进退温经汤 Jin Tui Wen Jing Tang Modified Warm the Menses Decoction

This is the next entry in this series of entries.  If you haven’t read the previous 3 entries, I recommend you go back and read them.  Each entry is an expansion of the previous one.

Here we expand on the idea of opening through by looking at blocked menstruation when there is cold.  Dr. Xia has created this formula based on Wen Jing Tang (Warm the Menses Decoction). What i didn’t realize before reading this chapter, is that there is another formula named Wen Jing Tang besides the one from the Jin Gui Yao Lue (Essentials from the Golden Cabinet).  There is a formula of the same name from the Fu Ren Da Quan Liang Fang (Complete Book of Effective Formulas for Women).  The ingredients of this formula are as follows:

Dang Gui             6

Chuan Xiong         6

Rou Gui                6

Cu Chao E Zhu     6

Mu Dan Pi            6

Ren Shen             10

Niu Xi                  10

Gan Cao              10

We want to compare this with Dr. Xia’s formula which is as follows:

Dang Gui             10

Chi Shao              10

Bai Shao               10

Chuan Xiong        6

Gui Xin                9

E Zhu                   9

Chuan Niu Xi       10

Dang Shen            12

Chao Gan Cao      3

Shan Zha              10

Yi Mu Cao            15

Chuan Duan        10

What we want to see are some of the basic herbs for opening through in Dr. Xia’s modified formula.  So we see Chuan Niu Xi as the main opening through herb. Shan Zha and Yi Mu Cao also help to open through the menstruation.  In addition, we have E Zhu and Shan Zha that are herbs that help break down blood stasis and the endometrium.  This formula is used premenstrually so it is meant, not only to promote the discharge of menstruation but also to prepare the endometrium for discharge.  Notice that the symptom of large clots is repeated as Dr. Xia goes over what this formula can be used for. 

Dr. Xia uses Rou Gui and Xu Duan to warm, going into a lot of detail regarding the function of Rou Gui. 

I find it interesting to see the limited way Dr. Xia writes about Wen Jing Tang.  He describes as an herb for treating bleeding in older women.  period!  For any of you who have read my Wen_Jing_Tang, you know how broad I consider the applications of this formula!

At any rate, this formula focuses on warming and opening through and at the same time on breaking down congealed accumulated blood stasis.  The Jin Gui Yao Lue Wen Jing Tang is warming and vitalizing but also very moistening and enriching. 

Here is Dr. Xia’s writing on this formula:

Jin Tui Wen Jing Tang (Modified Wen Jing Tang)

Formula Constituents:

Dang Gui             10

Chi Shao              10

Bai Shao               10

Chuan Xiong        6

Gui Xin                9

E Zhu                   9

Chuan Niu Xi       10

Dang Shen            12

Chao Gan Cao      3

Shan Zha              10

Yi Mu Cao            15

Chuan Duan        10

Method of Use:

One package is for one day, to be taken premenstrually and during menstruation

Function:

Warms the menses and scatters cold, vitalizes the blood and opens the menses

Clinical usage:

Late menstruation, scanty menstruation, cold pain in the lower abdomen, cold thighs, aversion to cold, menstruation color is purple and dark, pulse is wiry and thin or deep and rough.

Formula explanation:

This formula is aimed at warming the menstruation and vitalizing the blood as well as opening through the menstruation.  It contains Gui Xin which warms the menses and scatters cold.  It also opens through the blood vessels and stops pain.  In this formula Gui Xin is the principle herb.  I usually use Rou Gui.  Dang Gui supplements the blood and synchronizes the menstruation.  It also functions to vitalize blood and stop pain.  Chuan Xiong vitalizes the blood and moves Qi.  It is known as the “Qi within the Blood herb”.  When combined with Dang Gui, it also synchronizes the menstruation.  Ren Shen [or Dang Shen] supplements the Qi and supports the correct.  It helps the Gui.  Gui and Xiong promote the unimpeded flow of Yang, thereby warming the menses and scattering cold.  Peng E Zhu vitalizes blood and transforms the congealed.  It disperses and scatters accumulated stasis.  Niu Xi also vitalizes blood and synchronizes the menstruation and, in addition, it induces the other herbs downward.  Mu Dan Pi can discharge and descend floating fire as well as vitalize blood and synchronize the menstruation.  Shao Yao and Gan Cao moderate tension and stop pain.  I also add Shan Zha and Yi Mu Cao to vitalize blood and promote menstruation.  These will also promote the contraction of the uterus.  Chuan Duan supplements the Kidneys and vitalizes the blood.  It helps the Rou Gui to benefit the Yang and scatter cold, warm the menses and vitalize blood.  All these herbs together boost the Qi and open through the Yang, warm the menses, scatter cold, vitalize blood and dispel stasis.  It is appropriate to use when cold Qi abides in the blood chamber leading to congealed and coagulated Qi and Blood manifesting as late menstruation and painful menstruation.

Clinical Application

This formula is not only appropriate for cold and stasis knotted together leading to accumulation type late menstruation, scanty menstruation and amenorrhea.  It can also be used for illnesses such as cold stasis infertility, post partum lochia failing to stop and deficiency cold type anemia.

1.Cold and stasis knotting causing accumulation type infertility: This type of infertility will manifest with late or scanty menstruation with dark purple blood, clots, lower abdominal pain with a cold feeling, soreness of the 4 limbs and low back, thin wiry pulse and white sticky tongue moss.

2.Cold and stasis knotted together causing accumulation type post partum lochia failing to stop: This presentation will manifest with dark blood with clots, lower abdominal cold feeling with pain, soreness of the low back, thin pulse and purple sides to the tongue with a sticky white moss.

3.Cold and stasis knotted together causing accumulation type anemia:  This presentation will manifest with dizziness, nervousness, sallow complexion, coldness of the 4 limbs, abdominal distention and pain with a cold feeling, thin rough pulse, pale red tongue with purple sides.  For this you can add herbs such as Huang Qi and Shu Di.

Modifications:

This formula can be modified according to the pathological changes of the illness.  If there is abdominal pain with a lack of free flow of the menses add 10 g Wu Ling Zhi, 12 g Yan Hu Suo and 9 g Hong Hua.  If the menstruation is scanty and dark purple colored, add 10 g Tao Ren and 9 g Hong Hua.  If the menstruation is relatively profuse and red purple colored with relatively large clots add 6-9 g Chao Pu Huang (wrapped), 10 g Hua Rui Shi and 6 g San Qi Fen (add as draft).

Clinical Experience

The formula is a modification based on the Wen Jing Tang (Warm the Menses Decoction) the Fu Ren Da Quan Liang Fang (Complete Book of Effective Formulas for Women).  This is also called Liang Fang Wen Jing Tang (Effective Formula for Warming the Menses). Before the Fu Ren Da Quan Liang Fang (Complete Book of Effective Formulas for Women) Wen Jing Tang (Warm the Menses Decoction), there was a Wen Jing Tang (Warm the Menses Decoction) from the Jin Gui Yao Lue (Essentials from the Golden Cabinet).  Why is there such a broad use of Liang Fang Wen Jing Tang (Effective Formula for Warming the Menses).  There are two reasons.  First, the Jin Gui formula must be distinguished from the Liang Fang formula, as they are not the same.  They treat differing conditions.  The Jin Gui formula treats the following disease presentation: bleeding that will not stop with internal stasis in 50 year-old women.  The author of the Liang Fang considered this to be a formula to treat cold Qi abiding in the blood chamber causing Qi and blood congealed stasis with umbilical and abdominal pain and a deep tight pulse.  Therefore, the Liang Fang Wen Jing Tang (Warm the Menses Decoction) is easy to use.  Secondly, the Liang Fang Wen Jing Tang (Warm the Menses Decoction) conforms to the special characteristic of Chen Ziming’s theoretical ideas from his Fu Ren Da Quan Liang Fang (Complete Book of Effective Formulas for Women).  In my opinion, this text is a first-rate treatise.  It has great significance for the development of gynecological theories.  It contains theory and special points for treatment.  It emphasizes wind cold as a cause of illness and the use of herbs tends toward pungent, hot, warm and scattering herbs.  Because of this, later generations evaluated his work, saying “19 [illnesses] tend to be from wind cold, use coarse hot pungent and scattering herbs”.  In fact, the idea that wind cold causes disease, was influenced by the Zhu Bing Yuan Hou Lun (Treatise on the Origins and Manifestations of Various Diseases).  The Fu Ren Da Quan Liang Fang (Complete Book of Effective Formulas for Women) Wen Jing Tang (Warm the Menses Decoction) could be said to represent the theory and treatment characteristics from this text.   We can say that Jin Tui Wen Jing Tang (Modified Wen Jing Tang) is taken from the Fu Ren Da Quan Liang Fang (Complete Book of Effective Formulas for Women) Wen Jing Tang (Warm the Menses Decoction).  The intention of the Liang Fang formula is to warm the menses and synchronize the menstruation while soothing and scattering wind cold.  From the point of view of expelling the menstruation, we can see that this formula is based on Si Wu Tang (Soup of Four Things).  Gui is added.  We say “Gui” because, in the Song Dynasty, there was not much differentiation of types of Gui.  E Zhu and Niu Xi are added to open through the menses and vitalize the blood as well as to induce the downward movement of blood.  By warming and opening through we are able to warm and scatter.  I also add Ren Shen (Dang Shen) and Gan Cao to support the correct.  This is also influenced by the Wen Jing Tang (Warm the Menses Decoction) from the Jin Gui Yao Lue (Essentials from the Golden Cabinet). In dispelling the evil we don’t want to forget the correct Qi.  When synchronizing the menses, one should have a good footing in the blood level.  This means that in dispelling excess, one should simultaneously support the correct, which is the blood as well as the Qi.

Detailed analysis of the principle herbs in this formula

Rou Gui

Rou Gui is sweet and pungent with great warmth.  It enters the Liver and Kidney.  It supplements the Ming Men ministerial fire.  It is good for deep and chronic cold.  It treats presentations such as reversal in the 4 limbs, back and knee soreness and pain, deficiency cold and bad food, clear food diarrhea, acute spasms, blocked menstruation, abdominal pain, Shan lumps, inhibited urination, and upper heat with lower cold.  It is as Li Yuansu says “It supplements insufficiency of the lower jiao, treats deep and chronic cold, stabilizes diarrhea, stops thirst, dispels wind cold from the Ying/Wei, treats exterior deficiency spontaneous sweating”.  Wang Haogu considers it to supplement insufficiency of the ming men, boost fire, scatter Yin.  I consider the major function of Rou Gui to be to warm and supplement the Ming Men and to treat lower warmer deep and chronic cold.  The character, flavor and function of it is similar to Fu Zi and both of them are high ranking herbal substances.  They dispels cold and removes dampness, warms and supplements the lower source.  In these ways Fu Zi and Rou Gui are basically the same.  This is how they are used in the Jin Gui’s Ba Wei Wan (Eight Flavor Pill) or Ji Sheng Shen Qi Wan (Cythula and Plantago Kidney Qi Pill).  However, there are aspects of Rou Gui that are different than Fu Zi.  For example, in the Shang Han Lun (Treatise on Damage from Cold), when there is great sweat with Yang depletion, you must use Fu Zi and not Rou Gui.  The is because Rou Gui can induce sweating.  In the Ben Jing (Classic of the Materia Medica), Rou Gui primarily treats the middle.  It “induces sweating and stops agitation”.  So obviously Rou Gui is not the right herb for the sweating of Yang depletion.  However, in addition to treating deep and chronic cold, Rou Gui does synchronize the Ying and Wei and inspire the Qi and blood.  This all relates to Qi and blood cold stasis.  Within the synchronizing of Qi and regulating of blood, Rou Gui warms and illuminates.  When there is cold constraint blocked menstruation with abdominal pain, this should be used.  Within the herbs to supplement the Qi and blood, Rou Gui functions as an assistant and envoy in that inspires the qi and blood, promoting the generation of Yang and the expansion of Yin.  From this we can know that Fu Zi enters the Qi level whereas the function of Rou Gui is more at the blood level.  This clarifies the differences and similarities between Rou Gui and Fu Zi.

E Zhu.

E Zhu is bitter, pungent and warm.  It enters the Liver channel, moving Qi and cracking blood.  It scatters accumulations and transforms food stasis.  It treats pain in the Heart and abdomen, stoppage and stagnation of food and drink, blocked menses that gather and build up.  This is a special herb of the Liver family, cracking accumulated, built up evil blood.  It course phlegm and food.  I often use this and San Leng because both of them crack the blood and move the Qi.  They treat presentations such as when the menses are not open through and there are lumps and accumulations.  The Ming Jia Ben Cao ( Materia Medica of Famous Families) says “San Leng cracks the Qi within the blood while E Zhu cracks the blood within the Qi”  This means that, though both of these herbs are able to crack the blood, San Leng is stronger at cracking blood while E Zhu is strong at cracking Qi.  Therefore these herbs are often used together.  Combining them can increase the scattering hardness and cracking accumulation effect.  However, when using formulas that attack hardness and crack accumulations, it is easy to damage the correct Qi and therefore, when working with deficient patients, they should be used with [Ren[ Shen and [Bai} Zhu in order to look after and protect the correct Qi.  This is a formula that supports the correct and dispels evils and so the herbs in the formula warm the menses and open through stasis in order to recover the regularity of menstruation.  Therefore only E Zhu is used of the two.  It regulates the blood within the Qi and promotes the smooth and easy flow of menstruation.

Case Example

I treated a woman with late menstruation with dysmenorrhea and obtained good results.  Her name was Zhang and she was 23 years-old.  Her menstruation had been late for 2-3 years.  During menstruation she had abdominal pain.  In the past ½ year she also had pain mid-cycle that became severe when she drank cold beverages.  (She had participated in a match and had eaten lots of popsicles!).  That month her menstruation was drenching.  It took 10 days to clear.  After that, at every menstruation she felt lower abdominal pain that became increasingly intense.   She suspected that she had endometriosis.  At every menstruation she had an obvious cold feeling in her lower abdomen.  Her menstruation was scanty, dark and purple and it contained large clots.  During menstruation she felt lower abdominal bearing down pain.  Her pulse was thin and her tongue was pale with purple edges.  I gave her Jin Tui Wen Jing Tang (modified Wen Jing Tang), adding 6 g Ai Ye and 9 g Hong Hua.  After two months, her menstruation was regular and her dysmenorrhea was cured.  The length of her cycle also shortened.

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