In this post I look at cold as a root of blood stasis.  I identify cold as a root factor in almost half of my dysmenorrhea cases.  In my experience, there are some unique characteristics to treating blood stasis as the root cause of dysmenorrhea and these are the same characteristics for treating other types of pain in which cold is a factor.

Cold causes blood stasis very intensely and quickly.   The pain from blood stasis due to cold is also relatively intense.  Think of a child swimming in cold water and how they start to shiver and develop blue-purple lips, fingers and toes.  I have a small spring fed pond behind my clinic.  The water is very cold all year round.  If I dip my feet into it, within 2 minutes they start to ache.  Cold causes blood stasis and this blood stasis causes pain.  However, as soon as the child is warmed up, the lips, fingers and toes turn pink again!

The good news about pain due to blood stasis is that warming the area of pain is very often enough to vitalize the blood and stop the pain.

As we saw in the last post, Dr. Xia wrote:

There is the principle that when the blood is warm it will move.  When there is dysmenorrhea, there is a relationship with blood stasis.  For this it is appropriate to warm the Yang and vitalize the blood and this is not really because there is cold there.  Generally blood stasis does not manifest with Heart and Liver fire flourishing.  The transformation of stasis and the opening through of the collaterals must be assisted with herbs to warm the Yang.

Dr. Xia is talking about the importance of using warmth to vitalize blood regardless of the root pattern.  Warmth moves and cold stops.  This is a general principle for treating pain.  Even in cases in which pain has a strong heat component, the herbs for clearing heat are combined with herbs that warm.  This means that if the root cause of the blood stasis is cold or if the patient has a Yang deficiency constitution, you will be able to use warming herbs very liberally.  Very often there is no need to use any herbs to vitalize the blood.  Simply melting the iceberg is enough.

When a patient comes to me with dysmenorrhea that is improved with warmth accompanied by, a cold butt, pale tongue body, a general aversion to cold and a particular aversion to cold in the lower body I know that cold is a factor in the pain.  The next step for me is to determine if there are other root factors involved as well.

If the only cause of the blood stasis is cold or yang deficiency, there will be no need for any blood vitalizing herbs.  Simply warming the womb will renew circulation and stop the pain.  If the patient is thin and tending to dryness, I use Wen Jing Tang. This formula can be modified to be relatively more warming or relatively more enriching.  By combining warm and pungent herbs with sweet blood enriching herbs, warmth is directed into the blood.  This will stop pain without adding any herbs to stop pain or strongly vitalize the blood.

Ai Fu Nuan Gong Tang is also a wonderful and effective formula.  Again it can be seen that there are no herbs here to strongly vitalize blood or to stop pain.

For robust patients with rough or dry skin, I often use Ma Huang in combination with herbs to direct the formula to the womb and to the blood.  If there is Kidney Yang deficiency herbs such as Fu Zi, Xian Mao or Ba Ji Tian can be added.  I often notice that my patients with cold womb pain also have a very red tipped tongue combined with agitation and insomnia.  For this I often integrate Jiao Tai Wan by adding a good dose of Huang Lian.  This not only calms the spirit but also directs the fire downward.

Of course there is a relationship between cold womb dysmenorrhea and infertility and habitual miscarriage.  Dr. Qiu writes:

“When the Kidney Yang is insufficient, the Ming Men Fire wanes, the uterus is cold and vacuous and a woman is unable to receive Jing and become pregnant the treatment to use is Gui Xian Tang Cinnamon Immortals Soup with added flavors. This prescription warms the Yang and heats the uterus, replenishes the Jing and boosts the Kidneys so that the Chong and Ren Mai will be abundant and so the fetal wrapper can receive and sprout life. The Qi will then be warm and harmonious like the springtime, the container of creation will transform and become and there will be pregnancy”.

Below are some discussion on this topic with case studies written by my teacher Dr. Qiu Xiao-Mei.  She uses formulas such as modified Wu Zhu Yu Tang and Dang Gui Jian Zhong Tang, which also follow the ideas discussed above.

Often a woman will receive a cold evil because she wades in cold water, gets caught in the rain or she eats too many cold foods during menstruation.

This causes stasis in the uterus.  When blood meets cold the blood becomes congealed, the blood is unable to move freely and this causes pain.  As Zhang Jing-Yue wrote “When a woman eats cold or toxic foods, if there is cold stasis in the channels, external cold gets in or she is not cautious with cold, the effect is congealed knotting and lack of movement.  When this stays and gathers, there is pain”.

Principle Pattern:  The patient may feel cramping or gripping pain before or during menstruation, the application of warmth will ease the pain, she may vomit clear liquid, have coldness in her four limbs.  The menstrual liquid may be dark red and scanty or irregularly pour or drip with no ease of flow.  The blood may contain clots.  Her pulse may be deep and slow or deep and tight.  Tongue moss may be thin and white.

Treatment method:  Warm the menses and scatter cold

Principle formulas:  Wu Zhu Yu Tang Jia Jian (Wu Zhu Yu, Rou Gui, Fang Feng, Xi Xin, Dang Gui, Qi Ye, Chaun Xiong, Gan Jiang).

Case Example:  Ms. He was already married and 36 when she came for her first visit in June of 1962.  In the past, during her menstruation she had waded in water and three days before her menses she had experienced abdominal pain and felt cold.  When she had her menses for 3-5 days the pain became severe though was slightly relieved with the application of warmth.  She was unable to eat and vomited clear liquid.  She had spontaneous sweating, dizziness, inability to leave her bed, back soreness and down bearing pain in her abdomen.  Her menses were late, the color was murky and the amount scanty.  Her facial color was dull white, wan and thin and she felt worried and depressed. During her menses she was unable to work.  Her pulse was deep and rough.  Her tongue moss was thin white.  Western medical diagnosis was endometriosis.  She did not want to have surgery but wanted to try Chinese herbs for treatment so she switched from the other hospital to my clinic.

Differential diagnosis:  Cold damp congealing and static.

Treatment method.  Benefit the Yang and expel stasis.

Formula:

Gui Zhi                       4.5
Chao Bai Shao           9
Dang Gui                   12
Chuan Xiong             4.5
Zhi Gan Cao              3
Ai Ye                           4
Dan Shen                   15
Xiang Fu                     9
Yu Jin                          6
Mu Xiang                   9
Pao Jiang                    4.5
Rou Gui Wei              2.4 (make into a pill and take)

Second Visit:  After taking the abover formula the abdominal pain lightened, she was able to eat and did not vomit.  The sweating also stopped, her facial color was more luminous and her spirit was happy.  Her pulse was slow and moderate and her tongue moss thin and white.  The previous formula had been effective so I continued with the same method with a few changes:

Gui Zhi                       4.5
Dang Gui                   9
Dan Shen                   12
Chuan Xiong             3
Chao Bai Shao           9
Xiang Fu                     9
Ai Ye                           3
Xu Duan                    9
Pao Jiang                    3
Rou Gui Wei              1.5 (make into a pill)

Third visit:  Warming, opening through and moving the blood, the congealed cold in the uterus was warmed and scattered.  The abdominal pain was gone.  After this, she would take 5 packages of this formula before her menses and there was no sign of a problem.  She was able to return to her normal activities.

Discussion:  In this case, the western diagnosis was endometriosis but, based on my differential diagnosis she had cold damp congealed stasis in the uterus.  Because of the cold, the blood did not move.  This caused the menses to come late and the cold Qi stagnating in the lower Jiao caused extreme pain that was slightly relieved by the application of warmth.  I used Gui Zhi Tang with Rou Gui.  The idea was to aide the Yang to expel the congealed as well as to regulate and harmonize the luxuriant Wei.  This way the heat dispels the cold.

Many cases of dysmenorrhea are caused from a vacuity of Yang and uterine vacuity cold.  The blood looses its warm movement and the menses do not flow smoothly.  Lack of openness causes pain and leads to dysmenorrhea.

Principle pattern:  The patient may have pain before or during menstruation that feels cold.  The patient may like pressure and warmth on her abdomen.  The menses may be scanty and pale.  She may fear cold, lack warmth in her 4 limbs, have a sticky thin bowel movement, a deep slow pulse and a pale tongue.

Treatment method:  Warm the menses and supplement vacuity

Principle formulas: Wen Jing Tang and Dang Gui Jian Zhong Tang

Case Example: Ms. Li was 32 and already married when she came to see me on August 12, 1954.  She complained of 10 years of dysmenorrhea.  It was worst when the menses began, liked pressure and warmth and year by year had become worse.    Her menses arrived late by 9-15 days and was pale in color and thin.  She bled for 6-7 days without a lot of blood and stayed in bed 3-4 days.  She also experienced low back soreness, weak legs, fear of cold and eating made it worse.  After she had been married for 8 years, she still had not become pregnant.  Her pulse was deep and thin and her tongue moss was thin white.

Differential diagnosis:  Liver and Kidney vacuity cold

Treatment method: warm the menses and scatter cold, regulate and supplement liver and Kidney

Formula:
Dang Gui                   12
Chuan Xiong             6
Chi Shao                    9
E Zhu                          6
Wu Zhu Yu                3
Niu Xi                         9
Gou Qi Zi                   9
Pao Jiang                    3
Rou Gui Wei              3
Tu Si Zi                       9
Gou Ji                         9

Second Visit:  August 24, 1954:  After 10 packages of the above formula her menses were 5 days late and the color had changed to red though the quality was still thin and the pain had decreased so that she stayed in bed just two days.  She had no problem eating.  She still had back soreness and abundant discharge and her menses lasted just 2 days.  Her pulse was thin and her tongue moss was thin and white.  I gave her 9 packages of Ba Zhen Tang and Si Zhi Xiang Fu Wan.  I advised her to take 9 gms of the pills and 1 package of the soup each day.

Third Visit:  December 12, 1954:  Ms. Li reported that after 10 years of dysmenorrhea, after the herbs the pain was gone.  Her menses had normal color and regularity had been normal for 3 months.  Her pulse was moderate and her tongue body was red.  I gave her the following formula:

Dang Shen                15
Bai Zhu                       9
Fu Ling                       9
Zhi Gan Cao              3
Dang Gui                   9
Bai Shao                     9
Shu Di Huang           30
Chuan Xiong             1.5
Du Zhong                  30
Tu Si Zi                       15
Ba Ji Tian                    12
Zi He Che                   3 gm swallowed with each dose

I advised her to take it before sleep.

Forth visit: March 25, 1955.  She took the above formula for more than a month.  Her last menstruation was January 20 and it lasted 5 days.  She reported feeling dizzy with an aversion to cold.  She also had a bland taste and poor appetite with vomiting.  Her pulse was thin and slippery and her tongue moss was thin and white.  A pregnancy test was positive and she was suffering from morning sickness.

Discussion:  This patient had dysmenorrhea for more than 10 years that responded favorably to heat and touch.  Her period was late, pale in color and scanty in amount.  Her back and legs were sore and weak.  Her pulse was deep and thin.   The differential diagnosis focused on Liver and Kidney vacuity cold.  The Chong mai is the sea of blood and the Ren governs the Bao Tai.  The Ren and Chong are both subordinate to the Liver and Kidneys.  This Liver and Kidney insufficiency, Chong and Ren not nourished, and vacuity cold of the uterus lead to an inability to absorb Jing and become pregnant.  In this case the dysmenorrhea is connected to the infertility.  At her first visit I gave her Wen Jing Tang modified.  Dang Gui, Chuan Xiong, Chi Shao, E Zhu, Wu Zhu Yu, Rou Gui and Pao Jiang nourish blood, vitalize blood and scatter cold so that the cold can be dispelled and the uterus can then be warm.  Niu Xi, Tu Si Zi, Gou Qi Zi and Gou Ji assist the insufficiency of the Liver and Kidney.  At the second visit I gave her Ba Zhen Tang to fortify the Spleen and regulate the menses.  I added Si Zhi Xiang Fu Wan to rectify the Qi. This way I worked with the Qi and Blood at the same time.  When the Qi is moving in the proper way the blood is harmonized and the menstrual cycle becomes normal and the pain is gone.  At the third visit I changed to using Yu Lin Zhu San to fortify the Spleen and Stomach, reglate the Ying and Wei, supplement the Liver and Kidney so the Qi and Blood can be abundant and the sea of blood full.  The result was pregnancy.

For some women, the pain is so extreme that they KNOW it is not normal. It is often accompanied by other symptoms such as vomiting, fainting, migraines, exhaustion, and digestive upset.  Dysmenorrhea can be very debilitating.  In addition, many of our patients who suffer from dysmenorrhea are unable to become pregnant. 

As a teacher of Chinese herbal medicine, I am aware that our foundational educations often leave practitioners with very limited tools for treating this illness.  All we really learn is that dysmenorrhea is blood stasis and to treat blood stasis we give formulas like Tao Hong Si Wu Tang or Xue Fu Zhu Yu Tang.  These types of formulas will have very limited if any effectiveness.  So, I thought I would do a series of blogs posts on dysmenorrhea.

Some of this information is taken from the writings of Dr. Xia Gui-Sheng, some from one of my teachers Dr. Qui Xiao-Mei, some ideas regarding the use of classic formulas and some ideas from my own experience.  You can see other writings of the two above mentioned doctors by looking at the categories to the right.

I am starting this series with a wonderful passage from the writings of Dr. Xia Gui-Sheng from his book Gynecology Formulas and Herbs: My Clinical Experience in 15 Chapters.

The passage below is one of my favorites because it shows us that Dr. Xia had to go through his own experience of feeling limited by what he had learned.  He thought about his experience deeply and, over time, integrated what were the essential ideas.

Dr. Xia, when exploring the treatment of dysmenorrhea, realizes the importance of the following:

1. Regulating the Qi and freeing flow
2. Stopping ppain
3. Warming
4. Going to the right location – the uterine vessels
5. Suffering is related to the Heart

“When treating dysmenorrhea, pain is the principle symptom.  In the course of exploring the treatment of dysmenorrhea, I’ve looked into formulas such as Xue Fu Zhu Yu Tang, Ge Xia Zhu Yu Tang, Shao Fu Zhu Yu Tang and Hu Po San.  In the beginning, I followed the idea that “when there is free flow, there will be no pain and that pain is due to lack of free flow.  I first used Xue Fu Zhu Yu Tang, which is Tao Ren and Hong Hua with Si Wu Tang, Chai Hu, and Jie Geng to up-bear and Niu Xi and Zhi Qiao to down-bear and I observed some effect but it was far from ideal.

I continued to consider dysmenorrhea, realizing that I must stop pain.  Therefore, on a foundation of vitalizing the blood, transforming stasis, opening through the menstrual blood, I also added stop pain herbs such as Wu Ling Zhi and Yan Hu Suo.  To integrate this idea, I used Ge Xia Zhu Yu Tang.  This formula is also a commonly used gynecology formula but it still did not have an ideal effect.

I continued to consider this.   There is the principle that when the blood is warm it will move.  When there is dysmenorrhea, there is a relationship with blood stasis.  For this it is appropriate to warm the Yang and vitalize the blood and this is not really because there is cold there.  Generally blood stasis does not manifest with Heart and Liver fire flourishing.  The transformation of stasis and the opening through of the collaterals must be assisted with herbs to warm the Yang.  I add Rou Gui and Ai Ye for this.  This is integrating the ideas of Shao Fu Zhu Yu Tang.

For the Yang heat to transport the warmth to the uterine blood vessels I also add Du Zhong and Chuan Duan to supplement the Kidney and benefit the Yang.  This not only addresses the idea of warming to move the blood. It also addresses the idea of treating the root.  In practice this sure enough brings results.

However, for really stubborn serious dysmenorrhea, this is also not ideal for controlling the pain.  One must reconsider the location of the pain. In this case the pain is in the Heart and Liver.  The Heart and Liver not only control the movement in the blood vessels, they also are the seat of the experience of pain.  Because of this, one must also use the method to calm and settle the Heart and spirit while emolliating and harmonizing the Liver.  Adding Hu Po San to the formula that is vitalizing blood, opening the collaterals, stopping pain and warming the Yang completes the effect.

This becomes my experiential formula Tong Jing Tang”.

Tong Jing Tang

Application Method

During menstruation take on package each day decocted in water

Function

Vitalize blood and transform stasis, warm the menses and stop pain

Applications

This formula is principally used for primary dysmenorrhea, which is called functional dysmenorrhea.

Formula Constituents

This formula contains Gou Teng and Dan Pi which both clear the Heart and Liver, calming the Spirit and Hun.  Pain has a relationship with the Heart and Liver Spirit and Hun.  Only when the spirit is calmed and sedate can pain be controlled.  This is the premise behind stopping pain.  Based on the idea “when there is free flow there is no pain” I use Chi Shao, Wu Ling Zhi and Yi Mu Cao to vitalize blood, transform stasis, regulate menstruation and stop pain.  Rou Gui, Chuan Duan and Du Zhong supplement the Kidney, warm the uterus, warm the Yang and vitalize the blood.  These herbs not only assist in vitalizing the blood, transforming stasis, and promoting the easy flow of Qi and blood, there is a deeper layer of meaning as well.  When the Yang Qi is warm and glowing the stasis in the womb is dissolved and the congealed stasis in the womb can be dispelled.  Yan Hu Suo and Wu Ling Zhi not only transform stasis and regulate the menstruation, they are also herbs that stop pain.  Fu Ling calms the spirit and disinhibits dampness.  It assists in discharging turbidity and transforming dampness.  Altogether, these herbs are effective in treating dysmenorrhea.

Case Example

Functional dysmenorrhea is most often seen in unmarried women but can be seen in married women as well.  I treated a 30-year-old woman named Qian who suffered from dysmenorrhea for 10 years.  She had been married for 2 years without becoming pregnant.  On the first or second day of her menstruation she had extreme pain.  The amount of menstruate was average but the blood had clots in it.  Premenstrually she experienced chest oppression, agitation, breast distention, back soreness and fear of cold.  Her tongue was pale red and her pulse was wiry and thin.  Although her BBT showed that she was biphasic, the luteal phase was unstable.  There was an irregular wave and in general, the temperature was low.  This illness was not only dysmenorrhea.  It was also causing infertility.  Because of this, I needed to work in two key phases.  During menstruation I gave her Tong Jing Tang and during ovulation I gave her Bu Shen Cu Pai Luan Tang.  I treated her for 3 menstrual cycles and after this her dysmenorrhea was relieved.  I continued on for another 3 months and she became pregnant”.

It was my right ankle so I could easily remount and I decided I wanted to finish my ride.  It was also better for her for me to not make a big deal out of the accident.

Later my ankle swelled up and walking became really difficult.  I took an epson salt bath and slept well.  The next day I decided to use some of my knowledge for myself.

I brought out my 7-star hammer and cups and Amber Massage Salve and got to work.

I hammered my swollen ankle hard enough to draw blood and slathered some salve on it. (Click for little movie of the hammering to bring out the blood IMG_0701)

Then I placed  a firm cup on the area.

I moved the cup around.  More blood was drawn this way.

The result of this treatment was that my ankle was about %50 better by that evening and about %75 better by this morning!  I did the treatment again this morning.  The photos here are from the 2nd treatment today.  It is a rather intense treatment but so worth it!   I’m going riding again today!

Here is Dellah rolling after this infamous  ride while Sierra and Pumpkin look on.

I am in the process of editing this material now and thought this clip would make a good blog entry.  I place it here in the spirit of helpful tidbits.  This bit was part of Dr. Fu’s discussion on Ban Xia Xie Xin Tang.

In this short presentation Dr. Fu also speaks about the origin of Zhang Zhong-Jing’s formulas. He refers to Dr. Yi Yin, 伊尹, who was a cook originally!

I think you will learn something here about how and why to use Da Zao in your formulas.

Click here to open the presentation

We will be offering this entire course beginning in June as a 6 week online course.  Registrants will have the opportunity during the 6 weeks to ask Dr. Fu questions and discuss the material between themselves.  3 hours of the presentation will be posted each week for a total of 6 weeks/18 hours.  This innovative interactive course gives 18 CEUs.  Stay tuned for more information!

The first weekend of the Graduate Mentorship Program launched the new 2012 program.  40 students attended the program live while over 50 streamed live all the way from the Netherlands, Israel, Vancouver, California and beyond.  There are another 25 who are doing the program totally through the distance learning format, watching the video footage after the weekend and participating in the mentorship aspects.  It was such a great group of students!  Really, it is so nice for a teacher to have students looking awake and interested for 3 whole days.  It seemed that students felt comfortable as well.  They asked many great questions so there was a spirit of  conversation and exploration.  Students who were streaming live were also able to ask questions through the chat function and moderator.  When ever I asked a question, many students piped up and spoke as well.  For me, the weekend was really fun.

I’m very excited for the remaining time with this group.  So many smart and inspiring people!

And check out Didi’s website

You can make a donation to support her book..contribute here

With this in mind, the Graduate Mentorship Program offers both the three-day weekends (8 of them altogether) and then, in addition, offers the weekend repeated bit by bit, in weekly assignments. These assignments involve watching about a 1 hour video presentation that has been edited from footage of the class – with questions in mind to think about for the week.  As the weekends progress, flashcards are also there to review diagnosis and formulas. This way, taken in small doses, the material becomes very digestible.  There will be questions and ideas for students to write about in our forum.

Another important aspect of the Graduate Mentorship Program is the community that gets created among us all in relation to the medicine.  This community is created only in part by meeting each other in person at White Pine Institute.  It is also created through the the “tea house” – like forum that is formed for the students of the program.  I take this idea of a tea house from Michael Max’s vision of his blog/journal Junkyard Daoist.  He writes “Junkyard Daoist..is more like a teahouse.  A place where people gather, linger, discuss, argue and share in the company of those with similar interests and perhaps very different minds.  In this way maybe we can better understand our craft”. The resource are for the Graduate Mentorship Program is just this kind of cyber-teahouse dedicated to the participants of the program.  It is a place in which we can all discuss the weekends and weekly assignments, bring case questions, grapple with conceptual conundrums and share our success stories.

One of the really wonderful aspects of this Graduate Mentorship Program teahouse (I’ll have to give the teahouse a name…..any ideas?)  is the virtual library it houses.  As we are having our lively conversations any one can walk over to the library and take out an article or show us a video to further illustrate their idea.  Yes, we have a voluminous “Student Library” that is available only to participants (past and present).  The library houses institutional subscriptions and back issues of many major journals such as The Lantern, and  The Journal of Chinese Medicine.  It also gives students access to many online courses and subscription only web-sites such as Classical Chinese Medicine, Hun Yuan Research Institute and World Acupuncture.  These rich resources, full of wonderful articles and videos, are used in the program and are available only to students.

What is this “material” we work with in the Graduate Mentorship Program?  What is the program about?  What is learned?  The foundation of the course is diagnosis.  Most of our initial Chinese medical education involves learning techniques, herbs and formulas while not emphasizing our ability to see and synthesize the key diagnosis that can unlock the knots of disharmony.  We learn to gather information from our patients through a variety of methods – touching, asking, seeing, hearing etc. – but how do we process this information so it leads us to very clear and effective treatments? Also, we want to make sure our gathering of information is mindful and skilled. In this program we revisit touching diagnosis with a strong abdominal and pulse diagnosis component.  We also revisit asking diagnosis with new concepts for how to question and new ears to hear the answers.  We revisit looking diagnosis with new eyes for seeing the constitution of our patients, their skin, their eyes and their tongues.  Then we learn to take the bag full in information and see the core simple mechanisms at play that explain the plethora of minutia.

When our diagnosis is clear and well articulated, determining the correct treatment follows rather seamlessly.  Proper diagnosis is also our best way to insure safety in our work.  When we are confident that our diagnosis is accurate, we can easily stand behind stronger and more focused methods, herbs and formulas. In fact, it is impossible to really understand herb and formulas without the ability to deeply diagnose.

It is for this reason that, during the first weekends of the Graduate Mentorship Program, the focus is on diagnostic skills.

Good diagnostic skills can only develop when the practitioner has a deep and dynamic understanding of physiology.  Physiology is the description of how the healthy body works.  If we don’t understand physiology and rather have a sort of cut and dry method of categorizing symptoms, we will inevitably jump to muddled conclusions.  How can it be that Yang or Qi deficiency can lead to hot flashes?  How can a purgative formula allow the blood to rebuild?  How can warming be a foundation for supplementing Yin?  We cannot understand these ideas without a deep understanding of how things work.  If we only enrich Yin for hot flashes, nourish blood for blood deficiency and give Yin enriching herbs for Yin deficiency, we will have fairly mediocre results.  When we understand the relationships between Yin, Yang, Qi, Blood, Up, Down, Inside, Outside, Wet, Dry etc. our diagnosis can find the key knot that inhibits the dynamic of health and the treatment will follow naturally. For this reason, this course teaches classic physiology, taking that which students have learned in school and seeing it in a dynamic and integrated frame of reference.

We then take these skills and this clarity into various areas of medicine.

Because my own experience, both studying in China and in my own practice has had an emphasis on women’s health, this emphasis is reflected in the Graduate Mentorship Program. We bring our diagnostic skills into the treatment of women through menarche, fertility, pregnancy, postpartum and menopause. However, once our diagnostic skills are grounded, our ability to understand and work flexibly and accurately with formulas increases by leaps and bounds.  We can apply these skills in other areas as well.  So, the course also takes students into the world of classic and experiential formulas as they apply to digestive issues, respiratory issues and the areas of medicine we see so frequently, working with cancer patients and patients with “modern illnesses” such as hypertension, diabetes etc.

Throughout, we develop our ability to understand diseases through the lens of our good diagnosis rather than trying to match our patient to a formula or disease factor in a book.  Rather than treating diseases directly, we learn to treat the person who is suffering so that their natural healthy dynamic – that in itself resolves disease – is returned.

As we apply our perceptive/diagnostic skills to these areas of medicine, students are given handouts that eventually become a library of clinical reference.  Many past students use the notebooks from these classes as a key reference in their clinics.  These handouts are well organized to provide clarity in diagnosis and treatment.  In addition, there is a plethora of supplemental material on each topic.  This material includes discussions and case studies that has been translated by Sharon and is not available any where else.  The study is brought to life by the vast experience of our predecessors.

For the first time, the Graduate Mentorship Program includes an acupuncture component.  In the early part of the program a basis for integrating acupuncture concepts with our herbal diagnostic skills is formed.  There is a strong emphasis here on palpation diagnosis.  As we look at formulas, we will consistently discuss acupuncture corollaries.

If you would like to read what others have said about the program, we have a testimonial page.   There are also plenty of previous participants who would be happy to discuss their experiences.  I welcome any questions.

On to our final installment of my questions for Nigel:

Not wanting to take Nigel’s generosity too far….I finish my questions (for now!)

Okay, one more and I’ll leave you alone….at least for a little while..

On the  handouts you gave us at the start of class – the ones with the pictures of Osaka’s 13 abdomens – the ‘Inside Emergency’ # 9 says that the ‘Li Ji’ is a result of overstrained rectus abdominus compensating for low abdominal pressure.  I don’t get what this means.  Could you explain it to me a bit more?  How do the muscles strain in response to low abdominal pressure?

So Dr. Otsuka, being a physician, is using standard western medical language here. Intra-abdominal pressure is of course the normal pressure maintained within the abdominal cavity which, when elevated, is often associated with vascular compression (itself a result of varying pathomechanisms though most commonly to fluid eg: ascites)causing cardiac problems such as Congestive Heart Failure and hypertension amongst other things. Lowered abdominal pressure occurs when there is hyper-flaccidity of the of both the voluntary and smooth muscles.  This occurs both on the surface of the abdomen and within the abdominal core. It is often associated with orthopedic problems leading to insufficient muscular support of the spine. The cuases may be poor tonus in weak individuals who do not exercise enough or possible internal associations with poor metabolic functions (including hypothyroidism, obesity etc.).

In the Ri Kyu abdomen which you ask about, there are actually 2 possible presentations. One would be a generally flaccid and chilly abdominal wall which is lax and powerless (Fuku Fu). In Kampo this is always associated with cold conformations and requires warming, nourishing formulas either containing Fu Zi, Gui Zhi or the ginger family. Si Ni Tang, Zhen Wu Tang, Li Zhong Tang even Si /Liu Jun Zi Tang are example formulas in this category.

However, when D. Otsuka talks of “compensation” in these cases, he means that the body, in order to try and maintain structural integrity (ie: for the spine to be protected and properly supported), will tighten in a reactive and somewhat unnatural way. In such cases the voluntary surface muscles of the abdomen (particularly the rectus abdominis m.) or even the entire layer of connective tissue covering the abdomen, will involuntarily tighten and eventually become spastic. This will give rise to the abdominal conformation of which you speak – the Ri Kyu abdomen. This presentation is then typically treated with the Jian Zhong family of formulas or various other formulas depending on the other co-existing abdomen findings. The so-called “jumping fishes” of the Da Jian Zhong SHO are simply another, different manifestation of the same kind of reactive, involuntary spasm occuring in response to lowered abdominal pressure and attempting to compensate for it. It’s almost like compensating for a particular emotional vulnerability by automatically becoming angry – a response in such cases that is usually an involuntary and spontaneous defense mechanism.

This lowered abdominal pressure will also by the way give rise to the “butterfly” or “bowtie” abdomen which is a lower, rather than a middle abdomen finding. As you know Otsuka interprets this lower abdominal finding as a Jin Gui Shen Qi Wan Sho. Again, the use of an aconite formula to warm and nourish and thereby relax the tension by restoring proper circulation.

So in summary the Ri Kyu (spastic) abdomen should be seen as a different manifestation of the same etiology (cold and deficiency) as the Fuku Fu Nan Jyaku Mu Ryoku (lax and powerless). It’s just the body reacting differently in each case. It could be argued perhaps that the latter is a more advanced stage as there is no longer energy and warmth left even to produce a last-ditch defense at the surface. It could also be argued in Kampo constitutional analysis that the spastic response occurs more readily in cold deficient types who are DRY whilst the flaccid response occurs more readily in cold and WET types.

Those constitutional distinctionsare perhaps for another discussion!

Thank You Nigel!  Happy Dragon Water Year!

Many kinds of pulsations can occur on the abdomen.  Here, Nigel helps me tease this all apart.

I am also trying to understand pulsations in general.  It seems they can be caused by:

1. water – which in turn could be more Kidney (Zhen Wu Tang), Spleen (Bai Zhu/Sheng Jiang type formulas) or excess water (Wu Ling San type) – all of which over lap.  Am I missing something in terms of what could cause water accumulation/splash sounds?

Yes this is right. Water accumulation causes the Qi to stagnate (or vise versa) leading to pulsations. In this mechanism, the pulsations are a result of impediment (by a Yin substance) to the normal downward flow of Qi in the abdomen. This is a case of the influence of the more material (Yin water) dominating that of the immaterial (Yang Qi).

In deficient patients often as you say Spleen tonics may be used: Si/Liu Jun Zi Tang family for example.

Where accumulation from middle Jiao Qi depletion predominates and fluid stasis is secondary, Xiang Sha Liu Jun Zi Tang may apply, but where stagnant fluids are the major evidence in a similar case, Fu Ling Yin may be preferable.

Ren Shen Tang (aka. Li Zhong Tang) will govern in cases that are colder, though apart from nausea and excessive salivary activity (drool), this formula does not evidence many Water Nobose symptoms.  This is unlike Huan Fu Hua Dai Zhe Shi Tang, another Ren Shen formula, where these are clearly evidenced by repeated hiccup, vomiting and acid reflux. In this case, these upward signs are settled in part by the Dai Zhe Shi. In similar cases where cold stasis in the stomach is more in evidence, with water nobose signs such as vomiting of clear liquids, headache and stiff neck and upper back muscles, Wu Zhu Yu Tang is appropriate.  Wu Zhu Yu Tang is yet another Ren Shen formula very similar to Li Zhong Tang, but whose action in this case is rendered much more warming by the inclusion of the powerfully warming Evodia fruit.

Basically, the more the presence of cold, the more stasis there will be. The more Stasis (initially of Qi) there is, the more likely fluids are to collect and get stuck in the Stomach (“the sea of fluids”) and upper intestines, further impeding normal downward flow and giving rise to nobose. (Nobose is rebellious upsurge and refers to an ‘uncomfortable sensation of heat, congestion or mounting pressure in the upper body, especially the head, often with visible flushing in the face’.  Taken from Kampo Treatment for Climacteric Disorders: A Handbook for Practitioners). Thus, all these formula examples include evidence of the splash sound in Fukushin (abdominal palpation).

The primary clinical decision in selecting from among these formulas, is to establish the following:

1. The degree of cold that may be part of the etiology
2. Whether the stasis is due to deficiency or the other way around, and
3. The strength of the patient’s constitution.

In formula terms, this will determine whether you can simply remove the obstruction (see the paragraph on Pinellia formulas below) and having lifted the impediment to normal middle jiao Qi function, simply wait for the flow of Zhen (True) Qi to be restored.  In this case one would not  need the explicit Qi tonics such as Ren Shen. If there is evidence of underlying root depletion of the middle jiao Qi however then Ren Shen formulas will be called for. Where there is clear evidence of cold stasis (as opposed simply to Yang depletion resulting in stasis and cold) then warming formulas will be required and Ren Shen alone will be insufficient, as evidenced by several examples above.

Where Tai Yin or Shao Yin level dysfunction is concerned,  the resulting Qi stasis in the middle or lower jiao will always include increased water accumulation (due to diminished Yang activity) resulting in pulsations (the Jing Mai or vessels are constricted by the surrounding fluid creating localized pressure giving rise to a pulsing sensation).

Ren Shen and/or Fu Zi formulas are indicated in such cases often combining together is such examples as Fu Zi Li Zhong Tang or Si Ni Tang jia Ren Shen. These are Tai Yin and Shao Yin patterns whereas Wu Zhu Yu Tang would be an example of a Shao Yin/Jue Yin pattern formula with cold water accumulation in the stomach and pulsations on the abdomen as well as a splash sound. Cold water accumulations in the lower intestines with watery diarrhea and pulsations and a splash sound on the abdomen of course matches the Zhen Wu Tang SHO.

There are however many cases of water accumulation in the abdomen that do not require such a firm hand in terms of strengthening or warming with Ren Shen or Fu Zi. Regulating the Qi flow and promoting normal fluid transformation in the middle jiao may be all that is required formula examples of which include: Ping Wei San where “abdominal thunder” (borborygmus) is a cardinal sign; or in similar cases where there is counterflow (nausea, palpitations, dizziness and other anxiety signs): Ling Gui Zhu Gan Tang, Ling Gui Gan Cao Tang and other such “running piglet formulas” evidence of what Kampo calls: Water Nobose. In cases of cold constraint leading to Water Nobose signs similar to those mentioned above but including more of a tendency for epigasrtric pain, acid reflux, nausea and vomiting, An Zhong San will apply, again a formula with no Ren Shen.

Further example formula groupings that often include splash sounds in the abdomen contain Ban Xia, a herb used to free up a subjective feeling of obstruction (glomus) “under the heart”, a symptom confirmed in Kampo abdominal diagnosis by the finding: Shin Ka Hi Ko (Subjective and Objective Epigastric Obstruction). The action of this herb can encourage the downward movement (drainage) of both stagnant Qi and fluids in the upper intestinal tract. Example formulas in this group would include Ban Xia Hou Pu Tang, where the glomus may also be experienced in the chest or throat along with multiple anxiety symptoms. There is also Xiao Ban Xia Tang, used frequently in Japan for morning sickness when this Sho is identified (it’s composition being 3 of the 5 herbs of Ban Xia Hou Pu Tang minus the Zi Su Ye and Hou Pu). There are also a well-known “family” of formulas containing Ban Xia that come to mind here: Ban Xia Xie Xin Tang (and the common modifications of this formula such as Gan Cao Xie Xin Tang and Sheng Jiang Xi Xin Tang). However, interestingly these formulas do also contain Ren Shen and therefore do assume not only Qi and fluid stasis in the middle jiao but also some degree of deficiency also.

In Tai Yang cases of cold attack to the stomach, intestines and sometimes bladder Wu Ling San is indicated and there are plenty of pulsations on that abdomen! In this formula Sho of course the predominant signs confirming water nobose include nausea (exacerbated by drinking water though there is thirst), headache, facial edema and reduced urinary output or urinary block.

There are also Liver Patterns which will cause accumulation of Qi and in the long term water also. Ascites from Liver disease is an obvious western example of this. So Yin Chen Wu Ling San, Chai Ling Tang and even Chai Pu Tang (in certain watery asthma cases) will all have abdomens with Kyo Kyo Ku Man (hypochondria painful fullness) and water splash sounds as well as pulsations.

2. Deficiency with a tight abdomen (Gui Zhi and Ren Shen type formulas)

These pulsations are usually directly related to pure Qi disturbances and largely occur in dry, deficient types. I mentioned this earlier regarding Gui Zhi Jia Long Gu Mu Li Tang for example. Thus formulas that are basically Gui Zhi Tang derivatives are almost always marked by pulsations on the abdomen. (I notice Dr. Huang Huang in his book  Zhang Zhong-jing’s Clinical Application of 50 Medicinals

mentions about Gui Zhi in the very first line that it “descends and settle the Qi”. Thus a typical counterflow Qi running piglet formula such as Ling Gui Gan Cao Tang has an abdomen full of pulsations. It is not exclusively true to say though that Gui Zhi formulas are always and only suited to dry counterflow conditions. Ling Gui Zhu Gan Tang for example is the exception here and in addition to pulsations will also often have a splash sound in the abdomen. However, this formula Sho is characterized by other Water Nobose signs such as dizziness, vertigo, heavy head, headache and balance problems.

3. Fullness in the middle (Ban Xia Hou Po Tang) or Chest.

Again these are primarily Qi disturbances in this case marked more by accumulation than by counterflow. The Xie Xin Tang group as well as many of the Chai Hu formulas I mentioned above would fit this category where pulsations may or may not be accompanied by splash sounds, epigastric or hypochondriac tightness.

4. Kidney weakness (pulsations in the lower abdomen)

Here the mechanism is Kidney weakness leading to cold water accumulation, leading to pulsations (as in for example Zhen Wu Tang), or Kidney weakness failing to communicate with heart leading to counterflow Qi pulsations as in Gui Zhi Jia Long Gu Mu Li Tang or even Kidney weakness leading to a failure to moisturize the blood causing blood deficiency and stasis pulsations disrupting the circulatory system and leading to cardiac signs as in Zhi Gan Cao Tang.

And you could add a #5, which of course is the whole Oketsu group of formulas both for excess and deficient patterns in which pulsations almost always occur on the abdomen as a result of constrained Qi flow, due to Oketsu.  Da Huang Mu Dan Pi Tang, Tao He Cheng Qi Tang, Da and Xiao Cheng Qi Tang, Tiao Wei Cheng Qi Tang – these formulas for the Jitsu (Excess) blood stasis patient all have pulsations on the abdomen. Gui Zhi Fu Ling Wan and Zhe Chong Yin, the two main non-Da Huang blood stasis formulas used in kampo also have abdominal pulsations. Not to mention all the many derivatives of Si Wu Tang which also have pulsations and often blood stasis signs around the navel area. These deficient patterns reflect an underlying blood deficient root, though pulsations will accompany the branch pattern manifestations related to blood stasis.

I am looking through the book KAMPO: A Clinical Guide to Theory and Practice and class materials and it is difficult to find a summary of what pulsations mean in terms of diagnosis.  Am I on the right track?

Definitely on the right track. You might summarize pulsations into the standard triple grouping in Kampo as in Qi, Blood and Fluid related pulsations. One could genralize and suggest that pure Qi pulsations tend to occur on the midline in the upper portions of the abdomen (fire area in Nan Jing), Fluid pulsations occur Ren 12 to the navel (Earth area in NJ) and Blood pulsations occur around and below the navel (Water area in NJ). You could also expect Qi pulsations as the most Yang and therefore insubstantial to be subject to the most frequent and immediate changes. For example the pulsations of

some Ling Gui Gan Cao Tang types or Gui Zhi Jia Long Gu Mu Li Tang types may diminish or even disappear in the course of a single acupuncture treatment or reappear with an upsetting thought or feeling. They are whimsical and never really completely resolve. However the Yin pulsations – related to dysfunctions at the water and blood levels – are a different matter. Slow to change but ultimately resolvable. When the blood stasis of a patient taking Tao He Cheng Qi Tang for example improves so too will the pulsations and this change can be lasting.

In the book Cardiac pulsations are talked about.  Is there a category of pulsations that occur in the chest?  Are these felt by the patient or the practitioner?

Well, technically 動悸 (Doki -throbbing pulsations) are the pulsations experienced by the patient in the abdomen and palpable by the practitioner as well.   心悸 (Shin Ki -heart pulsations) are cardiac pulsations primarily experienced by the patient. Shin Ki can potentially also be palpated by the practitioner at the apical pulse (more or less on the left side of the chest in or around the 5th intercostal space). In western terms we might relate these findings to:

a) 動悸 (Doki) – any and all manner of vascular pulsations both subjectively and objectively felt usually along the trajectory of the abdominal aorta. These most commonly will occur in disorders of the nervous system indicating an autonomic nervous imbalance but may also have structural implications (eg: aneurism).

b) 心悸 (Shin Ki) – these relate to actual heart arrhythmias including palpitations, tachycardia, fibrillations etc.

As promised, here is the first installment of a short series of entries on Kampo.  These next three entries are all taken from a written conversation between Nigel and myself, in the form of questions and answers.  I hope you all find this as interesting and useful as I do!

In a deficient person with a tight abdomen and pulsations – how would you differentiate whether to use Gui Zhi Jia Long Gu Mu Li Tang vs. Zhi Gan Cao Tang?

Firstly on the abdomen the location of the pulsations will be different for each formula. Gui Zhi Jia Long Gu Mu Li Tang will often have pulsations along the midline in the upper portion of the abdomen especially around Ren 12/13/14 (though they can also occur lower down at the navel area). In the case of Zhi Gan Cao Tang the pulsations are always around and below the navel and less commonly higher up. What is more helpful in differentiating these two abdomens though is the other findings that tend to occur along with the pulsations. Gui Zhi Jia Long Gu Mu Li Tang is a Qi formula and the abdomen, especially the rectus, will generally be thin, tight with a tendency for Shin Ka Hi Ko (Epigastric subjective and objective tightness). This kind of abdominal presentation is generally referred to constitutionally as the Gui Zhi Tang abdomen and is seen as related to the Chu Ki Kyo (Zhong Qi Xu) dry type as opposed to the Deficient Middle Qi Wet type for whom the Si Jun Zi Tang family is usually prescribed. Sometimes the abdomen will be cool and clammy, which is a Qi deficiency sign.  On the other hand,  Zhi Gan Cao Tang is a Blood formula and so, the abdomen will show Oketsu (blood stasis) findings, typically clustered around the navel (the Terasawa Oketsu points) and often Sho Fuku Fu Jin (lax and powerless lower abdomen). Ri kyu (rectus tightness) may also be found in relation to Zhi Gan Cao Tang. The skin will be dry and rough, which is a blood deficient sign. With an overly deep palpation technique, Ri kyu in the lower abdomen area is sometimes mistaken for Oketsu. Thus in the first formula, the pulsations arise from Qi nobose (flushing upward) reflecting in symptoms such as anxiety and sleep disorders and sometimes sexual dysfunction whereas in the second, Zhi Gan Cao Tang, they arise from the obstructive influence of Oketsu due to blood dryness in the lower abdomen.

In an excess person with abdominal fullness and pulsations – how would you differentiate Da Chai Hu Tang from Chai Hu Jia Long Gu Mu Li Tang?

This is more straightforward since the constitutional typing is quite different. Both are Strong Constitution Qi types with well-developed / toned musculature, however they nonetheless differ in body mass. The Da Chai Hu Tang abdomen is ample, broader and more inflated and full (with gas etc) than the Chai Hu Jia Long Gu Mu Li Tang abdomen which is thinner, more wiry and less distended, with a tendency for the abdominal wall to be thinner and the surface muscles such as rectus abdominis to be tighter. In addition the Da Chai Hu Tang type is relatively more wet and the Chai Hu Jia Long Gu Mu Li Tang type more dry.  This means that the Da Chai Hu Tang type is more prone to damp accumulation when there is Qi stasis. The Chai Hu Jia Long Gu Mu Li Tang abdomen does not reflect this fullness in terms of mass and, in the presence of this dryness, excess Yang Qi will of course rise more quickly and more dramatically.  This gives rise to all the characteristic psycho-emotional and sleep disturbances of that formula SHO (Presentation).  This is compared to the abject fullness and accumulation in the middle and lower jiao which characterize Da Chai Hu Tang. Pulsations will occur on both abdomens but the intensity of the Chai Hu Jia Long Gu Mu Li Tang ones will be especially dynamic and often very visible on the surface of the abdomen. This is due to the absence of any Yin factor (Eg: water/damp) to check them. Conversely,the Da Chai Hu Tang pulsations will be more subdued, subsumed as it were by the engorged fullness of the abdomen as a whole. Da Chai Hu Tang is also Fuku Man (abdominal fullness) where Chai Hu Jia Long Gu Mu Li Tang is not.

Perhaps a quick clinical profile might serve to highlight some differences between these two closely related formulas:

A hypertensive patient with the Chai Hu Jia Long Gu Mu Li Tang Sho will tend to be a thin, wiry, hyperactive and anxious type whose blood pressure can be very labile and is always elevated by anxiety-provoking situations and experiences. Typically they do NOT fit the profile of obese, more sedentary types with high cholesterol and sclerotic changes in the vascular system typical of the congested Da Chai Hu Tang type who is damp, hot and full. The hypertensive state of the latter is likely to be constant and worsened by poor eating habits and lack of exercise. The former will do well with learning how best to manage stress in their lives and maintain relative emotional stability whilst the latter will undoubtedly need to make major dietary and exercise routine changes in order to improve the condition.

In other words, how do you determine when to use the Shells and Bones?  Is there a key symptom or sign that tells you to use shells?

As we know these substances descend and anchor Qi and tend to be very cooling. As such they appear in formulas treating either deficient or excess types but who, in both cases, have a dry constitution. The drier the type the more unstable the Qi.  The tendency for Qi to rise increases and with the Qi,  heat may flare as well. Chai Hu Jia Long Gu Mu Li Tang patients often have night sweats and feel hot at night when they experience palpitations, insomnia and nightmares. Gui Zhi Jia Long Gu Mu Li Tang patients, though KYO (deficient) and often HYO SHO (cold constitution), nevertheless, they can experience mild sweating at night with insomnia and palpitations as the Yang Qi, after the day’s activities, is without an anchor.  The Yang Qi instead remains at the surface and cannot be contained. What distinguishes the pulsations in these cases is the intensity with which both the patient and the practitioner experiences them. This is due to the thinness and tightness of the abdominal wall in these dry types.

The pulsations in Da Chai Hu Tang are less due to the upward surge of Qi itself. They are rather more due to the accumulation of Qi in the abdomen thus the formula concentrates strongly on dispersing and draining rather than descending, cooling and anchoring. In the case of Zhi Gan Cao Tang the pulsations are due to blood stasis caused by blood dryness and so blood moistening and invigorating is called for.