By Sharon Weizenbaum
By way of introduction, I’d like to write a bit about women’s physiology and the tubular quality of the Ren vessel and the Bao Tai. Though I have not heard of these pathways written or spoken of as “tubular” per se, thinking of them in this way has helped me to visualize and understand women’s physiology, patho-physiology and the use of herbs in formulas.
So, please bear with me…If we think of the Ren vessel/Bao Tai as a tubular pathway extending from the upper body (Heart and chest) to the womb, physiologically, this tube provides the route for the Heart fire to descend to warm the womb and for the Kidney water to ascend to control, moisten and cool the Heart. This pathway allows the communication and interaction of fire and water between the upper Jiao and womb. We can also see that what travels within this tube is the interaction of fire and water which is the red blood.
The scenario that requires the use of formulas like Jia Jian Tong Yu Tang (Modified Open Through Stasis Decoction), is characterized by blood in this tube becoming congealed and blocking the tube. If we think about the Qi mechanism and the necessity for there to be a constant free flow of Qi up and down, we can see that a plug in this tube could cause a disruption in this free flow. The Heart Qi and fire may be unable to move down to the womb. This can cause a myriad of upward rebellion symptoms along with the primary pathology of the uterine contents, whether blood, lochia or fetus, failing to move out freely.
Dr. Xia’s Jia Jian Tong Yu Tang (Modified Open Through Stasis Decoction) is his foundational formula to, for lack of a better analogy, sort of blow the plug out like a spit ball out of a straw.
What we want to know how to do in the clinic is to recognize when there is this kind of plug in the tube – i.e. how to diagnose this. Additionally we want to know which herbs discharge this manifestation of blood stasis and how to modify a formula for the various presentations we will see clinically.
The presentation may vary in terms of aspects such as excess/deficiency or heat/cold and it can also vary in terms of presenting symptoms such as headaches, insomnia or, as I mentioned in the last post, difficulty swallowing. Main complaints can vary from PMS, dysmenorrhea, PCOS, endometriosis and infertility to amenorrhea. We also want to know how to administer the purgative therapy safely – this has to do with careful diagnosis and timing of the treatment.
The main signs I use clinically to diagnose the presence of this “plug” is the combination of lack of free flow of the uterine contents with lower abdominal discomfort and fullness. Lack of free flow by itself can be due to pathologies such deficiency of blood or Yin fluids or cold etc. in which case blowing out the plug would be unsuitable if not detrimental. Lower abdominal fullness and discomfort could also be due to many pathologies such as uterine infection, simple blood stasis that does not block the menstrual flow or other stasis in the lower abdomen.
Lack of free flow of the uterine contents manifests as amenorrhea, scanty menstruation, menstruation the stops and starts, failure of the lochia to discharge or non progression of labor. All of these pathologies can come form other disease factors besides this one and so it is very important that the lack of free flow is paired with abdominal discomfort and fullness.
The primary herbs that Dr. Xia uses for opening through menstruation here are:
Chuan Niu Xi
Below is Dr. Xia’s writing on the 1st formula in the 7th chapter of his text.
Jia Jian Tong Yu Jian 加 减 通 瘀 煎
Modified Opening Through Stasis Decoction
Translated by Sharon Weizenbaum>
Tong 通 means to open the flow and Yu 瘀 is stasis and refers to blood stasis. Jian refers to the method of cooking which is to boil. Opening stasis refers to a strong method of transforming stasis. One should use stronger vitalizing blood herbs when the intention is to open the passageways, free the flow of blood stasis, scatter and transform blood stasis. Based on the pathological condition of the patients, I have modified Zhang Jing-yue’s Tong Yu Jian (Open Through Stasis Decoction) into my own experiential formula.
Method of Application:
One package is for one day, divided into two doses.
Regulates Qi and vitalizes the blood, opens through stasis and synchronizes the menstruation.
This formula treats blood stasis type late menstruation, scanty menstruation, prolonged menstruation and dysmenorrhea.
This formula treats blood stasis type irregular menstrual pathology. This includes blood stasis type dysmenorrhea and amenorrhea presentations. It places Dang Gui Wei in an important position for vitalizing blood and transforming stasis. However, these days pharmacies do not discriminate between Dang Gui Wei, Dang Gui Tou and Dang Gui Shen. Consequently we assist the function of Dang Gui to open stasis with Tao Ren and Hong Hua making this a stronger blood vitalizing formula.
Zhang Jing-yue’s original formula contains Hong Hua but is without Tao Ren. Tao Ren must be added. Generally, because of the demands of opening through stasis, I base my formula on Tong Yu Jian (Open Through Stasis Decoction), though, according to the clinical presentation I also add Ze Lan Ye and Chuan Niu Xi to open the pathways of the menstruation. The goal is to vitalize the blood while guiding its flow and opening through the menses. Therefore, in addition to using herbs to vitalize blood and transform stasis, one should also assist with herbs to synchronize and regulate Qi and move stasis.
The point is to first give herbs to move the menstrual Qi. It is said that “When menstrual blood does not move, first move the Qi because when the Qi moves, the blood will move. When there is Qi stasis, there is blood stasis and when there is blood stasis, the blood obstructs the Qi movement”. Because of this, I add Xiang Fu, Wu Yao and Mu Xiang. These 3 herb flavors regulate the Qi and synchronize the Qi of the Liver, Kidney and Spleen Zang.
When regulating Qi and moving stasis it helps to vitalize blood and open the menstruation and so you can add Qing Pi. This herb helps promote easy flow and discharge and strengthens the regulating and synchronizing of the Liver Qi. Because the Liver stores the blood and governs free flow and discharge, when you want to help the flow and discharge of the menstrual blood and this will regulate Qi and synchronize the menstruation. Therefore when regulating the Qi and synchronizing the menstruation, one should lay stress on the Liver. One can add Shan Zha.
Master Zhang uses this not only to vitalize blood and open the menstruation, but also to synchronize and regulate the Qi mechanism. Because of all this, Jia Jian Tong Yu Tang (Modified Open Through Stasis Decoction) is frequently used in the clinic.
According to Jing Yue Quan Shu: Fu Ren Gui (The Complete Works of Jing Yue: Women’s patterns), Tong Yu Jian (Open Through Stasis Decoction) treats Qi stasis, congealed blood, inhibited menstruation and vessels and extreme abdominal pain. In addition to treating late menstruation, lack of smooth flow of menses and painful menstruation, Jia Jian Tong Yu Jian (Modified Open Through Stasis Decoction) can also treat post partum congealed blood excess pain as well as blood reversal or blood rebellion.
Late Menstruation, scanty menstruation and painful menstruation:
This formula can be used when there is scanty menstruate that does not flow smoothly. This presents with abdominal pain that resists pressure, purple blood with dark with clots, pain and distention in the abdomen, chest oppression and vexation. The pulse is thin and wiry and the tongue is purple and dark. In this circumstance you can add herbs such as Rou Gui and Ze Lan Ye.
Post partum blood stasis abdominal pain:
During the post partum time, if the lochia stops too soon or does not flow out smoothly and this is accompanied by purple dark blood with clots, lower abdominal distention and pain, low back soreness and weakness with chest oppression, abdominal distention, purple dark tongue and a thin rough pulse, one should add Ze Lan Ye, Yi Mu Cao and Yan Hu Suo to this formula.
Blood stasis blood fainting:
This presentation can be due to trauma from an accident, or it can simply manifest when there is scanty menstruation with abdominal pain. The patient suffers from dizziness, fainting, cold limbs, nausea and vomiting, abdominal distention, a thin pulse and a purple dark tongue. In this circumstance you can add herbs such as Shi Chang Pu, Guang Yu Jin, Zhi Mo Yao or Zhi Ru Xiang.
This formula is from the Jing Yue Quan Shu: Fu Ren Gui (The Complete Works of Jing Yue: Women’s patterns and it can be modified as below:
- If there is cold stasis add Rou Gui and Wu Zhu Yu
- If there is full fire with inner heat with blood that does not move due to dry blood add Chao Shan Zhi, Dan Pi.
- With slight heat and blood deficiency add Bai Shao and Gui Shen.
- With blood stasis with very scanty blood add Su Mu and Chong Wei Zi
- With dry knotted stool add Da Huang and E Zhu or add Mang Xiao and Tao Ren.
Tong Yu Jian(Open Through the Menses Decoction) is really 3 formulas.
- Tong Yu Jian (Open Through the Menses Decoction) comes from the (Jing Yue Quan Shu: Fu Ren Gui (The Complete Works of Jing Yue: Women’s patterns). My Jia Jian Tong Yu Tang (Modified Open through the Menses Decoction) was developed based on this formula and my own clinical experience.
- The second formula is from the Xian Nian Ji (Immortal Collections): Vol. 4. This formula uses Gui Wei, Da Huang, Hong Hua, Su Mu. These are strong herbs for dispelling stasis but in this formula the dosages are light. It is for moving evil blood and is used primarily for dispelling when there is post partum congealed blood and stasis leading to poor flow of the menstruation. This is considered evil blood.
- The third formula is from Guang Lue Liu Shu: chapter 25. It uses Pu Huang, Wu Ling Zhi, Chuan Yu Jin, Xiao Zhi Shi, Bai Zhu Tang, Jian Ze Xie, Xi Chi Shao, Tao Ren Ni, Ming Hu Bo. This formula is used to treat blood stasis in which the abdomen becomes filled with fluid. The pulse is rough and not smooth.
In the Fang Lun Xuan Lu (Selected Writings on Formula Theory) it is written: “When blood stasis is not dispersed, the Spleen and Stomach loose their ability to be fortified and to transform and transport the minute essences. The turbid Yin gets stopped up and this leads to abdominal distention and fullness. This is called Blood Tympanites (Gu 臌).
Pu Huang cracks congealed blood, it opens the channels and collaterals. Wu Ling Zhi cracks congealed blood and also descends the turbid Yin. Tao Ren cracks the congealed and also moistens dryness. Chi Shao cracks the congealed and also discharges fire. Zhi Shi disperses distention and fullness. [Bai] Zhu Tan fortifies the Spleen Qi. Yu Jin synchronizes the Qi and opens depressive knotting. Ze Xie separates the clear Yang. Hu Bo disperses congealed blood and allows open permeability, allowing the congealed to be transformed and for the Qi to be synchronized.
The result is that the Chong vessel is clear and harmonized, the Spleen and Liver Qi transform and the blockage is immediately opened. How could abdominal distention not recede”.
What these formulas treat is not the same. However, the meaning of the formulas is identical. They can be used together in the clinic and adjusted according to the presentation. When I use Tong Yu Jian (Open Through Stasis Decoction) in the clinic, I often add Shi Xiao San (Powder for Loss of Smile), Tao Ren, Ze Lan and Chuan Niu Xi. This strengthens the force of transforming stasis and opening the menstruation. This is because, when the menstruation is blocked and not flowing smoothly, this is usually related to congealed blood and Qi stasis.
So we can say that if we want to open the menstruation we must transform stasis. If we want to transform stasis we must assist this by moving the Qi. Qi and blood movement complement each other. Therefore, in relation to illnesses of menstruation, the meaning of opening through stasis is to open through the menses and transform stasis.
In my own clinical practice I see patients who have serious endometritis. This may develop after dilation and curettage surgery and it can give rise to adhesions of the uterine cavity. The degree of adhesions can vary as can the extent to which it influences the menstruation. It may give rise to scanty menstruation or even amenorrhea. In general though, this is due to stasis and obstruction in the uterus with lack of free movement of the blood. Tong Yu Jian (Open Through Stasis Decoction) can treat this but the effect is only good in relatively light cases. For more serious cases surgery must be used to sever the adhesions and this formula can be used after that.
Detailed analysis of the principle herbs in this formula:
Hong Hua and Shan Zha
There are three principle herbs in this formula: Dang Gui Wei, Hong Hua and Shan Zha. Dang Gui Wei is represented by Dang Gui and has been discussed in previous chapters so here I will discuss Hong Hua and Shan Zha.
Hong Hua is also called Hong Lan Hua. It is pungent and its nature is warm. It enters the Heart and Liver. Its function is to vitalize blood and open through menses. It dispels stasis and stops pain and can be used for congealed blood type amenorrhea and post partum congealed static blood abdominal pain.
The Ben Cao Guang Mu (The Grand Compendium of Materia Medica) considers Hong Hua an herb to “vitalize blood, moisten dryness, stop pain, disperse swelling and open through the menses”. It also says “Blood is generated in the heart wrapper, stored in the Liver and belongs to the Chong and Ren vessels. Hong Hua is the likeness of blood and therefore, in men it is able to move the blood vessels and in women it opens through the menstrual water. In large amounts it moves the blood and in small amounts it nourishes the blood.
The Ben Cao Hui Yan (Treasury of Words on the Materia Medica) says “Hong Hua cracks the blood, moves the blood, vitalizes the blood and synchronizes the blood. Primarily it is used to treat the 100 diseases of pregnancy and birth in which the blood is damaged. It is also used to treat blood vexation, blood dizziness, unconsciousness with an inability to speak, the lochia striking the Heart, gripping pain around the umbilicus, difficult birth, uterine lining failing to discharge or expired fetus in the abdomen.
All of these are presentations of birthing which Hong Hua can treat. If there is post partum blood dizziness, lock jaw with clenched fists or an evil enters the blood chamber with incessant talking to the point of craziness or blood oppression with interior distention and the patient falls over stiffly as if dead. These are all post partum presentations for which Hong Hua cannot help but calm.
If there is amenorrhea with no opening through with cold and heat mixed together or late menstruation with abdominal pain and dark purple dripping or traumatic injury with Qi and blood congealed and accumulating – these are all due to a lack of harmony of Qi and blood. How can Hong Hua fail to synchronize”?
Shan Zha is sweet and sour and its nature is slightly warm. It enters the Spleen, Stomach and Liver channels. Its function is to disperse food and fortify the Stomach. When we analyze the pharmo-dynamics of Shan Zha we see that it increases the secretion of the digestive enzymes and is also able to promote the digestion of fats. This is accompanied by an ability to strengthen Heart function and lower the blood fat. This can be used for presentations that include indigestion, post partum congealed obstructed abdominal pain, hernia and chest obstruction heart pain.
The Shen Nong Ben Cao Jing Shu (Commentary on ‘Shen Nong’s Classic of the Materia Medica) says “Shan Zha enters the foot Yang Ming and Tai Yin channels. The Ben Jing Classic of Materia Medica says that the flavor is sour and the Qi is cold. That this is able to disperse the digestion and move congealed blood indicates that it is not cold. Shan Zha is able to enter the Spleen and Stomach, scatter abiding accumulated stasis and water dysentery with post partum blocked pain in the abdomen. Generally Shan Zha is thought to transform food and fluids, fortify the Spleen and Stomach, move knotted Qi and disperse congealed blood. Because of this it is a suitable food for children and birthing women.
The Ben Jing Classic of Materia Medica also says that this is cold and so it has a function as a wash for scabies. We can see that fundamentally Shan Zha fortifies the Spleen and disperses food stasis. It also functions to vitalize the blood, transform stasis and disperse accumulated stasis.
Tong Yu Jian (Open Through the Menses Decoction) is a formula I use frequently in the clinic for lack of free flow of the menstruation. I often use it with Yue Ju Wan or Wu Wei Tiao Jing San (Tang). The results are quite good. For acute abdominal pain use Hong Hua Jiu and the pain will stop. The Jin Gui (Essentials From The Golden Cabinet) discussed early on that the single flavor Dang Gui in Dang Gui Wan (San) is used for painful menstruation.
The Xian Dai Zhong Yao Xue Da Ci Dian (The Modern Great Dictionary of Chinese Herbs) says that as a principle herb, Shan Zha treats functional dysmenorrhea. Use 30 gm without the pit, Sunflower seed with the husk 15 gm. After roasting, grind these into a powder and add 60 gm of brown sugar. Take one package a day divided into 2 doses or decoct. Every time before the menses take two packages and do this for 2 cycles. I treated 105 patients: 30 had a cure, 50 improved and 25 were without effect. The effect was good for those with blood stasis and deficiency cold.
I treated one case of long cycle. Ms. Zhang was 35 and her menstruation was scanty and did not flow smoothly. The color was purple red with small clots and there was lower abdominal acute pain. When she bled this pain lasted for 12-15 days. She had an IUD. Her gynecology and bi-manual check-up revealed no abnormalities and the position of the IUD was normal. It had been there for 5 years. Her menstruation had lengthened for the last 5 months. Her pulse was thin and wiry and her tongue body was dark red with a yellow sticky moss.
On the first day of her menstruation, I gave her 7 packages of Jia Jian Tong Yu Jian (Modified Open Through the Menses Decoction). She stopped bleeding after 8 days. At the next menstruation I again gave her 7 packages of Jia Jian Tong Yu Jian (Modified Open Through the Menses Decoction). She bled for 7 days and on day 2 and 3 the amount of blood increased. She then resumed a normal menstrual cycle.