Amenorrhea in the Shanghan Zabing Lun

Below is an overview of amenorrhea formulas found in the Shanghan zabing lun. Part I offers a list of formulas according to the pathogenic factor that can cause amenorrhea. Part II lays out original translations of all the formula lines that refer to amenorrhea, either directly or indirectly.

Zhang Zhongjing focused on three primary etiologies for amenorrhea: stagnation (of blood, water, and/or qi); cold; and deficiency. A few hundred years later, medieval Chinese gynecological physicians (and intellectuals) seem to have viewed the causes of amenorrhea in much the same way as Zhang Zhongjing. To Sun Simiao’s mind, for instance, core factors causing amenorrhea included e lu (“malignant dew,” lochia) and blood deficiency. Later, in the 13th century, Chen Ziming would attribute amenorrhea to such factors as overwork and the accumulation of cold or heat in the uterus. All of these factors were present in the Jingui yaolue.

What did change by the time of the Tang and Song was the therapeutic response to amenorrhea. “Sun repeatedly warns against using harsh drugs,” Sabine Wilms writes in The Art and Science of Menstrual Balancing in Early Medieval China. “Instead, his theoretical discussions express a preference for stabilizing and tonifying drugs.” Later physicians were much more hesitant to use focused, purging formulas (like Xiayuxue Tang or Didang Tang) to treat women’s blood stasis, due to a fear that women (especially post-partum women) were generally too prone to deficiency to handle such medicinals. Thus, the Qianjin Fang, for instance, brings us formulas such as Ganjiang Wan, which includes a wide spectrum of medicinals, both blood-tonifying and blood-purging (in addition to qi- and yang-tonifiers).

Zhang Zhongjing does offer a number of supplementing gynecological formulas, not to mention plenty of tonifying formulas that are not women-specific, but he rarely combines the actions of blood-tonifying and blood-purging in a single formula. (Dahuang Zhechong Wan is the main such Jingui formula that stands out as an exception to me.)

Danggui and Dahuang, a core pairing in Ganjiang Wan, are never combined in the Jingui; such combinations seem to have been a later innovation. I question whether combining the two actions of blood-tonifying and blood-purging hinders one’s ability to properly purge old blood, by weakening the “direction” of the formula.

Part I. Formulas According to Pathogenic Factor

JGYL 22.8
婦人之病，因虛、積冷、結氣，為諸經水斷絕，至有歷年，血寒積結胞門。寒傷經絡，凝堅。
Women’s diseases are caused by xu, cold accumulation, and bound qi, [all of which] sever menstrual flow. [If] this endures for years, blood and cold accumulate and bind in the gateway of the uterus; cold damages the jingluo, [causing] congelation and hardness.

We can discern three primary pathogenic factors for amenorrhea in classical Chinese herbalism. They are as follows (with the formulas that best treat them):

1. Formulas to Purge Binding Blood

Guizhi Fuling Wan
GZ • FL • MDP • TR • SY

Taohe Chengqi Tang
TR • Dahuang • GZ • GC • MX

Xia Yuxue Tang
Dahuang • TR • ZC • Mi

Xiao Chaihu Tang
CH • HQn • BX • RS • SJ • DZ • GC

Didang Tang/Wan
SZ • MC • TR • Dahuang

Dahuang Mudanpi Tang
Dahuang • MDP • TR • MX • DGR

Dahuang Gansui Tang (water & blood bind)
Dahuang • GS • EJ

Honglanhua Jiu
HH • Jiu

Fanshi Wan
FS • XR • Mi

Chengqi Tang family
Dahuang • ZS • HP • MX

For blood stasis plus blood deficiency:

Dahuang Zhechong Wan
Wenjing Tang

2. Formulas for Cold Accumulation/Yang Xu

Fuzi-based Formulas:
Guizhi Fuzi Tang, Zhenwu Tang, Wutou Guizhi Tang, Da Wutou Jian, etc.

Formulas for Warming the Blood:
Wenjing Tang, Danggui Shengjiang Yangrou Tang

3. Formulas for Qi & Blood Xu

Danggui-based Formulas:
Danggui Shaoyao San, Danggui San, Danggui Sini Tang, Danggui Jianzhong Tang

*Also see JGYL lines 14.19 and 14.20 for a discussion of water accumulation affecting menstrual flow. No specific formulas are recommended. The physician’s task is to determine whether the root pattern is blood or water; she can then directly treat at that level. If it’s a water pattern, treating the water will rectify menstrual flow.

Part II. Shanghan zabing lun Lines

The following lines from the Shanghan lun and Jingui yaolue feature the above formulas in the context of amenorrhea.

SHL 106
太陽病不解，熱結膀胱，其人如狂，血自下，下者愈。其外不解者，尚未可攻，當先解其外。外解已，但少腹急結者，乃可攻之，宜桃核承氣湯。
In an unresolved taiyang disease, heat binds in the bladder and the patient seems manic. If there is an unprompted descent of blood: this purgation will bring about recovery. If the exterior [condition] has not been resolved: one cannot yet attack [the interior condition], but should first resolve the exterior. When the exterior has been resolved and there is only urgent binding in the lower abdomen: one can then attack [the interior]; Taohe Chengqi Tang is appropriate.

SHL 124
太陽病六七日，表證仍在，脈微而沉，反不結胸，其人發狂者，以熱在下焦，少腹當硬滿，小便自利者，下血乃愈。所以然者，以太陽隨經，瘀熱在裏故也，抵當湯主之。
By the sixth or seventh day of a taiyang disease, the exterior pattern is still present. If the pulse is faint and submerged, yet there is an absence of chest-bind, and the patient is manic: this is due to heat residing in the lower jiao. There should be hardness and fullness of the lower abdomen and free-flowing urination. Purging the blood will bring about recovery, since [the pernicious influence] followed the taiyang channel, [causing] stagnant [blood] and heat in the interior; Didang Tang governs.

SHL 125
太陽病，身黃，脈沉結，少腹硬，小便不利者，為無血也。小便自利，其人如狂者，血證諦也，抵當湯主之。
When a taiyang disease features yellowing of the body; a submerged, knotted pulse; hardness in the lower abdomen; and impeded urination: it signals an absence of blood[-amassment]. If, [however,] urination is free-flowing and the patient seems manic: it confirms a blood pattern; Didang Tang governs.

SHL 126
傷寒有熱，少腹滿，應小便不利，今反利者，為有血也，當下之，不可餘藥，宜抵當丸。
When a case of cold-damage features heat and lower-abdominal fullness: urination will typically be impeded. If, however, [urination] is free-flowing: it signals blood[-amassment]. One should purge, without sparing any medicinals; Didang Wan is appropriate.

SHL 144

婦人中風七八日，續得寒熱，發作有時，經水適斷者，此為熱入血室，其血必結，故使如瘧狀，發作有時，小柴胡湯主之。
If, by the seventh or eighth day of a case of wind-strike, a female patient experiences bouts of alternating cold and heat that emerge at regular intervals, and an interruption of menstrual flow: this means heat is invading the blood chamber. One can be certain that the blood is binding, which causes an ague-like condition featuring periodic flare-ups; Xiao Chaihu Tang governs.

SHL 237
陽明證，其人喜忘者，必有畜血。所以然者，本有久瘀血，故令喜忘，屎雖硬，大便反易，其色必黑者，宜抵當湯下之。
When the patient has a yangming pattern and experiences a tendency to forget things: there must be blood amassment. This is because long-term blood stasis causes forgetfulness. When the stool is hard, yet easy to pass, and is black in color: it is appropriate to purge with Didang Tang.

SHL 257
病人無表裏證，發熱七八日，雖脈浮數者，可下之。假令已下，脈數不解，合熱則消穀善飢，至六七日，不大便者，有瘀血，宜抵當湯。
When a patient has no exterior pattern, but has heat-emission lasting seven to eight days: one can purge, even if the pulse is floating and rapid. If, after purgation has been induced, the pulse is still rapid: heat will gather, causing ravenous hunger. If there is no defecation for six or seven days: [it indicates] the presence of stagnant blood; Didang Tang is appropriate.

JGYL 6.18
五勞虛極羸瘦，腹滿不能飲食，食傷，憂傷，飲傷，房室傷，饑傷，勞傷，經絡營衛氣傷，内有乾血，肌膚甲錯，兩目黯黑。緩中補虛，大黃䗪蟲丸主之。
The five deficiency-taxations feature extreme emaciation, abdominal fullness, and inability to drink or eat. Damage has been caused by food, worry, drink, sex, hunger, and taxation. There is injury to the qi of the jingluo, to the ying and wei. When there is dried blood in the interior, the skin is scaly and coarse, and the eyes are dark: one must revive the center and tonify deficiency; Dahuang Zhechong Wan governs.

JGYL 18.4
腸癰者，少腹腫痞，按之即痛如淋，小便自調，時時發熱，自汗出，復惡寒。其脈遲緊者，膿未成，可下之，當有血。脈洪數者，膿已成，不可下也，大黃牡丹湯主之。
A case of intestinal abscess features lower-abdominal swelling and pi-glomus. Upon palpation, there is strangury-like pain. Urinary flow is normal and there are frequent episodes of heat-emission, along with unprompted perspiration and an aversion to cold. If the pulse is slow and tight: [it means] pus has yet to form; one can purge [static blood],* which will result in blood [in the stool]. If the pulse is flooding and rapid: [it means] pus has already formed, in which case one cannot purge [static blood]; Dahuang Mudan Tang governs.

*This line’s final phrase—“Dahuang Mudan Tang governs”—likely belongs here instead, which would significantly alter the message of this line. With this amendment, the last part of the line would read as follows: If the pulse is slow and tight: [it means] pus has yet to form, and one can purge [static blood]; Dahuang Mudan Tang governs. [Taking it] will result in blood [in the stool]. If the pulse is flooding and rapid: [it means] pus has already formed, in which case one cannot purge [static blood].

JGYL 20.2
婦人宿有癥病，經斷未及三月，而得漏下不止。胎動在臍上者，為癥痼害。妊娠六月動者，前三月經水利時胎。下血者，後斷三月衃也。所以血不止者，其癥不去故也，當下其癥，桂枝茯苓丸主之。
In lodged concretion disease, a woman experiences a nearly-three-month interruption of her normal menstrual cycle, and then has incessant menstrual leakage. If there is [a sensation akin to] fetal-stirring above the navel: this signals damage from chronic concretion. [By contrast,] when there is [actual] fetal-stirring that occurs [naturally] during the sixth month of pregnancy: there are no menstrual abnormalities during the three months prior. [In lodged concretion disease,] a discharge of stagnant blood follows the three-month interruption; the bleeding will persist until the concretion is removed. One must purge the concretion; Guizhi Fuling Wan governs.

JGYL 21.6
師曰：產婦腹痛，法當以枳實芍藥散，假令不愈者，此為腹中有乾血著臍下，宜下瘀血湯主之。亦主經水不利。
The master says—For postpartum abdominal pain: as a rule, one should use Zhishi Shaoyao San. But if it fails to bring about recovery: this means there is dried blood entrenched in the abdomen, below the navel; it is appropriate that Xia Yuxue Tang governs. [This formula] also governs inhibited menstrual flow.

JGYL 21.7
産後七八日，無太陽證，少腹堅痛，此惡露不盡，不大便，煩躁發熱，切脈微實，再倍發熱，日晡時煩躁者，不食，食則讝語，至夜即愈，宜大承氣湯主之。熱在裏，結在膀胱也。
When, by the seventh or eighth day following childbirth, there is hardness and pain of the lower abdomen, in the absence of a taiyang pattern: this means that the baleful dew [lochia] has yet to be fully discharged. There will be an absence of bowel movements; vexation and restlessness; heat-emission; and a slightly excess pulse. If the heat-emission increases two-fold, with vexation and restlessness in the late afternoon: [one can expect] a lack of appetite and delirious speech should one eat; at night, relief will arrive. [For such a pattern:] it is appropriate that Da Chengqi Tang governs. The heat resides in the interior, binding in the bladder.

JGYL 22.1
婦人中風七八日，續來寒熱，發作有時，經水適斷，此為熱入血室。其血必結，故使如瘧狀，發作有時，小柴胡湯主之。
If, by the seventh or eighth day of a case of wind-strike, a female patient experiences bouts of alternating cold and heat that emerge at regular intervals, and an interruption of menstrual flow: this means heat is invading the blood chamber. One can be certain that the blood is binding, which causes an ague-like condition featuring periodic flare-ups; Xiao Chaihu Tang governs.

JGYL 22.9
問曰：婦人年五十所，病下利數十日不止，暮即發熱，少腹裏急，腹滿，手掌煩熱，唇口乾燥，何也？師曰：此病屬帶下，何以故？曾經半産，瘀血在少腹不去。何以知之？其證唇口乾燥，故知之，當以溫經湯主之。
Question—What is it when a fifty-year-old woman presents with ceaseless menstrual spotting lasting several weeks; heat-emission at dusk; tension within the lower abdomen; abdominal fullness; vexing heat in the palms; and dryness of the lips and mouth? The master says—This disease is classified as ‘below-the-belt.’ How does it occur? Previously, she had a miscarriage, and the stagnant blood residing in the lower abdomen was not removed. How does one know this? The proof is in the dry lips and mouth; this is how one knows. Using Wenjing Tang governs.

*A comment following preparation and administration instructions says:
亦主婦人少腹寒，久不受胎，兼取崩中去血，或月水來過多，及至期不來。
[This formula] also governs women’s lower-abdominal cold, which, if chronic, leads to infertility. Furthermore, it can be taken for blood loss [due to] menstrual flooding, or for an early arrival of the menses, or for a failure of the menses to arrive at the appropriate time.

JGYL 22.13
婦人少腹滿如敦狀，小便微難而不渴，生後者，此為水與血俱結在血室也，大黃甘遂湯主之。
If, after giving birth, a woman has lower-abdominal fullness shaped like a serving bowl, mildly difficult urination, and thirstlessness: this means water and blood are binding together in the blood chamber; Dahuang Gansui Tang governs.

JGYL 22.14
婦人經水不利下，抵當湯主之。
When a woman’s menstrual flow is inhibited: Didang Tang governs.

JGYL 22.15
婦人經水閉不利，藏堅癖不止，中有乾血，下白物，礬石丸主之。
When a case of obstructed menstrual flow features a firm, intractable mass in the uterus, [signaling] the presence of dried blood, and the discharge of a white substance: Fanshi Wan governs.

JGYL 22.16
婦人六十二種風，及腹中血氣刺痛，紅藍花酒主之。
For the sixty-two varieties of women’s wind, including stabbing pains of blood and qi in the abdomen: Honglanhua Jiu governs.