shen Ling 神 灵) and frequently yawning and stretching, Gan Mai Da Zao Tang (Glycyrrhiza-TriticumJujuba Decoction) is indicated. This formula also tonifies Spleen-Qi. COMMENTS 1) This is another very well known and important formula for mental-emotional stress. Modern Chinese books frequently say that this formula is for “hysteria” but this comes from a misunderstanding both about what the formula is for and about hysteria itself. In modern terms, I would say that this formula is simply for depression and anxiety. Of course, “depression” is a Western-defined disease, which has little meaning in Chinese medicine and I would say that this is for depression occurring against a background of Qi and/or Yin deficiency.

2) There are some interesting observations to be made about the symptoms as they are in the original text. First of all, there is the question of zang zao which literally means “visceral restlessness”: I simply translate zang zao as “agitation”. In my opinion, zang zao suggests a certain intensity of the restlessness or agitation. This chapter is actually the first mention of zang zao. The second interesting observation is that the text actually does not say that the patient is sad, but actually and literally that the patient likes to be sad and also that the patient likes to weep. I assume that is why modern Chinese books call this hysteria. For example, the book Synopsis of Prescriptions of the Golden Chamber translated by Luo Xiwen actually translates zang zao as “hysteria”. It says: “The patient suffers from hysteria and tends to weep constantly”. In my opinion this must be interpreted in the context of a book written in the Han dynasty which was dominated by the Confucian philosophy.

Confucius had a very low opinion of women and in one passage of the Analects he says that women are like “petty people”—if you keep them too close they become immodest if you keep them at a distance they become resentful (Analects 17.25). The famous “accomplished person” (Jun Zi) that is such an important Confucian ideal and that is often translated as “gentleman” did refer to men, not women. Therefore the picture that comes over in this clause is that of a “hysterical” woman who “likes” to be sad and to weep. 3) Another interesting observation of the symptoms as they are in the text is “appearing as though possessed by spirits”. Note that the word for spirits here is not gui, but shen ling which indicates the spirits of dead people but not the gui which can attack human beings causing disease. The reference to shen ling here could be translated in a modern way in saying that the patient appears haunted. 4) The reference to yawning is interesting and it usually refers to stagnation of Qi of the Lungs and/or Heart.

5) I do not agree with the explanation of the pathology of this syndrome in modern Chinese books. They say that this condition is caused by excessive thinking that leads to Qi stagnation, which transforms into Fire damaging the Heart and Spleen and scorching the Yin fluids. There is no evidence whatsoever of this in an analysis of the herbs in this formula. 6) Gan Mai Da Zao Tang is primarily a tonifying formula: it tonifies primarily Heart and Spleen and Qi, Blood and Yin. Modern Chinese books do say that this formula can be used for Qi and Yin deficiency, but curiously they say that Qi an Yin deficiency after major surgery.

7) A particular and interesting feature of this formula is that it is based on three very mild herbs which are actually foods as well as being herbs. None of the ingredients has any particularly strong effect in calming the mind, and yet together these three ingredients, in my experience, have a very powerful effect in depression and anxiety. As the formula contains only three herbs, I often may add these three herbs to another formula I am using when I suspect that the cause of the problem is mental-emotional. 8) This formula may also be used for hyper-activity in children. 9) Modern Chinese books say that this formula has an oestrogen-like action, and it can therefore be used for menopausal hot flashes and night sweating; however, I do not see where this oestrogen-like action would come from.

10) Modern Chinese books again attribute the pathology of this syndrome to Liver-Qi stagnation, which I personally find quite absurd. For example, the “Popular Guide to the Essential Prescriptions of the Golden Cabinet” by He Ren says that the pathology of this syndrome is Blood deficiency (which causes the agitation), Heart-Fire harassing the mind, together with Liver-Qi stagnation.1 11) Some modern Chinese books explain the action of this formula through its sweet taste and they say that the sweet taste moderates the Liver, resolving Qi stagnation (reverse Ke cycle of the 5 Elements from Earth to Wood). Again, I do not agree with this view. 12) The emperor herb within the formula is actually Fu Xiao Mai which nourishes the Heart and calms the mind.

1. He Ren 1981 A New Explanation of the Synopsis of Prescriptions from the Golden Cabinet (Jin Gui Yao Lue Xin Jie), Zhejiang Science Publishing House.

CHAPTER 22 - CLAUSE 9 A woman in her fifties has suffered from incessant menstrual bleeding for more than ten days. In the evening there is heat effusion (fa re 发 热), a feeling of urgency (li ji 里 急) in the lower abdomen, abdominal fullness, hot palms and dry lips and mouth. Why? The master said this is a case of a gynaecological disease. Why is that? There is a history of late miscarriage with stagnant blood left over in the lower abdomen. How does one know this? The pattern manifests with dry lips and mouth, that is how one knows it. Wen Jing Tang is indicated. This formula is also indicated for women with Cold in the lower abdomen and long-standing infertility. Also treats uterine bleeding due to Flooding [Beng 崩] or delayed menstruation. COMMENTS 1) First of all, in the first sentence the text does not say incessant menstrual bleeding but incessant diarrhoea. However, all modern Chinese books say that should be understood as menstrual bleeding in this case.

2) It is interesting that although the recommended formula is Wen Jing Tang, which is for Cold in the uterus, it is recommended here to treat excessive menstrual bleeding, which one does not usually associate with Cold. 3) The pathology of the recommended formula Wen Jing Tang is quite complex. There is Cold and Blood stasis in the uterus as a result of a miscarriage. The Blood stasis damages the Chong and Ren vessels and leads to excessive menstrual bleeding. The loss of blood itself leads to Blood deficiency, and this in turn to Yin deficiency, and that is why the lips and mouth are dry and the palms are hot. The other symptoms such as abdominal fullness and urgency indicate Blood stasis. 4) The use of the term li ji is interesting because li ji is always associated with the pathology of the Chong Mai. Indeed in this case there is Blood stasis and the Chong Mai is always involved in Blood stasis.

Dry lips and mouth, hot palms

COLD Chong Ren BLOOD STASIS

Weaken

Bleeding

BLOOD XU

YIN XU

5) Although the pathology of the syndrome from the original text is quite complex, the formula Wen Jing Tang can be used simply for Cold in the uterus. It is especially useful in the treatment of painful periods or infertility deriving from Cold in the uterus. Endometriosis also frequently manifests with Cold in the uterus. 6) This formula is primarily for Full Cold in the uterus (but, with modifications, it can be used also for Empty Cold, i.e. one associated with Kidney-Yang deficiency).

Wu Zhu Yu

Fructus Evodiae

Gui Zhi

Ramulus Cinnamomi

Dang Gui

Radix Angelicae sinensis

Warm the Uterus, expel Cold

Chuan Xiong Rhizoma Chuanxiong Bai Shao

Radix Paeoniae alba

Mu Dan Pi

Cortex Moutan

E Jiao

Colla Corii Asini

Mai Dong

Radix Ophiopogonis

Ren Shen

Radix Ginseng

move Blood, nourish Blood and regulate the periods moves Blood, clears Empty Heat

nourish Blood and Yin

Ban Xia

tonify Qi, strengthen the Spleen Radix Glycyrrhizae and help to nourish Blood Regulates Chong Mai Rhizoma Pinelliae preparatum

Sheng Jiang

Rhizoma Zingiberis recens

Gan Cao

EXPLANATION OF THE FORMULA - Wu Zhu Yu and Gui Zhi warm the uterus and expel Cold: they are the emperor herbs. - Dang Gui, Chuan Xiong and Bai Shao move Blood and eliminate stasis, nourish Blood and regulate the periods. - Mu Dan Pi moves Blood, eliminates stasis and penetrates the periods: it also clears empty Heat. These last four herbs are the minister herbs - E Jiao and Mai Men Dong nourish Blood and Yin and promote fluids; E Jiao also stops bleeding. - Ren Shen and Gan Cao tonify Qi, strengthen the Spleen and help to nourish Blood. - Ban Xia regulates the Chong Mai via the Yang Ming: by regulating the Chong Mai it will have to move Blood. - Sheng Jiang warms Stomach-Qi and harmonizes.

CHAPTER 22 – CLAUSE 12 For women with persistent spotting [xian jing 陷 经] and trickling [lou 漏] of dark blood, use Jiao Jiang Tang. COMMENTS 1) The term xian jing literally means “sinking period”: it refers to uterine bleeding from Qi deficient and sinking. This is confirmed by the use of the word lou which means “trickling” as in “Flooding and Trickling” (Beng Lou 崩 漏) and of the word xian which means “sinking”. 2) Jiao Jiang Tang is not a recognized formula: it is just E Jiao and Sheng Jiang. Modern Chinese books say that the formula could be Jiao Ai Tang Colla AsiniArtemisia Decoction (also called Xiong Gui Jiao Ai Tang ChuanxiongAngelica-Colla Asini-Artemisia Decoction.

XIONG GUI JIAO AI TANG Chuan Xiong Rhizoma Chuanxiong E Jiao Colla Corii Asini Ai Ye Folium Artemisiae argii Dang Gui Radix Angelicae sinensis Bai Shao Radix Paeoniae alba Sheng Di Huang Radix Rehmanniae Gan Cao Radix Glycyrrhizae

3) Of particular interest in the formula is the use of E Jiao, Bai Shao, Sheng Di Huang and Dang Gui to nourish Blood. This confirms the usual approach to the treatment of Lou [of Beng Lou], i.e. uterine bleeding consisting in spotting rather than a flood. It is important not to overemphasize the bleeding and try to stop it at any cost. Rather than concentrating on stopping bleeding, one must treat the root and nourish Blood. 4) Of further interest in this syndrome, is the presence of Blood stasis as a complicating factor in uterine bleeding. Although there is spotting, there is also Blood stasis and that is why the formula has Chuan Xiong. 5) Some commentaries say the formula has also Gan Jiang.

CHAPTER 22 – CLAUSE 11 When the pulse is Wiry and Big at the Cun Kou [the pulse at the wrist] and the Wiry quality is diminished by applying pressure and the Big pulse is like a scallion, the fact that [the wiriness] diminishes indicates Cold while the scallion stalk pulse indicates Deficiency. Deficiency and Cold contend with each other: the pulse is called Leather [ge, drumskin]. Women with this pulse will suffer from late miscarriage [ban chan, over 3 months pregnancy]. Use Xuan Fu Hua Tang. XUAN FU HUA TANG Xuan Fu Hua Flos Inulae Cong Bai Bulbus Allii fistulosi Qian Cao Gen Radix et Rhizoma Rubiae

HOLLOW (KOU 芤) a) PULSE DESCRIPTION The Hollow pulse can be felt at the superficial and deep levels but not at the middle one: it is, as its name implies, hollow like an onion stalk. This pulse also feels quite solid on the sides of the fingers when rolling the fingers from side to side. b) CLINICAL SIGNIFICANCE The Hollow pulse indicates loss of Blood and it appears after a haemorrhage. It should be stressed that this indicates a pathological haemorrhage and not, for example, the normal menstrual bleeding. It may also appear after a profuse loss of fluids from sweating, vomiting or diarrhoea. If the pulse is Hollow and Rapid, it may indicate a forthcoming haemorrhage. The Hollow pulse is not common. HOLLOW pulse: summary of clinical significance • Loss of blood • Loss of fluids

LEATHER (GE 革) a) PULSE DESCRIPTION The Leather pulse can be felt at a superficial level, stretched like the skin of a drum and empty at the deep level: it feels hard on the outside but empty inside, like a drum. b) CLINICAL SIGNIFICANCE The Leather pulse indicates severe deficiency of Blood, Essence or Yin. It also indicates Qi floating upwards because it is not rooted by Blood. Common patterns presenting with a Leather pulse include depletion of Blood and/or Yin and these may appear in habitual miscarriage, menorrhagia and nocturnal emissions. In my experience, the Leather pulse is frequently felt in advanced cases of multiple sclerosis. LEATHER: summary of clinical significance • ∙Severe deficiency of Blood • ∙ Severe deficiency of Essence • ∙ Severe deficiency of Yin

COMMENTS 1) This Clause is interesting from the pulse diagnosis point of view. Firstly, it describes pulse qualities with the same terms we use: Wiry, Big, Hollow [kou] and Leather [ke]. 2) It confirms that the Hollow pulse gives way on pressure, i.e. it is empty in the middle like a scallion stalk. It makes the interesting point that the Hollow pulse by itself indicates deficiency and the fact that the Wiry quality diminishes on pressure indicates Cold, something that we do not say. 3) Surprisingly, it then says that the combination of that quality and the fact that they diminish on pressure makes what we call the Leather pulse. We nowadays say that the Leather pulse may indicates miscarriage and this idea obviously derives from this Clause. 4) The choice of formula seems incongruous and some doctors think it is in the wrong place of the text.

CHAPTER 22 – CLAUSE 10 In gynaecological diseases with inhibited menstruation and abdominal fullness and pain, with the period coming twice in a month, use Tu Gua Gen San. TU GUA GEN SAN 土 瓜 根 散 Tu Gua Gen Cucumeroides Bai Shao Radix Paeoniae alba Gui Zhi Ramulus Cinnamomi Di Bie Chong Eupolyphaga

COMMENTS 1) “Inhibited” periods here mean that there is abdominal fullness and pain during the period and possibly also scanty (even though they come twice in a month). 2) Although the text does not say it, the pathology here is Blood stasis. 3) Tu Gua Gen is from the family of gourds and cucumbers and it moves Qi and invigorates Blood (like E Zhu).

CHAPTER 22 – CLAUSE 14 For women with period not coming, use Di Dang Tang. Also indicated for men with fullness, urgency [ji 急] and Blood stasis in the bladder. DI DANG TANG Shui Zhi Hirudo Meng Chong Tabanus Tao Ren Semen Persicae Da Huang Radix et Rhizoma Rhei COMMENTS 1) This is clearly a situation of amenorrhoea from severe Blood stasis. The text does not say this but we can deduce that from the formula suggested.

2) This is a very strong formula that I would use only for severe cases of Blood stasis in the Uterus with masses such as a myoma or severe endometriosis or carcinoma. 3) The reference to the use of the formula in men with bladder problems is interesting. This would be Blood stasis in the Bladder. However, I would also interpret reference to the “bladder” as the prostate. The symptoms of “fullness and urgency” suggest also a pathology of prostate hyperplasia. 4) Ji is a symptom that is difficult to translate. It may mean many different things. In general, it may refer to a pain that causes great anxiety. It also refers to symptoms with “urgency” such urinary urgency or a diarrhoea with many bowel movement in succession.

LI JI

里 Hand grabbing a person

急

Heart

JI = urgent, anxious, impatient, rapid, fast, irritated, annoyed, violent, hot-tempered, hot-headed

Huan Ji 缓 急: “moderate urgency” (Gan Cao and Bai Shao)

CHAPTER 20 – CLAUSE 2 In women with Blood-Masses [zheng 症], if within 3 months after the periods stop and there is incessant spotting [lou 漏] and the foetus stirring about the umbilicus, this indicates damage from intractable Blood-Masses. If the foetus stirs in the 6th month of pregnancy and the periods occurred normally in the three months before they stopped , it indicates pregnancy. If there is uterine bleeding, it indicates Blood stasis in the three months following cessation of menstruation. Therefore bleeding is causes by remaining Blood-Masses which should be treated with the moving downwards method [xia 下]. Use Gui Zhi Fu Ling Wan.

Gui Zhi Ramulus Cinnamomi Fu Ling Poria Mu Dan Pi Cortex Moutan Chi Shao Radix Paeoniae rubra Tao Ren Semen Persicae

COMMENTS 1) The first thing that strikes in this Clause is the use of Gui Zhi Fu Ling Wan in pregnancy! This is something we would never do in our practice. Gui Zhi Fu Ling Wan invigorates Blood, eliminates stasis and dissolves masses: it is therefore strongly contraindicated in pregnancy. So, what are we to make of this? I think that, if a woman has masses, then a formula like Gui Zhi Fu Ling Wan may be applicable. For example, a myoma will grow in pregnancy and the use of Gui Zhi Fu Ling Wan should be weighed against the complications deriving from the growth of the myoma. Also, it is interesting that the text advises starting with 1 pill only and increase to 3 if necessary. This shows that the author recognizes that invigorating Blood and dissolving masses is contraindicated in pregnancy. Modern Chinese books say that, if there are Abdominal Masses in pregnancy, it is OK to invigorate Blood and dissolve masses because the herbs will act on the masses and not on the foetus.

2) The second observation is the bleeding deriving from Blood stasis. 3) Treating the Blood-Masses by “moving downwards” implies the use of Da Huang which is also contraindicated in pregnancy. 4) It is interesting that the stirring of the foetus above the umbilicus in the first three months of pregnancy is attributed to the Abdominal Masses. In normal pregnancy, the stirring of the foetus would be felt later, around the 5th month of pregnancy. 5) Gui Zhi Fu Ling Wan is an important formula for Abdominal Masses from Blood stasis. With modifications, it can be used for ovarian cysts, endometriosis, myoma.

CHAPTER 20 CLAUSE 4 Some women suffer from spotting (Lou 漏); some suffer from miscarriage (after three months) followed by incessant spotting; some from bleeding in pregnancy. If abdominal pain occurs in pregnancy, it indicates obstruction of the uterus. Use Jiao Ai Tang.

XIONG GUI JIAO AI TANG Chuan Xiong Rhizoma Chuanxiong E Jiao Colla Corii Asini Ai Ye Folium Artemisiae argii Dang Gui Radix Angelicae sinensis Bai Shao Radix Paeoniae alba Sheng Di Huang Radix Rehmanniae Gan Cao Radix Glycyrrhizae

COMMENTS 1) This clause discusses treatment of Lou due to a deficiency of Qi and Blood with some Cold in the Uterus. The formula used is interesting because it confirms an important principle in the treatment of Lou (compared to Beng 崩). The treatment principle for Lou is to treat the cause of the bleeding (which may be Blood Heat or Qi Xu), but also to nourish Blood. Another important principle is not to concentrate too much on astringent medicinals to stop bleeding. That is why this formula nourishes Blood with Dang Gui, Bai Shao, E Jiao and Sheng Di Huang. E Jiao also stops bleeding. Also, Sheng Di Huang and Bai Shao “calm Blood” which is a method of treatment for bleeding. 2) Whatever the cause of the uterine bleeding, there is always a deficiency and “lack of consolidation” (不 姑) of the Chong and Ren Mai.

COMMENTS 3) The formula is interesting also because it includes Chuan Xiong (and Dang Gui) to invigorate Blood. This is another part of the strategy of treatment to stop bleeding. This is necessary partly because invigorating Blood prevents cloying from herbs that stop bleeding or because Blood stasis itself may aggravate bleeding. 4) The formula also expels Cold from the uteru with Ai Ye.

CHAPTER 20 – CLAUSE 6 For incessant vomiting in pregnancy, use Gan Jiang Ren Shen Ban Xia Wan. Grind ingredients, mix with fresh ginger juice and make into pills. COMMENTS 1) The ingredients of the formula stop vomiting by tonifying Stomach-Qi, making Stomach-Qi descend and resolving Phlegm. 2) The use of pills is interesting. I have always felt that pregnant women suffering from morning sickness cannot possibly drink decoctions. Also, the text recommends mixing the herbs with fresh ginger juice which improves the taste and itself stops vomiting. 3) According to some, Ban Xia is contraindicated in pregnancy but others think not.

4) This formula is for severe vomiting of pregnancy with Cold in the Stomach, rebellious Qi of the Chong Mai and possibly Cold Phlegm in the Middle Burner. 5) There has been a controversy for centuries about the use of Ban Xia in pregnancy: some doctors say it is contra-indicated, some not. It obviously depends also how it is combined. For example, here it is combined with Ren Shen. 6) I personally would advise caution.

CHAPTER 20 – CLAUSE 8 For oedema of pregnancy (“water Qi”) with a feeling of heaviness of the body, difficult urination, cold feeling as if sitting in water, dizziness on rising, use Dong Kui Zi Fu Ling Wan. COMMENTS 1) This describes oedema of pregnancy from Dampness in the Bladder together with Phlegm. Dampness in the Bladder causes difficult urination, while Phlegm causes dizziness. Dampness in the muscles causes the feeling of heaviness and cold feeling. 2) Dong Kui Zi is actually considered forbidden in pregnancy but obviously it is not when the pathology warrants its use. 3) This condition is characterized by Fullness, i.e. it is “Yang oedema” associated with pregnancy.

CHAPTER 20 – CLAUSE 9 For pregnant women, it is recommended that they take Dang Gui San frequently. Frequent use during pregnancy will ensure a smooth delivery and a healthy foetus. Also indicated for a variety of post-partum diseases. Dang Gui Radix Angelicae sinensis Bai Shao Radix Paeoniae alba Bai Zhu Rhizoma Atractylodis macrocephalae Huang Qin Radix Scutellariae Chuan Xiong Rhizoma Chuanxiong COMMENTS 1) This Clause is interesting for its recommendation that pregnant women take a formula for prevention.

COMMENTS 2) Modern Chinese books say that this formula is for Blood deficiency and Damp-Heat, but there is no evidence of this from the text. Modern doctors obviously deduce this from the ingredients with Bai Shao and Dang Gui nourishing Blood and Huang Qin resolving Dampness and clearing Heat. 3) I personally do not agree with this view also because the text does not give a pathology for this condition. For this reason, I think this is a formula that Zhang Zhong Jing advises pregnant women to take as a preventive formula to prevent miscarriage. In fact, Bai Shao, Bai Zhu and Huang Qin prevent miscarriage. 4) It is interesting that many of Zhang’s formulae for pregnancy include Chuan Xiong which is theoretically forbidden in pregnancy. 5) I would personally eliminate Chuan Xiong from the formula.

CHAPTER 20 – CLAUSE 10 To nourish the foetus in pregnancy use Bai Zhu San. Take 3g of powder three times a day and once in the evening. If there is pain, add Bai Shao; if there is pain below the heart, double the dose of Chuan Xiong; if there is mental restlessness [xin fan], vomiting and inability to eat or drink, add Xi Xin and Ban Xia. Bai Zhu Rhizoma Atractylodis macrocephalae Chuan Xiong Rhizoma Chuanxiong Shu Jiao Pericarpium Zanthoxyli Mu Li Concha Ostreae COMMENTS 1) One interesting aspect of this Clause is the preventive use of a herbal formula and especially one designed to nourish the foetus (rather than the mother)

2) Again, the use of Chuan Xiong in pregnancy is surprising but it must have been common during the times the text was written. The use of Shu Jiao (pepper) is also unusual. 3) Mu Li is used for its astringent quality and therefore preventing miscarriage.

CHAPTER 21 – CLAUSE 1 Women after childbirth usually suffer from three diseases: convulsions, collapse and constipation. After labour there is Blood deficiency and profuse sweating, this facilitates invasion of Wind and convulsions; as there is collapse of Blood, profuse sweating and cold, there is Collapse [lit yu mao 郁 冒]; as there is collapse of fluids, the Stomach has dryness and this causes constipation. COMMENTS 1) First of all, it is difficult to translate “yu mao” but the essence of the passage is that it is Collapse caused by Blood collapse. A modern Chinese book translates it as “constraint veiling” but it does not explain what it is. Other modern Chinese books simply call it “syncope”.

2) The puerperium is characterized by two possible conditions: a deficiency of Qi, Blood or Yin, or Blood stasis. The force required for delivery taxes the woman’s Qi, the loss of blood during childbirth injures Blood and Yin, the sudden expulsion of the placenta injures the Yuan Qi, the Ren and Chong vessels are depleted and the blood vessels and channels are empty. All these factors mean that a Deficiency (of Qi, Blood, Yin) is the overriding pathological condition of women after childbirth.

However, this is not to say that there are no Full conditions after delivery. Zhang Jing Yue says in the “Complete Works of Jing Yue” (1624): “After childbirth Blood is lost and there is often a Deficiency. However, there are conditions of Deficiency, conditions without Deficiency, and Excess conditions. In these three cases, one must consider the woman and the pattern to differentiate between Deficiency and Excess. In treatment, one must not stick to one’s views complacently and when one tonifies one must also pay attention to eliminating pathogenic factors.”1

1. Zhang Jing Yue 1986 The Complete Works of Jing Yue (Jing Yue Quan Shu), Shanghai Science and Technology Press, Shanghai, p. 669. First published in 1624.

Dr Chen Jia Yuan also places the emphasis on deficiency of Blood as the main condition after birth but he does not overlook pathogenic factors either: “After birth Blood is deficient and one must therefore tonify Blood. However, there may also be other patterns which must be treated and one should drive out the stale and generate the new.”2 Apart from the above deficiencies, a stasis of Blood is the other common pathological condition after childbirth. Stasis of Blood after delivery may be due to retention of old blood in the uterus or retention of lochiae. Deficiency of Blood or stasis of Blood after childbirth are, in fact, the two underlying conditions for mental changes in the puerperium: deficiency of Blood may cause post-natal depression while stasis of Blood may cause psychosis.

2. Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong ch#), Ancient Chinese Medicine Texts Publishing House, Beijing, p. 23. Chen's book, written during the Qing dynasty (1644-1911), was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang) and published in 1729.

Dr Chen Jia Yuan differentiates between treatment methods to be adopted according to a time scale. He says: “The treatment principle must be adapted according to timing: within 20 days from the birth Qi and Blood are still unsettled, the lochiae are being discharged and the main treatment principle is to ‘break Blood’ [i.e. strongly invigorate Blood]. After 20 days from the birth, Qi and Blood are settled and they have returned to the channels, even if there is still a lochial discharge, one should not move, but tonify Qi and Blood as well as simultaneously invigorate Blood.”1

The three questions after childbirth: 1) Pain: tells us whether there is stasis or not 2) Constipation: tells us whether the fluids are exhausted or not 3) Breast milk: tells us whether Stomach-Qi has been injured (scanty milk)

1. Eight Secret Books on Gynaecology, p. 65.

CHAPTER 21 – CLAUSE 6 As a rule, post-partum abdominal pain is treated with Zhi Shi Shao Yao San. If the condition is not relieved, this indicates that there is dry Blood in the abdomen below the umbilicus: use Xia Yu Xue Tang. Also treats inhibited menstruation. The colour of the freshly purger blood should resemble that of pig’s liver. Da Huang Radix et Rhizoma Rhei Tao Ren Semen Persicae Di Bie Chong Eupolyphaga COMMENTS 1) Firstly, the Jin Gui Yao Lue uses stronger treatment methods during pregnancy and after childbirth than we would. Here, for Blood stasis, it is very uncompromising using Da Huang to move downwards (which helps to invigorate Blood) and Di Bie Chong, that has some toxicity.