Chapter 2　Academic Thoughts of Chen Mushan's Gynecology

Over a thousand year's clinical practice, Chen Mushan's Gynecology school has been handed down to the 25th generation now in one continuous line. The successors not only carry on old generations’ tremendous skills and excellent experience, but also create new academic theories and unique methods which have been passed down from generation to generation and have been widely used.

Many formulas and essays in the books of Su An Yi Yao and Jin Zhai Yi Yao have been cited by the works of Chinese medicine gynecology and have played an important role in the development of modern Chinese medicine. Some academic thoughts in the books not only enrich the theory of Chinese medicine gynecology, but also greatly promote its clinical application, especially such theories as “regulating menstruation is the fundamental of all kinds of women's disorders”, “the theory of monthly fostering fetus”, “the method of clearing heat and cooling blood to calm fetus”, “phlegm accumulation induces irregular menstruation”, “focusing on qi in treating male diseases while focusing on blood in treating female diseases”, “harmonizing qi to regulate menstruation”, etc.

The distinctive characteristics of Chen Mushan's Gynecology are proficiency in clinical practice, knowledgeability in classics, familiarity with many other academic schools, seeking for etiology in diagnosis, treating disease from its root; while the outstanding methods of Chen's Gynecology are regulating menstruation, harmonizing and tonifying qi and blood, nourishing liver and kidney, strengthening spleen and stomach, emphasizing and nourishing congenital root meanwhile benefiting acquired root, building up chong and ren, regulating and promoting extra meridians, etc.

Chen Mushan's Gynecology is not just limited to one theory, but learns widely from others;it systemically and comprehensively raises the theory of Chinese medicine on gynecology with its strong characteristics.

Seeking the Root Causes in Diagnoses, Emphasizing Inquiry

In the book of Su Wen–Yin Yang Ying Xiang Da Lun (《素问·阴阳应象大论》), it says: “Yin and yang are the fundamental of universe, the rules of all things in the world, the roots of all the changes, the origin of life and death, and the mansion of spirits; therefore, when treating patients, you must seek the root cause and treat from its root.” Chen's family always follow such principles to differentiate diseases and determine treatment, such as based on the rules of yin and yang, the category of exterior and interior, cold and heat, excessiveness and deficiency, to have a comprehensive analysis, then to distinguish what is the primary disease and what is the secondary one, whether the condition is acute or chronic, to find out the root cause and the branch, whether it is in fu organs or zang organs, the origin of seven emotions or six exterior pathogens, etc. In the treatment, emphasizing restoring genuine qi and getting rid of pathogens, meanwhile paying attention to disease development and transformation.

In clinical practice, Dr. Chen Xueqi emphasizes that inquiry is extremely important in finding out the actual reason, in order to treat patients from the root. The author finds that most female patients are ashamed to share their privacy with others, such as menstruation, leucorrhea, pregnancy, parturition, emotions and other hidden facts, so doctors must be very careful and patient in consultation. Doctors can use direct or indirect questions in inquiring, try not to embarrass her but to get the true medical information. In four diagnostic methods, inquiry is the most important part, hence, the ancestors of Chen Mushan's Gynecology had self-compiled the song Ten Questions of Chen Mushan's Gynecology which includes inquiries of marriage, gestation, menstruation and leucorrhea, diet, urine and bowel movement, reaction to cold and heat, sleep, past history and etiology, etc. combined with other three diagnostic methods, to differentiate the pathogens and diseases, and then to make accurate diagnoses, in order to determine an appropriate treatment.

For example, one patient complained of postpartum stomachache, after an elaborative history inquiry, the doctor found out that the patient had eaten 6 sweet eggs in one day and had constipation for 9 days. With the four diagnose methods of Chinese medicine, the doctor concluded the patient's stomachache was evoked by food stagnation, so the treatment was to open the six fu organs, and promote qi to move downward. Another example, one patient had post-miscarriage metrorrhagia with yang hyperactivity and blood depletion. From inquiring, the doctor found that the patient only had fetus and clots discharge but without amnia, so the doctor used herbs to eliminate stasis and restore genuine qi, to get rid of residue amnia, and it achieved good effects. If the patient has postpartum edema of the four limbs due to blood deficiency, the doctor would use herbs to nourish and benefit qi and blood instead of eliminating fluid retention by drainage, which is prohibited when the patient is in deficient status, drainage method would make it worse.

If the patient has postpartum fever, the doctor needs to differentiate whether it is due to external or internal reasons. The former reason could be related to common cold, typhoid, summer heat, food stagnation, etc., while the internal pathogen could be qi deficiency, yin deficiency, and blood stasis and lactation obstruction.

For dysmenorrhea, if the pain comes before menstruation, it is an excessive type and it's better to promote qi movement and activate blood circulation; if it comes after menstruation, it is a deficient type and it's better to strengthen qi and blood. For metrorrhagia, the treatment is to clear heat, cool blood and tonify blood for excessive type; however for deficient type, it's better to lift yang, tonify yin and then cool blood.

In terms of internal causes, it is quite pertinent to explore the disease mechanism from the aspects of liver (seven emotions), spleen and kidney. In the case of liver constraint and qi stagnation and liver heat disturbing chong and ren, the doctor needs to soothe the liver and resolve constraint, regulate meridians of chong and ren; if the meridians of chong and ren are impaired, and qi and blood is deficient, the doctor needs to tonify the extra meridians with herbs warm in nature; if liver and kidney are deficient with mild fire, the doctor needs to nourish wood and water which means tonifying liver and kidney. If the menstruation is lingering and is accompanied with pain, it means blood stasis; without pain, it means blood deficiency.

As for amenorrhea, it is better to regulate drainage for excessive type, and supplementing for deficient type. Blood stasis, blood depletion, phlegm accumulation, emotional depression, or external pathogenic wind and cold trapped in womb, stomach and spleen deficiency, and kidney deficiency with essence depletion are the results of internal and external causes. According to the different colors of menstrual blood, different factors such as blood heat with wind, blood heat ambushed with fire, or wind cold in the womb are to be distinguished.

In summary, seeking the root cause is the primary principle for treating any kind of diseases.

Regulating Menstruation by Using Tiangui Theory

The theory of tiangui (天癸) is a high-level summary of the growth, development, aging and reproductive function of Huang Di Nei Jing (《黄帝内经》). Chen Mushan's Gynecology has complete knowledge of the theory, and always attaches great importance to regulation of tiangui in treatment.Tiangui is the essence of the kidney's reproduction, which plays a key role in female's growth, development, reproduction and aging. Chen's family believe kidney is the source of tiangui, and tonifying kidney can regulate tiangui; while spleen and stomach nourish tiangui, strengthen spleen to consolidate tiangui; liver qi comforts tiangui, so soothing liver can benefit it; and tiangui and chong and ren mutually strengthen and benefit each other. Therefore, by tonifying kidney, strengthening spleen, soothing liver and regulating chong and ren, irregular menstruation and other disorders can be cured.

Tiangui first appeared in the book of Su Wen–Shang Gu Tian Zhen Lun (《素问·上古天真论》), which says: “When a girl turns 14 years old, tiangui appears, her ren meridian is opened,taichong meridian becomes vigorous, and she starts to have regular menstruation, which means that she is able to gestate; tiangui becomes withered when a woman turns 49 years old, ren meridian becomes insufficient, and taichong meridian becomes deficient, so she can't gestate.”

When one becomes aging, along with gradual declined kidney essence, tiangui also becomes diminished until completely withered. Tiangui plays an important role in women's menstruation and gestation; many clinical reproductive disorders actually are the manifestation of tiangui dysfunction.

Chen Mushan's Gynecology's master work of tiangui is The Supplementary Explanation of Chen Su'an'Fu Ke Bu Jie–Tian Gui Zong Lun (《陈素庵妇科补解·天癸总论》). In the book, it says: “Gui is the water of north; the foot taiyang bladder channel is ren, while the foot shaoyin kidney channel is gui. Kidney qi is vigorous when a girl turns 7 years old, tiangui appears when a girl turns 14 years old, and kidney qi becomes constant and even at the age of 21; however, when one turns 49 years old, tiangui is almost withered.”

Chen Mushan's Gynecology believes that tiangui is prescribed congenitally, stored in kidney and nourished by acquired food essence. When a girl grows up, kidney qi becomes vigorous and sufficient, tiangui gradually gets matured, and then they have regular menstruation, gestation, delivery and lactation. So doctors always emphasize regulating liver, spleen and kidney to strengthen tiangui. Specific understanding is as follows.

1.Tiangui originates from kidney, so tonifying the kidney can regulate tiangui.

If kidney qi is prosperous and genuine kidney yin is constantly supplemented, tiangui is gradually formed and matured at a certain stage (in the puberty period), then regular menstruation appears.

In TCM theory, kidney governs the storage and drainage of water, regulates the invisible water of gui. By storage, it generates fullness, and fullness promotes drainage; while after the drainage,tiangui has room to re-load and store again. They transform each other to form the rhythm of the menstrual cycle. It can be seen that tiangui plays a crucial role in maintaining regular menstruation. Irregular tiangui can lead to irregular menstruation, such as delayed menstruation, amenorrhea, polycystic ovary syndrome, dysfunction bleeding, premature ovarian failure.

Dr. Chen Xueqi believes that menstrual disorders are always due to the deficiency of tiangui. So the treatment is to tonify kidney and regulate tiangui. The recommended formula is Er Zhi Wan (二至丸) and Zuo Gui Yin (左归饮) to tonify kidney yin, and Er Xian Tang (二仙汤)and You Gui Yin (右归饮) to tonify kidney yang.

2.Spleen and stomach nourish tiangui, strengthening spleen consolidates tiangui.

Spleen and stomach are the sources of qi and blood, so their normal function has significant impact on tiangui. In TCM theory, spleen and stomach transform food essence to qi and blood; and kidney essence is transformed from qi and blood, while tiangui is transformed from kidney essence.Tiangui is congenitally acquired from kidney essence. Whether the kidney essence is prosperous or declined depends on the replenishment of qi and blood, which is transformed from acquired essence of water and grain. In another word, whether tiangui appears or not is dominated by kidney qi. However, its development and flourish need nourishment by food essence, qi and blood.

Spleen and stomach are both situated in middle jiao, and interact from internal to external. Normal stomach function of water and food digestion and normal spleen function of transportation and transformation promise sufficient nourishment of tiangui, regular menstruation, prosperous qi and blood and replenished blood sea.

Dr. Chen Xueqi believed that such disorders as irregular menstruation, metrorrhagia and metrostaxis and miscarriage are mostly related to weakness of spleen and stomach, deficiency of qi and blood and channels malnourishment. Thus, for insufficient tiangui, the treatment principle is to strengthen spleen and stomach, replenish qi and blood, in order to normalize the menstruation. In clinic, Si Jun Zi Tang (四君子汤) is used to tonify qi, Si Wu Tang (四物汤) to nourish blood, and Ba Zhen Tang (八珍汤) to benefit both qi and blood.

3.Liver qi regulates and comforts tiangui, soothing liver is to benefit tiangui.

Although the prosperity or decline of tiangui is dominated by the kidney, yet it has a close relation with the liver.

The drainage and fullness of tiangui depends on smoothness of liver qi, as liver is the organ of soothing qi and storing blood, and connection of chong and ren meridians. TCM ancestor Dr. Ye Tianshi (叶天士) said that “liver plays an important role in maintaining women's health and prevention of health problems”.

Kidney reproduction essence relies on the supplement of liver blood transformed essence. Smooth liver qi and sufficient liver blood not only nourish kidney essence and tiangui, but also promote qi movement, and enhance transportation and transformation function of spleen and stomach.

If qi and blood are harmonious, tiangui will be constantly supplemented, nutrition of chong and ren will be maintained. Liver stores blood, while kidney stores body essence, blood and body essence generates each other; yi (乙) and gui (癸) originate from the same source, coordinate and keep body in balance, jointly maintain the normal function of tiangui system and regular menstruation.

If liver blood is deficient, tiangui will be diminished, which will affect the functions of reproduction. So one of the treatments for tiangui is to soothe and nourish liver, or nourish liver and kidney simutaneously. Dr. Chen Xueqi thinks if tiangui dysfunction is due to emotional disorder, it's better to firstly soothe and nourish liver, meanwhile promote qi movement. Happy mood promotes liver qi circulation, which benefits the coordination between zang and fu organs, qi and blood as well as meridians. Chai Hu Shu Gan San (柴胡疏肝散) and Xiao Yao San (逍遥散) are commonly used in clinic to soothe liver and regulate tiangui.

4.Tiangui promotes chong and ren, in turn, chong and ren nourish tiangui.

In the book The Supplementary Explanation of Chen Su'an Fu Ke Bu Jie–Tian Gui Zong Lun,it says: “When tiangui appears, it indicates chong and ren meridians are opened, in this case there will be regular menstruation; that is to say, only when chong meridian is opened and ren meridian is prosperous, then is it possible to have regular menstruation. It means the emergence of tiangui,smooth and exuberant chong and ren meridians are the fundament of regular menstruation.

Congenital yuan qi and acquired food essential qi converge in chong meridian, which is also the sea of 12 meridians and blood; while ren meridian is the sea of yin meridians. Both chong and ren meridians begin with womb, which produces blood and promises fetus's life. However, if tiangui appears, it means qi and blood circulation of chong and ren are smooth and exuberant, then pouring into the womb and creating menstruation.

Kidney essence promotes the formation of tiangui, while tiangui is the material basis of chong and ren for dominating blood sea and promising fetus’ life. Either tiangui or chong and ren malfunction could affect the other side.

Tiangui connects the whole body, including four limbs, bones, five zang organs and six fu organs by way of chong and ren and many other meridians, so it can work on all over the body.Tiangui promotes growth, development and function of reproductive system through chong and ren; while chong and ren fulfill their function with tiangui’s promotion.

Dr. Chen Xueqi believes that nourishing tiangui can strengthen chong and ren; vice versa, enriching chong and ren can promote tiangui’s function. Likewise, if chong and ren are insufficient, womb will be malnourished or completely withered, so it will lead to irregular menstruation, pre-menopause syndrome, and premature ovary failure, etc. So then, for those problems, the treatments are to tonify kidney yin, supplement kidney essence, strengthen and promote chong and ren and extra meridians.

In clinical practice, Chen Mushan's Gynecology usually chooses Zuo Gui Wan (左归丸)to tonify kidney yin and supplement kidney essence and Ba Zhen Tang (八珍汤) to nourish qi and blood. Herbal medicines which enter chong meridian are Rou Cong Rong, Du Zhong, Ba Ji Tian and Fu Zi; while medicinals entering ren meridian are Zi He Che and Gui Jia, which rebuild qi and blood, supplement the blood sea, and produce sufficient blood and kidney essence, then creating regular menstruation. Dr. Chen Xueqi thinks periodic genital development not only depends on congenital kidney qi, but also depends on acquired water and food essence. According to TCM theory, spleen and stomach are the sources of qi and blood production. Liver is the root of chong and ren meridians, liver and kidney originate from same source. So only when kidney qi is sufficient, tiangui is ripe, chong and ren meridians are exuberant and smooth, and each of them coordinates and links each other, can they promise normal growth, development, fertility and regular menstruation.

Diseases caused by tiangui disorder, especially tiangui insufficiency usually are physiological or reproductive problems, such as irregular menstruation, amenorrhea, metrorrhagia and metrostaxis, pre-menopause syndrome, polycystic ovary syndrome, and premature ovary failure. Tiangui insuf ficiency is closely related to kidney, liver, spleen and stomach disorder, qi and blood deficiency, and chong and ren insufficiency. Therefore, the treatment must focus on tonifying kidney, nourishing liver, strengthening spleen and stomach, benefiting qi and blood and regulating chong and ren.

Treating Women's Diseases by Regulating Mnstruation First

From Han Dynasty to Tang Dynasty, birth and postpartum diseases drew great attention from doctors, but not leucorrhea, menstrual and other common diseases. Until Song Dynasty, TCM gynecology began to be classified as an independent subject, and gynecologists paid attention to menstrual and other common female diseases. Menstrual disorders were listed on the first chapter of Chen Su'an Fu Ke Bu Jie which says: “Many female diseases are related to menstrual disorder;regular menstruation promotes pregnancy and benefits the recovery of other health problems. Regular menstruation comes before preparation of pregnancy.”

Chen Mushan's Gynecology has many innovations in understanding and classification of menstrual disorders. In the chapter of “Regulating Menstruation” of Chen Su'an Fu Ke Bu Jie, over 50 recipes and comments have been listed, rich in content and fascinating. It says: “The flow of menstruation should be smooth without any stagnation. These conditions are all considered as abnormal, such as excessive or scanty or lingering bleeding, early or delayed period and blood stasis with pain. Therefore, in treating menstrual disorders, regulating menstruation should be given the top priority.” Even now, this philosophy still guides clinical practice, and is accepted widely by clinical practitioners.

Many female diseases are related to irregular menstruation, such as abnormal leucorrhea, infertility, difficulties of birth and lactation. Therefore, regulating menstruation plays an important role in restoring women's health.

Chen Regulating Menstruation Based on the Principle of Harmonization

The most common menstrual disorders are metrorrhagia and metrostaxis, excessive or scanty discharge, early or delayed period, prolonged period, dysmenorrhea, etc.

The 24th generation successor, Dr. Chen Dakun thought that the causes of menstrual disorder were complicate, mostly related to disharmony of qi and blood, imbalance of yin and yang, and deficiency of liver, spleen and kidney. However, women's constitution are frangible and could not tolerate strong drainage and clearance, so it's better to differentiate diseases carefully and give mild and safe treatment only.

Dr. Chen Dakun proposed the following methods in regulating menstruation.

1.Harmonizing qi and blood prior to menstruation regulation

Dr. Chen Dakun puts great emphases on nourishing and activating qi and blood to regulate menstruation. Blood is the fundamental of women's health, while qi activates blood function. In the book Ling Shu–Wu Yin Wu Wei (《灵枢·五音五味》), it says: “Most female diseases are caused by qi stagnation and blood insufficiency, which easily leads to blood loss and collapse.” It means qi and blood disharmony is one of the main reasons for inducing women's health problems. Chen's family believe that menstruation is transformed from blood, and qi and blood transform into each other. Qi is the commander of blood, and blood is circulated with qi movement. Suf ficient qi promotes engorged blood, and invigorating qi activates blood circulation. Whereas, qi stagnation leads to blood stasis; qi deficiency causes blood insufficiency, affecting normal menstruation.

Long-term qi stagnation can lead to amenorrhea, while qi movement can eliminate blood stagnation. Disharmony can be excessive type and deficient type; the aim of the treatment is to rebuild the balance. Nevertheless, menstrual disorders also can be caused by heat or cold, damp and phlegm, so treatment must be based on differentiation. The book also says: “Use pungent and warm herbs to treat wind, cold and damp amenorrhea. When the effect is gained, medication should stop promptly for fear that overuse might lead to excessive bleeding or metrorrhagia, and blood yin might be injured.”

As an example, “Irregular menstruation could relate to qi depression, so the treatment should focus on moving qi and blood and remove obstruction.” “If pain comes before period, it is qi stagnation, and it's better to move qi and harmonize blood; if pain comes during period, it is blood stasis, and the treatment is to move blood and harmonize qi; if pain comes after period, it is both qi and blood deficiency, and the treatment is to reinforce qi and blood.”

The distinctive characteristics of Chen Mushan's Gynecology are treating blood while taking care of qi, and vice versa, or treating qi and blood simultaneously but emphasizing one side according to differentiation. Qi and blood harmony has great importance for women's health, but it was not mentioned before Song Dynasty. It is Chen Mushan's Gynecology that has unique insights in this regard.

Chen's family suggest that nourishing blood should combine with strengthening qi and activating blood. Vigorous qi promotes blood circulation; qi and blood should be treated simultaneously in order to restore qi and blood balance and regular menstruation. The preferred formulas are modified Ba Zhen Tang (八珍汤), Chai Hu Shu Gan San (柴胡疏肝散), and Hong Hua Tao Ren Jian (红花桃仁煎), etc.

If menstruation in early stage is light in color and scanty in amount, it is blood deficiency with cold, Si Wu Tang (四物汤) with Dang Shen, Huang Qi and Xiang Fu is applicable; while in late stage, Si Wu Tang with Huang Qi, Chen Pi or Xiang Fu is recommended. If it is amenorrhea due to recurrent miscarriage, with impaired qi and blood, Ba Zhen Tang with Honghua (红花)and Taoren (桃仁) should be used. For dysmenorrhea, modified Ba Zhen Tang is the first choice. For excessive menstrual bleeding, metrorrhagia and metrostaxis, blood usually is deficient but qi is excessive, which tends to cause fire and disharmony of qi and blood, so the treatment is to use corresponding herbs to nourish blood, move qi and blood, while eliminating blood stasis and promoting generation of new blood, and nourishing yin and clearing heat.

Polycystic ovary syndrome and premature ovarian failure can be treated by Xiao Yao Wan(逍遥丸) and Wu Yao Chen Qi San (乌药沉气散), etc. Since Xiang Fu and Wu Yao move qi and eliminate qi stagnation, so normal menstruation follows.

For dysmenorrhea, the main cause is qi stagnation and blood stasis. Obstruction makes the pain. So it's better to use herbs that activate blood circulation, eliminate blood stasis and regulate qi movement, such as Shao Fu Zhu Yu Tang (少腹逐瘀汤). The philosophy is treating blood in order to regulate qi and treating qi to nourish blood, while qi and blood are to be treated simultaneously. The main treatment is to nourish and supplement blood coupled with soothing liver and relieving liver qi depression, such as Si Wu Tang (四物汤) with Xiang Fu and Chen Pi to harmonize qi and blood. It's good to choose herbs to strengthen qi, nourish blood and regulate chong and ren to treat dysmenorrhea, since poor-nutrition also can cause pain.

2.Regulating yin and yang is the key of regulating menstruation.

In yin-yang theory, women belong to yin. However, monthly menstruation always impairs yin and blood. Dr. Chen Dakun believes “one who is good at tonifying yang must be good at seeking yang from yin; while one good at tonifying yin must be good at seeking yin from yang.”Medicine for tonifying yang must be combined with herbs tonifying yin, in order to regain the equivalence and balance of yin and yang.

As for the patient with metrorrhagia and metrostaxis, her yin and blood are usually impaired, and blood deficiency tends to produce blood heat, while heat forces the blood to move out of the vessel violently and to worsen the bleeding, to induce more yin deficiency and yang excess. Therefore, the treatment must focus on nourishing yin and clearing heat. But one must be alert not to overuse cool herbs to destroy yin and subsequently damage yang. Yin and yang must be nourished simultaneously. It is advisable to add one or two herbs that tonify yang to a number of herbs that tonify yin. This treatment is called “reinforcing yang to tonify yin, replenishing yin to nourish yang”, which is the key point for treating metrorrhagia and metrostaxis because it nourishes five zang organs, benefits both essence and qi and balance yin and yang.

For the patient with dysmenorrhea, if she has yin deficiency with internal heat resulting in vigorous liver fire and liver fire, it's better to nourish blood before calming liver; once blood is supplemented, liver automatically becomes soft, which is based on TCM theory of nourishing water before suppressing wood; only when water is adequate, wood can be irrigated; to suppress yang, it's better to nourish yin first; if yin is even, then yang can be adherent.

For the patient with amenorrhea, if she has both yin and yang deficiency, manifested by insufficient essence and withered blood, it's advisable to add moderate herbs of tonifying yang into adequate herbs of nourishing yin, such as Zuo Gui Wan (左归丸) with Yin Yang Huo and Ba Ji Tian added in to seek yin from yang, to strengthen yin and yang simultaneously, and to regulate water and fire.

Similarly, if the patient has spleen and kidney yang deficiency, it's better to add moderate herbs of tonifying yin into adequate herbs of nourishing yang, such as You Gui Wan (右归丸) with Shu Di Huang and Shan Zhu Yu to seek yang from yin, to tonify fire from supplementing water.

3.Focusing on liver, spleen and kidney for regulating menstruation

For menstrual disorders, it is essential to focus on kidney and to take care of liver and spleen concurrently. According to TCM theory, menstrual fluid is produced by kidney, while kidney governs the store of congenital essence; spleen governs the control of the blood and the source of acquired qi and blood production. In the book of Nü Ke Jing Lun (《女科经论》), it says: “women's menstruation and lactation are all produced by the spleen and the stomach.” The liver stores blood and is in charges of qi movement, so the formation and operation of menstruation is closely related to liver, spleen and kidney.

In the therapy of menstrual disorder, Chen Mushan's Gynecology proposes tonifying kidney and liver to consolidate congenital root with Zuo Gui Yin (左归饮), You Gui Yin (右归饮)and Zhi Bai Di Huang Wan (知柏地黄丸); while supplying spleen and stomach to strengthen acquired body constitution with Si Jun Zi Tang (四君子汤), Ren Shen Bai Zhu San (人参白术散) and Ren Shen Yang Wei Tang (人参养胃汤).

The key point of menstrual disorder therapy is on kidney, meanwhile taking care of spleen and liver, as well as qi and blood, in order to regain the balance of yin and yang, harmonize qi and blood, and then create normal menstrual circle.

4.Harmonizing moderately rather than eliminating extremely in regulating menstruation

Dr. Chen Dakun believes that women tend to have qi excess and blood deficiency, so try to avoid using too fragrant, pungent and dry herbs, in case yin and liver blood will be impaired. The applicable herbs are Huang Qi, Yin Yang Huo, Ba Ji Tian, or those more even and neutral herbs, such as Xu Duan and Sang Ji Sheng. For example, try not to choose too warm herbs for metrorrhagia and metrostaxis, otherwise they will impair yin and blood and create heat, which forces blood to run out of the vessel.

In addition, try not to choose extreme cool herbs for regulating menstruation, even if it is necessary to use cool herbs to eliminate heat. And be cautious about not using over-dose and too many herbs, in case coldness should make blood stasis and impair stomach, or block the flow of menstrual blood. The applicable herbs are Huang Bai, Bai Wei, etc. For example, for dysmenorrhea with heat, over-dose cold herbs may produce blood coldness and blood stasis, which will worsen the symptoms; while over-dose cold herbs for metrorrhagia and metrostaxis, may induce lingering bleeding. Chen Mushan's Gynecology suggests the treatment principle in period is to activate blood circulation and promote blood flow. The applicable herbs are Dang Gui, Chuan Xiong, Hong Hua, Tao Ren and Yi Mu Cao. Avoid using extreme bitter, cold, pungent or dispersing herbs, in case blood stasis, period lingering, or dysmenorrhea and amenorrhea may present.

Herbs that are strong in breaking and moving blood should be avoided, since they easily impair blood and genuine qi. Yi Mu Cao and Ze Lan are the first choice.

For amenorrhea, use herbs that move blood, eliminate blood stasis, and promote generation of new blood, but do not use herbs that are strong in breaking blood. Similarly, do not use too fragrant and scurrying herbs. Mei Gui Hua and Fo Shou are always the best choice.

In summary, Chen Mushan's Gynecology emphasizes treating disease from its root by comprehensively tonifying qi and blood, regulating yin and yang, harmonizing liver, spleen and kidney to remove all the pathogens, reinforce genuine qi , and promote qi and blood movement. Never be anxious to get instant effects by using herbs pungent, warm, bitter and cold in property or herbs of breaking blood sharply. If it is really necessary, just choose these herbs, but pay attention to their processing, such as charred Huang Qi, charred Sheng Di Huang, charred Zhi Zi, and charred Pu Huang. Charred medicinals preserve their original function, but modify their fl avor and nature, avoiding too bitter and cold medicinals for the patients.

Treating Women's Diseases by Emphasizing Congenital Root and Nourishing Acquired Essences

For female diseases, Chen Mushan's Gynecology always puts emphases on kidney by tonifying kidney and benefiting liver simultaneously and meanwhile taking care of spleen and stomach.

1.Focusing on the congenital root is the fundamental of tonifying the liver and the kidney.

In the book of Su Wen–Shang Gu Tian Zhen Lun, it says: “When a girl turns 7 years old, kidney qi is vigorous, deciduous teeth are replaced by permanent teeth, and hair is growing; when a girl turns 14 years old, tiangui appears, taichong meridian is filled and ren meridian is opened, then she has regular menstruation and is eligible to be pregnant.”

In Huang Di Nei Jing, it says: “Menstruation begins when kidney qi is vigorous and discontinues when kidney qi is declined. If a girl has regular menstruation before 14, it means she has strong kidney qi and adequate congenital background; likewise, kidney qi and congenital background are weak if menstruation comes after 14, however a woman with a hypoplastic vagina is another exception.”

Kidney and liver are the organs of mother and child, which means mother's health problem could affect her child's health. Therefore, it's better to treat kidney and liver at the same time. However, blood is stored in the liver, the treasure of women. Women tend to have blood deficiency if they have metrorrhagia, excessive menstrual bleeding or postpartum bleeding, while blood deficiency induces qi excess, which can cause excessive fire and disharmony of qi and blood.

Chen Mushan's Gynecology suggests it's advisable to nourish blood before calming the liver. Once blood is sufficient, the liver becomes soft automatically; equally, nourish water first, then suppress wood; once water is filled, wood will be watered. In the same way, nourish yin first, then suppress excessive yang, because even yin builds steady yang.

Chen Mushan's Gynecology would treat kidney prior to treating liver or treat both simultaneously for such diseases as menstrual disorder, threatened miscarriage, postpartum health problems and menopausal syndromes. It always achieves remarkable effects to moisten wood by nourishing water for the treatment of dysmenorrhea, early menstruation, metrorrhagia and metrostaxis, pregnant epilepsy, vertigo, postpartum lochiorrhea due to liver constraint transforming into fire.

Polycystic ovary syndrome is mostly due to congenital deficiency, so the treatment should focus on strengthening liver and kidney. And for miscarriage prevention, it's better to use herbs to tonify kidney and calm the fetus, such as Du Zhong, Xu Duan, Fu Pen Zi, and Tu Si Zi. Only when the kidney qi and essence are sufficient, the miscarriage can be prevented and pregnancy can be continued.

2.Laying emphasis on strengthening spleen and stomach to consolidate acquired root

Chen Mushan's Gynecology highly praised Dr. Li Dongyuan (李东垣)’s theory of emphasizing on spleen and stomach to enrich gynecology. As spleen and stomach transport and transform food into acquired essence, chong and ren are connected to kidney and liver, which belongs to yangming channel. So one could survive with food and water, otherwise he or she will die. Human's health is closely related to stomach qi. Only when stomach and spleen qi are strong, it is possible to transform food nutrients into sufficient body essence, and then transport it upward to lung, downward to urinary bladder, five zang organs, six fu organs and then to all over the body. Contrarily, if stomach and spleen qi are insufficient, they will fail to transform food nutrients into sufficient essence, unavoidably body fl uid is insufficient so that many kinds of health problems will present.

In Chinese medicine philosophy, prosperous acquired body root relies on adequate congenital root; while congenital root is maintained by continuous nourishment of acquired food essence; congenital and acquired body roots supplement each other. Besides, spleen governs the blood, so strengthening spleen can treat blood deficient disorders, such as metrorrhagia and metrostaxis, chong meridian deficiency, etc. If spleen qi is deficient, it is unable to transport and transform food into body essence, qi and blood, and then it will lead to fluid retention and many other health problems. Chen Mushan's Gynecology uses the following formulas to tonify and strengthen spleen and stomach, such as Si Jun Zi Tang (四君子汤), Shen Ling Bai Zhu San (参苓白术散) and Gui Pi Wan (归脾丸).

As for the patients with metrorrhagia and metrostaxis, they tend to have kidney and liver deficiency, yin insufficiency and excessive fire. Internal heat disturbs chong and ren, so the treatment principle should be benefiting and nourishing body fluid and restraining wood. If the spleen and stomach are deficient, the spleen fails to govern blood, it's better to tonify middle jiao, benefit qi, and strengthen the spleen. Most patients need to have their kidney, liver, spleen and stomache fortified simultaneously.

For those with amenorrhea due to dieting to lose weight, their insufficient nutrients cause spleen and stomach deficiency, qi and blood inadequacy, and irregular menstruation or amenorrhea. The treatment should emphasize strengthening spleen and stomach, tonifying qi and blood. For miscarriage and threatened miscarriage, it's common to use Huang Qi and Bai Zhu to tonify qi, and Du Zhong to tonify kidney to calm the fetus. For postpartum qi and blood deficiency, Ba Zhen Tang (八珍汤) is often used. For postpartum disorders due to excessive bleeding, it's advisable to use herbs that tonify qi, blood, spleen and kidney.

In summary, the strength of acquired root relies on sufficient congenital root; while congenital root is maintained by constant nutrients from acquired food essence; both of them supplement and promote each other. Chen Mushan's Gynecology usually uses the methods of benefiting liver and kidney, strengthening spleen and stomach to treat such diseases as menstrual disorder, threatened miscarriage, postpartum disorders, and menopausal syndrome.

Dispersing Depression and Dissolving Phlegm—A New Method to Treat Menstrual Disorders

Chen Mushan's Gynecology believes: “Women are usually keen on staying indoors, and their characters are usually tenacious, thoughtful, depressed, irritable and sorrowful. All these emotional factors can lead to liver qi depression and phlegm accumulation.” So, he would suggest regulating qi, relieving depression and dissolving phlegm to treat some of female diseases.

Chen Mushan Gynecology has established the theory that some female diseases were brought up by liver qi depression and phlegm coagulation. In the book Chen Su'an Fu Ke Bu Jie–Jing Shui Bu Tong Tan Zhi Fang Lun (《陈素庵妇科补解·经水不通痰滞方论》), it says:“If spleen qi is deficient, earth is unable to overcome water, and fails to transform food into essences, but produces phlegm rather than blood. Long–term phlegm accumulation blocks uterus and creates mass, which occupies blood sea and leads to amenorrhea. Women who are overweight tend to create heat and phlegm that block blood circulation. Si Wu Tang (四物汤) and Er Chen Tang (二陈汤) are suggested to dissolve phlegm and activate blood circulation.” In clinical practice, the patient who has amenorrhea and overweight, needs to be treated with Er Chen Tang for their menstrual disorders as well as phlegm accumulation.

In the book Chen Su'an Fu Ke Bu Jie–Jing Xing Jian Dai Xia Fang Lun (《陈素庵妇科补解·经行兼带下方论》), it says that “as for the abnormal leucorrhea due to spleen deficiency, phlegm and dampness, it's advisable to strengthen spleen and dissolve phlegm so that leucorrhea will be automatically healed”. Chen Mushan's Gynecology also establishes the theory that if leucorrhea is due to phlegm, treating phlegm is prior to treating leucorrhea.

Clearing Heat and Cooling Blood—the Key to Fetus Calming

Fetus calming usually needs to be tonified and benefited. For example, in ancient physician Zhu Danxi's book of Ge Zhi Yu Lun–Tai Zi Duo Lun (《格致余论·胎自堕论》), it says: “If qi and blood are deficient and the fetus is malnourished, it will easily lead to miscarriage.” In the book of Nü Ke Jing Lun–Yin Fu Ke Ji Lue (《女科经纶·引妇科集略》), it says: “If kidney qi is insuf ficient and unable to astringe the fetus's yuan qi, miscarriage may happen.” The factors that mainly contribute to miscarriage are qi and blood deficiency, spleen and kidney deficiency, longterm sickness, poor appetite, weight loss, recurrent miscarriage, continuous childbirth, pregnancy in poor health condition, and the treatment should emphasize tonifying qi and blood.

For miscarriage, Chen Mushan's Gynecology does not just stick to the old method, but seeks its primary reason and treats from its root. Chen has established the theory of clearing heat and cooling blood for the prevention and treatment of miscarriage, and also given a detailed explanation of the etiology, pathogenesis of this theory and the use of the prescription.

Chen Mushan's Gynecology believes that in the first month of pregnancy, the fetus is nourished by the foot jueyin liver channel. The liver belongs to wood, and wood is likely to produce fire, so improper pungent food, overwork, and lost temper will impair blood qi and disturb the fetus; in the second month of pregnancy, the fetus is nourished by the foot shaoyang gallbladder channel. Ministerial fire resides in the gallbladder, excessive fire induces blood heat and forces blood to run out of the vessel and disturb the fetus, so the patient needs to calm down and avoid intercourse, avoid pungent, hot and fried food; in the third month of pregnancy, the fetus is nourished by the hand jueyin pericardium channel, which is xiang fire (ministerial fire).Ministerial fire arouses sexual desire, while sexual desire combusts xiang fire (ministerial fire),disturbs blood and forces bleeding and threatens the fetus, so the patient needs to keep calm and quiet, taking away sexual arousing factors.

Chen Mushan's Gynecology believes that most threatened miscarriages are caused by yin deficiency and internal heat, which disturbs the fetus's yuan qi (original qi) and makes the blood unable to be stored in the meridian, leading to miscarriage. So the treatment principle should focus on nourishing yin and clearing heat, benefiting blood and calming the fetus. Sheng Di Huang, E Jiao, Huang Qin, Zhi Mu, Mai Dong, etc. are commonly used.

Chen Mushan's Gynecology has initiated the theory of clearing heat and cooling blood to calm the fetus and prevent miscarriage, and it is the further development of the theory of nourishing qi and blood for miscarriage prevention. Clearing heat and cooling blood to comfort fetus is the distinctive characteristic of Chen Mushan's Gynecology, and it has great influence on the later generations, and now still guides the clinical practice. This method has achieved great clinical effects in treating recurrent miscarriage, ABO hemolysis, lack of blocking antibody, antiphospholipid antibody positive, threatened miscarriage due to yin deficiency, etc.

Postpartum Disorders Mostly Related to Qi and Blood

It is essential to use neutral and even herbs rather than harsh and strong ones for postpartum disorders, since the patient usually has qi and blood deficiency, or body fluid dissipation.

Chen Mushan's Gynecology believes postpartum disorders within 100 days after delivery usually are due to qi and blood deficiency, so relevant herbs needed to be used to restore qi and blood.

As for postpartum diseases, tonifying and benefiting are the main principles, in combination with eliminating blood stasis and activating blood circulation; Huang Qi Dang Gui Bu Xue Tang(黄芪当归补血汤) and Sheng Hua Tang (生化汤) are the first choice to supplement deficiency and eliminate stasis, that is, to treat from its root as well as from symptoms.

Chen Mushan's Gynecology emphasizes that if the patient externally contracts pathogenic factors after delivery, it's advisable to tonify qi and blood prior to moving qi, clearing heat or dispelling cold. It aims to consolidate genuine qi and then to get rid of pathogens, that is, treating root and external pathogens simultaneously. After delivery, the patient usually has qi and blood deficiency, over-dose and excessive perspiring herbs to eliminate wind cold or wind heat, may impair yang qi; excessive hot formula induces bleeding, and cold one leads to blood stasis. For example, Da Chen Qi Tang (大承气汤) may damage yin blood.

In summary, for postpartum diseases, first tonify qi and blood, and then eliminate pathogenic factors, invigorate blood circulation and remove blood stasis. With the development of modern medicine, postpartum emergencies and severe cases have been well treated, but for sweating, lochia, exogenous diseases due to postpartum qi and blood deficiency, obviously Chinese medicine has its obvious advantages.