Genevieve LeGoff on Question Six in Qi Zhongfu's "Hundred Questions on Gynecology"
What follows is a guest blog by Genevieve LeGoff, one of the wonderful experienced and knowledgeable practitioners of classical Chinese medicine (Between Heaven and Earth Acupuncture and Herbs) who I love to call on when I have a clinical question. I am always so grateful for her perspective and nerdy insights, in particular in the context of women’s reproductive issues and the treatment thereof with medicinal formulas (photos and captions courtesy of Genevieve, with permission from her daughters)….
Commentary on selected formulae from Question 6 in Qi Zhongfu’s Hundred Questions on Gynecology
Chinese medicine is a medicine of Time. Its principles are derived from the careful observation of time passing through the seasons, an elusive constant with ever-changing faces… Much of ancient Chinese medical literature is concerned with harmonizing with the latter, be they the seasons of the year or the seasons of life.
Sabine’s translation of Qi Zhongfu’s wonderful work (see her new book, Channeling the Moon) highlights an idea which is pivotal to the correct practice of Chinese medicine, but is often forgotten under layers of vulgarization: the idea of attunement. Just as certain moments in time, certain conformations resonate perfectly with a pure pitch of the celestial pipes, we too, as humans and doctors, can strive for the most perfect attunement of our bodily instruments with the seasons.
Of course, such an ability requires knowing what to harmonize to - the grasp of the meaning of the four seasons, the relationship between Sun, Moon and Earth.
Question 6 in Qi Zhongfu’s Hundred Questions on Gynecology (on the reasons for menstrual periods to be either early or late, or of variable quantity) exemplifies this principle perfectly. Here is Qi Zhongfu’s answer:
When women become ill, they primarily suffer from menstrual periods that are either profuse or scanty, or early or late, and accompanied by occasional pain. Doctors call all of these conditions menstrual disease and not once explain whether it is a case of Yīn prevailing over Yáng or of Yáng prevailing over Yīn. For this reason they are rarely able to be effective when they administer medicinals.
If it is a case of Yīn Qì being exuberant and overwhelming Yáng, the result is that the uterus is cold, the Qì becomes cool, and the blood does not move. This is what the Classics refer to as “winter-cold in heaven and freezing on earth.” As water congeals, it becomes ice, and this situation therefore causes menstruation to be scanty and to occur after the moon.
If it is a case of Yáng Qì being exuberant and overwhelming Yīn, the blood scatters and spills over. The classics refer to this as “summer-heat in heaven and heat on earth.” The menstrual fluids boil and overflow, and this situation therefore causes menstruation to be profuse and to occur before the moon.
Harmonize the woman’s Yīn and Yáng and attune her Qì and blood, so as to achieve the blessing of balance!
By virtue of menstruating every 28 days, women outwardly express their attunement to the moon. This is illustrated in the term for menstrual attunement, which contains 月, the Moon/month. Qi Zhongfu therefore distinguishes two major possible issues with menstruation:
- Yang prevailing over Yin, with menses arriving “before the moon”
- Yin prevailing over Yang, with menses coming “after the moon”.
Essentially, he has identified the two major categories of disease in classical, time-based medicine such as it is practiced, among other places, in Shang Han Za Bing Lun lineages. One can either be too slow in relation to the rotation of the Heavens around the Earth (from a geocentric perspective), or too fast. Before the proper time, or after.
All the other layers of intricacies, which become important to perfect herbal formulae, such as the texture of blood, qi stagnation, phlegm color etc., are lacking in direction without the warp and weft of proper timing and direction. The pole star of our thinking, then, should be: is the patient on time, early, or late?
This question relates, of course, to the very observable time of arrival of the period, but also to the more subtle circulation of Fire and Water in the human person. The discrepancy in timing, which also equates to manifesting qualities outside of the proper cardinal direction, can be rectified by eliciting counteracting movements with the use of flavors, qi, colors, activities… Once the directionality and timing are clear, any method can be used to heal.
Simply put in Qi Zhongfu’s words, the answer is to “harmonize Yin and Yang.”
In the case of Yin prevailing over Yang, the Sun is not reaching the Water; hence the North position, the lower abdomen, is cold - water congeals to ice, and Spring is late. Several scenarios are possible: Earth and Water can simply be frozen, or bogged, or long-standing cold can damage the blood, leading to stasis.
On the contrary, when Yang prevails over Yin, whether because the Yin is insufficient to anchor the Yang or because some external pathogenic heat has penetrated, the manifestations of Fire bring on an early Spring. Metaphorically speaking, the Sun rises too early.
The formulae Qi Zhongfu chose to illustrate these scenarios reflect the inner landscape of the patients they are intended for. By carefully analyzing their structure we can form a full clinical picture; the dialectic of herbs, reciprocally, whispers new insight on physiology.
Let’s have a look at a few selected formulae from this Question:
Dang Gui Yin
In the case of Yang prevailing over Yin, Qi Zhongfu recommends Dang Gui Yin, with equal amounts of these ingredients processed into a powder and simmered in water until reduced by 80 percent. In his words:
For Yáng Qì prevailing over Yīn if the menses are profuse, give Dāngguī Yǐn. It restrains Yáng and assists Yīn, and attunes the flow in the channels.
First appearing in the Jin Gui Yao Lue as a pregnancy support formula under the name Dang Gui San, this formula paints a very specific pathological picture: one where a weak, dry blood leads to the flaring of ministerial fire. In pregnancy, this can result in premature contractions or restless fetus, while in menstruating women it can lead to early periods.
We recognize a blood supporting group. The deep moistening action of Shu Di Huang, its cloying action restraining and cooling the rise of ministerial fire; the blood nourishing Dang Gui returning (the Fire) to its source; and as a river running dry often lacks in free flow, Dang Gui and Chuan Xiong help facilitate it.
The crux of the formula is Huang Qin, the Wood herb of the Water class in the Tang Ye Jing; it cools ministerial fire and leads it back to the root. Essentially it slows the rise of the Sun, or the arrival of Spring. In terms of conformations one might say that ministerial fire, born of Shaoyin, travels too fast and too prematurely through Jueyin and Shaoyang, so that blood is ejected too quickly through Taiyang (the Opening in Kai-He-Shu theory). Huang Qin, with its bitter and cold favor, counterflows the excessive upward rush of the ministerial fire so as to slow it down to the correct pace, in attunement with nature and the rhythm of the Moon.
I love using the analogy of the growth of Wood to explain ministerial fire dysregulation. A healthy plant or tree grows at a steady, harmonious pace. But if a plant is starved for water and nutrients, it will shoot up to seed prematurely and wither.
Bai Zhu is a mysterious element of this formula, and it is subject to much speculation. I personally think of it as a balancing element. Taiyin (the root of which is Damp) and Shaoyang (the root of which is ministerial fire) are related as polar opposites on the Taiji conformation wheel. Bai Zhu has many tubules going through its roots - as such, it helps regulate the waterways within Earth, contributing to the healthful creation of the life-giving Damp. The death of blood can lead to water accumulation in pathological places; while the blood is dry, water accumulates elsewhere. Fertile dampness, moisture well allocated throughout the body/soil, the absorption and digestion of nutrients which will become new blood able to embrace ministerial fire in its middle ~ such is the province of Bai Zhu.
Zi Shi Ying Wan
Zi Shi Ying
Yu Yu Liang
Chuan Wu tou
Sang Ji Sheng
Wu Wei Zi
The second scenario - Yin prevailing over Yang - is described by Qi Zhongfu under several formulae. Of particular interest to my proclivity for Fire Spirit type thinking, is Zi Shi Ying Wan, described in his text as
A treatment for women who tend to suffer from suddenly scanty menstrual periods, possibly occurring after the moon, with occasional pain.
The architecture of this formula strikes me as very similar to that of Jin Gui Shen Qi Wan. Like the latter, it addresses a clinical picture of concurrent Shaoyin and Jueyin deficiencies. Either a weak Shaoyin has failed to transform Water and has caused the dryness of blood, or longstanding blood dryness has led to fluid accumulation and the dousing of Fire (as described above in our discussion of Bai Zhu). The order of events varies and is a discussion akin to the one about the chicken and the egg… suffice to say that in this clinical picture, blood dryness is co-existing with Water overtaking Fire. Hence, ministerial fire can no longer rise, and this failure to pivot into Taiyang opening results in late menses. The aim of the formula then becomes to revive Fire so Water can be transformed, and to revitalize the blood so ministerial fire can properly travel through it.
Wu Tou powerfully leads Fire into the North. To assist its descent, heavy and sour medicinals are used: Zi Shi Ying, Long Gu, Wu Wei Zi, and Mu Li. Yuan Zhi assists in the communication of Heart and Kidney (the Shaoyin axix). Ze Xie, a diuretic, expels excess water to assist in the revival of Fire. Yet another group of herbs moistens and nourishes the blood (Du Zhong, Sang Ji Sheng, Dang Gui, Shi Hu, Cong Rong, Ren Shen indirectly), while yet another moves the blood and assists in the rebirth of ministerial fire: Gui Xin (of particular importance as the sovereign of the Wood class in the Tang Ye Jing), Chuan Jiao (Fire herb of the Wood class), and Dang Gui again.
Wen Jing Tang
Wu Zhu Yu
Mai Men Dong
Another interesting clinical presentation addressed by Qi Zhongfu, which strikes me as important to discuss, is Wen Jing Tang. In the Hundred Questions on Gynecology, he offers it as:
A formula to treat vacuity detriment in the Chōngmài and Rènmài, menstrual periods that are not attuned, whether coming profusely and incessantly or failing to arrive even past their proper time, or landslide collapse of the center with excessive and incessant bleeding.
It also treats any previously experienced detriment from pregnancy with retention of static blood, tightness and pain in the lesser abdomen, heat effusion and diarrhea, vexing heat in the palms, and dry lips and mouth, as well as presence of cold in the lesser abdomen and chronic failure to conceive.
This formula exemplifies a crossbreed of the two above scenarios. In Wen Jing Tang the blood is dry and Fire is weak, but this lack of Fire has not led to the accumulation of Water, nor has the blood dryness given symptoms of heat as pronounced as in Dang Gui Yin. Heat there is: the mouth is dry (but not parched), the palms are hot, the menses can be early. But there is also the coexistence of long-standing cold in the uterus, with a cold abdomen, pain, and possibly late periods.
As there is no water accumulation, this situation doesn’t call for an Aconite/diuretic method. Rather, Fire is led back to the root by Wu Zhu Yu, Ban Xia, and Sheng Jiang while blood is moistened and moved by the other ingredients. We find a delicate balance: Mu Dan Pi cooling ministerial fire, while Rou Gui fans and strengthens it. Because in this case Yin and Yang are both deficient and neither is prevailing over the other, we see ambivalent types of dysregulation with regards to time: period sometimes early, sometimes late, dry mouth but no thirst, Summer above and Winter below. The treatment therefore reflects this ambivalence.
Qi Zhongfu’s 6th Question is not only extremely pragmatic with regards to clinical practice, it is also extremely lofty and subtle in its implications. Indeed his insights and formulae express the most beautiful understanding of Life and Chinese medicine: the covenant between Heaven and Earth, perceived by the human Heart as the passage of time. Where the classics expose these canons in sometimes sibylline fashion, Qi Zhongfu poses himself, as we do, as an enquirer. His questions, centuries away, remain clinically relevant. It is to me both a relief and an honor to be able to accompany his thoughts and study his conclusions.
I hope many will be inspired to read Qi Zhongfu, and ponder on the nature of time and medicine. I am eternally grateful to Sabine for making such wonderful work available widely.