A B RIEF I NTRODUCTION TO PATHOMECHANISMS

Pathomechanisms offer us a description of the dynamic process through which disease develops
and transforms in the body. When assessing a patient, we generally use pattern identification as
the basis for determining treatment; however, we use pathomechanisms to analyze and explain
the changes that occur over time. Because pattern diagnosis only provides us with a snapshot
picture of the current state of illness, our ability to predict the progression of disease depends
upon our knowledge of pathomechanisms.
A comprehensive understanding of pathomechanisms allows us to practice Chinese medicine
more holistically. It helps us to better anticipate future complications and stay one step ahead of
the disease that we are treating. In addition, it expands our ability to prevent the development of
illness and allows us to live up to the motto that a superior practitioner treats disease before it
arises.
Generally speaking, diagnosis in modern Chinese medicine requires that the practitioner first
differentiate the disease based on TCM disease identification ( bin bng). Each disease
category is divided into patterns, so the condition is then further differentiated by pattern identi-
fication ( bin zhng). This process directs the practitioner to appropriate medicinal ther-
apy and acumoxa treatment. Although this foundation gives us a means of providing effective
treatment, it provides relatively little information on the origin, development, and potential pro-
gression of the condition.
The cause of a disease ( bng yn) is closely related to the pathomechanisms ( bng
j) involved. However, there is an important difference between these two related concepts. The
disease cause explains the origin of the condition, while pathomechanisms describe its dynamic
evolution and progression. In other words, diseases and patterns illustrate the current state of an
illness, the disease cause tells us its origin, and the pathomechanisms tell us everything that hap-
pened in between and everything that we can expect to happen in the future.

The Origin and Development of Pathomechanisms

The Chinese medical theories that explain normal physiology were preceded by theories that ex-
plained pathology. It appears that certain treatments were found to be empirically effective and
medical theory was adapted and created to explain the efficacy of the treatments. Most scholars
believe that the Chinese first observed patterns of dysfunction and then later created medical the-
ories to explain why the problems arose. Theories elucidating normal physiology were developed
in an attempt to explain why pathologies followed certain predictable trends.
Since pathology was the basis for developing an understanding of physiology, the theories
involved in pathomechanisms date back to the earliest sources of mature Chinese medical theory.
 The earliest major extant works in Chinese medicine were found in a noblemans burial
chamber known as M Wng Du, dating back to the early Hn Dynasty (168 BCE). At this time,
symptoms and diseases were
Developing Physiology from Pathology correlated with specific channels
As an example, we all know that the spleen is responsi- and pulses, but there was very
ble for controlling (or containing) the blood in Chinese little substantial development of
medicine. Thus, bleeding may occur from failure of the pathomechanisms or normal
spleen to contain the blood. Unlike the stomach and intes- physiology. Five-phase theory
tines, physical examination of the spleen would provide and visceral manifestation, the
few clues into its function in the days before the micro- hallmark systems that form the
scope. Because of this, we find that the functions of the basis of modern Chinese medical
spleen in Chinese medicine bear little resemblance to the physiology and pathology, were
functions of the spleen in Western medicine. not yet developed.
It is likely that certain treatments were observed to treat Pathomechanisms were first
bleeding long before the spleens function of controlling explicitly referenced in the
the blood was established. However, these interventions Hung D Ni Jng (The Yellow
were probably only effective in certain presentations of Emperors Inner Canon). The
bleeding. As visceral theory developed, trends in patients most famous section on
who experienced bleeding were observed and patients pathomechanisms in this text
were linked together based upon which treatments they revolves around the discussion
were responsive to. of the Nineteen Pathomecha-
Eventually, it was concluded that patients who had a nisms. It should be noted that
systemic presentation of spleen vacuity were susceptible to as medical theory evolved, some
certain types of bleeding and were responsive to certain of the conditions that are men-
types of treatment. Thus, it was determined that the spleen tioned in the Ni Jng are now
was failing to contain the blood, producing bleeding. By attributed to additional causes.
extension, the spleen was attributed the normal physiologic An interesting debate re-
function of containing and controlling the blood. How- volves around the use of the
ever, there is no evidence for this function under normal word j in the context of
physiologic conditions; it is only when pathology has de- pathomechanisms (called
veloped that the spleens function of controlling the blood bng j) in the Hung D Ni Jng
becomes apparent. (The Yellow Emperors Inner
Canon). The word j means a variety of things, but is often used in compound words to de-
scribe various mechanisms and machines. One of the original contexts that this word was used in
at the time of the Ni Jng was that of a trigger mechanism on a crossbow. A cocked crossbow
has a device that locks the drawstring down; this is attached to the trigger itself, which releases
the lock to shoot the bolt. Thus, the trigger mechanism (the j) is the key element that initiates all
the action. One interpretation for the use of this character is that the ancients saw the varied
manifestations of disease, but equated the starting point for everything going off to be related to
some type of trigger that caused the normal peace to be interrupted and the action to begin. Mili-
tary metaphors abound in Chinese medicine, and this weaponry metaphor may be intertwined
with the early understanding of bng j. Based on his research into the Ni Jng, Dr. Chen Yu-
Sheng of Chang Gung Memorial Hospital believes that this notion of j allows a practi-
tioner to treat at a deeper level than the treatment of signs and symptoms, patterns, and other
forms of already-manifest disease. To him, analysis into these essential triggers of disease al-
lows the practitioner to address the core problems that underlie and produce various disease mani-
festations.
The research of individual scholars such as Dr. Chen notwithstanding, most practitioners take
a more modern stance on pathomechanisms, and use them to evaluate the progression of disease
based upon the more well-developed framework that was provided by later literature. From the
earliest times, pathomechanisms have been used to explain the natural course of disease and have
been used by practitioners to prevent and predict illness, as well as to devise treatment strategies.
As time went on, Chinese medi-
cal texts proliferated and estab- The Nineteen Pathomechanisms listed in the Ni Jng
lished pathomechanisms to ex- ( S Wn, zh zhn yo d
plain the development of virtu- ln pin d q sh s, Plain Questions 74, Great Treatise on
ally all conditions known to the Essentials of Supreme Truth)
Chinese medicine.
All wind with shaking and [visual] dizziness is ascribed to the
liver
All cold with contracture and tautness is ascribed to the kidney
All q rushing and depression is ascribed to the lung
All dampness with swelling and fullness is ascribed to the spleen
All heat with visual distortion and tugging is ascribed to fire
All painful and itching sores are ascribed to the liver
All reversal with constipation or diarrhea is ascribed to the lower
body
All wilting (wi), panting, and retching are ascribed to the upper
body
All clenching, shuddering, and chattering [of the jaws] with the
seeming loss of the spirit is ascribed to fire
All tetany and rigidity of the neck is ascribed to dampness
All counterflow upsurging is ascribed to fire
All major abdominal distention is ascribed to heat
All excessive agitation and mania is ascribed to fire
All fulminant rigidity is ascribed to wind
All diseases with [abdominal] sounds, where tapping makes a
drum-like sound, are ascribed to heat
All diseases with aching pain and swelling of the instep, fright,
and fear are ascribed to fire
Modern literature on Chi- All cramps, arched-back rigidity, and turbid watery humors are
ascribed to heat
nese medicine abounds with
All disease with watery humors that are clear, pure, and cold are
explanations of pathomecha- ascribed to cold
nisms. All Chinese textbooks of All sour retching and vomiting, and fulminant downpour with
gynecology, like textbooks of lower body distress are ascribed to heat
internal medicine and other spe-
cialties, contain a list of the pathomechanisms involved in any given condition. Often an entire
chapter will be spent discussing the pathomechanisms early on in the text. In recent years in
China, there has been a major push to develop students knowledge of the pathomechanisms of
Chinese medical diseases. It is widely recognized in the Chinese medical community that a
strong foundation in pathomechanisms improves the reasoning skills of doctors and allows for
better clinical results.
At a time when many Chinese practitioners are emphasizing Evidence-Based Medicine and
integration with Western medicine, there is also a significant movement among our Asian col-
leagues to pursue traditional approaches and mastery of classical theory. The increasing attention
given to pathomechanisms in the Chinese world has not gone unnoticed in the Western Chinese
medical community. Thus, it is no surprise that recent years have seen a proliferation of written
works and presentations on pathomechanisms within the English-speaking world.
 Refined by the Passage of Time
Chinese medical theory is constantly evolving; many fundamental theories have been questioned,
analyzed, and refined throughout history. A number of diseases and pathomechanisms that were
recognized historically were discarded by subsequent generations, and a number of innovations
and new concepts have been presented over the years. This dynamic process has resulted in a
modern body of knowledge that has winnowed down obsolete theories while simultaneously ad-
vancing new explanations for conditions that were previously unknown or undeveloped in the
literature. From our modern vantage point, we see many examples of pathomechanisms that
failed to withstand the test of time, as well as many opportunities to advance Chinese medical
theory into new and unexplored dimensions.
Theories of physiological and pathological mechanisms that are now considered to be obso-
lete explanations from a bygone era abound in Chinese medicine. Some of these theories involve
basic fundamental premises of physiology, while others represent disease concepts and pathome-
chanisms that are now considered to be clinically useless or fundamentally flawed.
Examples where physiologic theory has fallen by the wayside can be found in the analysis of
modern bowel and visceral patterns. Ancient Chinese medical philosophers attempted to form a
symmetrical picture of bowel and visceral functions and pathologies so that the concept of the
body would remain in harmony with theories of yn-yng and the five phases. Consequently, all
visceral patterns were evenly distributed; patterns of kidney repletion were posited to balance pat-
terns of kidney vacuity, lung blood vacuity held a relative place with lung q vacuity, and liver q
vacuity stood in opposition with liver q stagnation. All of the various combinations of pathology
were developed in accordance with established yn-yng pairs and correspondences between the
five phases.
Despite these established groupings, many of the conditions that provided theoretical yn-
yng balance are no longer recognized in mainstream Chinese medical theory. For example,
there are no patterns of kidney repletion, no patterns of lung blood vacuity, and the notion of liver
q vacuity has been almost completely undeveloped. The reason that various conditions have
fallen off historically is due to Chinese medicines pragmatic focus on therapy. The development
of pathomechanisms is dependent upon the successful application of interventions; theory alone,
however balanced and beautifully composed it may be, is insufficient to sustain practitioner con-
fidence in the absence of useful therapeutic techniques. Because treatment results were used to
make sense of pathology, and pathology was in turn used to explain physiology, physiologic
mechanisms that lacked treatments and pathological manifestations eventually became obsolete.
In other words, the lack of medicinals to treat kidney repletion (along with the subsequent lack of
resolvable symptoms that could thus be ascribed to kidney repletion) was likely the primary rea-
son that kidney repletion patterns were phased out of orthodox medical theory long ago.
In addition, medical theory evolved to reflect changes in the perceived causes of disease.
Many instances of dated concepts can be found by comparing past literature to modern works.
For example, early Bn Co literature was influenced heavily by alchemy and demonic medicine.
The ability to kill demonic q was ascribed to the various parts of the peach tree, including the
peach kernel. In early medicinal books, to rn (Persicae Semen) was used to treat illnesses at-
tributed to demonic q, including demonic pregnancy ( gu ti). This disease was charac-
terized by a lump in the abdomen that was presumed to be a phantom fetus. As the demonic ex-
planation of this disease was replaced by the notion of blood stasis, the theory of the demon-
expelling action of to rn (Persicae Semen) was replaced with the notion that it eliminated blood
stasis. Today, to rn (Persicae Semen) remains an essential medicinal for the treatment of ab-
dominal lumps, but the theory surrounding its use has advanced considerably.
 Much later in history, a similar scenario emerged wherein a clinically effective treatment was
developed based upon theory that was later deemed to be obsolete. Wang Qing-Ren, the creator
of the family of formulas related to xu f zh y tng (House of Blood Stasis-Expelling Decoc-
tion), developed an entire group of formulas based on suppositions deduced from poor dissection
technique. Lacking proficiency in the art of dissection, Wang damaged the vascular network of
the patients that he dissected, causing blood to pool in the chest. Consequently, he deduced that
the large amount of blood that he saw pooled in their thoracic cavity was the cause of their illness,
and developed formulas to expel stasis from this House of Blood. Although it is now known
that his dissection methodology and theory were flawed, his remedies were effective and have
now become some of the most widely-used blood stasis-transforming formulas in the clinic today.
Although some pathomechanisms have been refined and modified to fit a changing world-
view while retaining clinically useful aspects, other pathomechanisms that were proposed histori-
cally are now no longer used at all. An example of an obsolete pathomechanism can be found in
the disease known as y mng gu jio, dreaming of intercourse with ghosts. This
was a disease in women equivalent to mng y (dream emission, basically equivalent to wet
dreams) in males. While dream emission in males is explained by normal pathomechanisms of
the bowels and viscera, the corresponding condition in females was attributed to ghosts. Modern
scholars believe that issues of gender inequality account for the discrepancy between the super-
natural and natural causes assigned to these diseases. Though ejaculation from dreams of a sex-
ual nature was accepted as a simple sign of hyperactive ministerial fire in males, when women
awoke from sexual dreams with increased lubrication the cause was attributed to unnatural
dreams of copulation with spirits. As Chinese medicine modernized, the references to dreaming
of intercourse with ghosts disappeared, and this disease name is now thought to be a relic from a
time when disparity between the sexes got too carried away.
It should be noted in passing that clear information on the entire issue of abnormal discharge
of semen has been largely obscured in English literature. Owing perhaps to the widespread belief
in China that Westerners are incapable of grasping the subtleties of TCM theory, many concepts
in Chinese medicine have been unduly simplified for Western audiences. Thus, although four
distinct conditions of involuntary seminal emission are described in modern Chinese textbooks,
most English texts tend to lump all of these conditions together with the use of the word sperma-
torrhea. This type of simplification causes Western readers to miss out on important distinctions
that may impact our clinical decisions. Consequently, many Westerners erroneously attribute
seminal loss primarily to insecurity of kidney q, while others even speculate that spermatorrhea
refers to masturbation! However, if a practitioner is well-versed in the meaning of the terms used
in Chinese medicine, they will be able to differentiate the distinct conditions that produce invol-
untary seminal emission and will vary their treatment appropriately. Since each of these distinct
conditions are produced via different pathomechanisms, a practitioner who has mastered their
study of pathomechanisms will be able to discern whether the condition is caused by effulgent
sovereign and ministerial fire, heart vacuity and liver depression, insecurity of kidney q, nonin-
teraction of the heart and kidney, or spleen vacuity q fall. Because all of these causes require
different treatments, the study of pathomechanisms has a profound impact on clinical success
when treating such conditions.
Western practitioners are perfectly capable of mastering the subtleties of Chinese medical
theory. Our literature should not simplify traditional concepts, and practitioners should strive to
understand the clinically indispensable elements of TCM disease differentiation and pathomecha-
nisms. The emphasis on clear term use and a strong understanding of pathomechanisms has been
heavily emphasized in recent years within the Chinese community. For example, the various dis-
orders of seminal emission mentioned above are clearly distinguished in Chinese medical diction-
aries, as well as in the authoritative term research conducted by Zhu Jian-Ping et al., the termi-
nology standards of the World Health Organization, and the English literature that follows the
translation methodology laid out by Wiseman and Feng in the Practical Dictionary of Chinese
Medicine. The Chinese have gone to great efforts to refine and develop the study of pathomecha-
nisms and diagnosis, and our patients will benefit greatly by our diligence in pursuing this clini-
cally useful information.

Bringing Pathomechanisms to the Clinic

Virtually all treatments in Chinese medicine are designed to prevent or reverse the progression of
disease. Although a great deal of Chinese medical theory was likely preceded by and based upon
empirical results, virtually all famous clinicians throughout history used their knowledge of
pathomechanisms to devise their strategies and treatment approaches.
Li Dong-Yuan, one of the
four great masters of the Jn- Practical Applications of Pathomechanisms:
Yun Dynasty, is well-known for Li Dong-Yuans Strategy to Resolve Hangovers
developing formulas based upon Li Dong-Yuan lived in the Jn-Yun Dynasty, a time when the
his understanding of the pathome- wonders and side-effects of distilled spirits were known through-
out Chinese society. In the words of Zhu Dan-Xi: Pure grain
chanisms involved in spleen-
spirits are very hot and very toxic in nature. Clear and fragrant,
stomach disharmony. His most [they are] suitable for the mouth; [because they] move q and
famous formula, b zhng y q harmonize the blood, [they are] also suitable for the body.
tng (Center-Supplementing Q- However, the side-effects produced by the excessive consump-
Boosting Decoction), which com- tion of grain spirits were also widely acknowledged.
bined medicinals that supplement Li Dong-Yuans famous formula g hu ji chng tng (Puer-
the spleen with medicinals that aria Flower Liquor-Resolving Decoction) was specifically de-
upbear yng, has become one of signed to treat alcohol accumulation, possibly manifesting with
the most common formulas in retching and vomiting, diarrhea or glomus blockage, headache,
clinical use today. Li Dong-Yuan or inhibited urination. Li wrote that hand and foot yng mng
channel-entering medicinals should be used to treat damp-heat
invented many useful formulas
toxins accumulating in the stomach and intestines. To explain
through his in-depth investigation his selection of medicinals, he offered the following explanation
of pathomechanisms. Thus, he is of the pathomechanisms involved: Alcohol is very hot and is
regarded as one of the most influ- toxic; it is formed from water. Thus, it [produces] heat with
ential pioneers in the history of concurrent dampness. The damp-heat accumulates in the stom-
Chinese medicine. ach and intestines, so all the pathoconditions [listed above] can
Looking back into the history be seen.
Based upon his analysis of the pathomechanisms involved in
of Chinese medicine, we find that
alcohol accumulation, Li created the following formula:
medical strategies have always g hu (Puerariae Flos) 1 qin
been rooted in explanations of du ku (Amomi Fructus Rotundus) 1 qin
pathomechanisms. As one of the sh rn (Amomi Fructus) 1 qin
earliest influential figures in Chi- m xing (Aucklandiae Radix) 1 fn
qng p (Citri Reticulatae Pericarpium Viride) 4 fn
nese medicine, Zhang Zhong-Jing chn p (Citri Reticulatae Pericarpium) 4 fn
used pathomechanisms to pioneer rn shn (Ginseng Radix) 4 fn
the theories surrounding Cold bi zh (Atractylodis Macrocephalae Rhizoma) (dry-fried) 4 fn
Damage in the Shng Hn Ln f lng (Poria) 4 fn
(On Cold Damage). Later on, shn q (Massa Medicata Fermentata) (dry-fried) 3 fn
gn jing (Zingiberis Rhizoma) 3 fn
all four of the great masters of zh lng (Polyporus) 3 fn
the Jn-Yun Dynasty expounded z xi (Alismatis Rhizoma) 3 fn
new theories of pathomechanisms Today, this same formula is produced by large pharmaceutical
and created effective treatments companies and is widely regarded as an effective formula for
based upon them. This same reducing the side-effects of excessive alcohol consumption.
process allowed the literature and
theory of Warm Disease to develop in the Qng Dynasty.
 Using pathomechanisms to devise treatments for use in integrative medicine: Just as the
great doctors in the past used pathomechanisms to devise novel approaches to established condi-
tions or previously unknown illnesses, innovative doctors in the present day continue to study
pathomechanisms to explore new options for their patients health. In the modern day, Chinese
doctors are presented with new illnesses as well as new perspectives made available through the
use of Western medical theory and diagnostic techniques. Additionally, the pursuit of Evidence-
Based Medicine has spurred a research effort focused on developing Chinese medical treatments
based on Western disease diagnosis. Consequently, practitioners have turned to pathomecha-
nisms in an effort to better understand disease progression and select appropriate interventions.
Chinese physicians often ponder the Chinese medical significance of symptoms seen in vari-
ous biomedical diseases. For example, why do we see vomiting of blood in advanced cases of
liver cirrhosis? What theories should we employ to treat new diseases such as SARS or AIDS?
What pathomechanisms explain the ubiquitous presence of nausea in patients receiving chemo-
therapy? Integrative medicine offers practitioners a unique opportunity to expand traditional the-
ory into the modern world, and in many cases practitioners use their understanding of pathome-
chanisms to discover effective new strategies in disease management.
A few examples of innovative strategies for modern conditions are outlined below:
Lupus: Although SLE was not recognized by Chinese medicine historically, it produces a
variety of dramatic symptoms that can be assessed through the eyes of Chinese medical theory.
Dr. Chang Hen-Hong, the Vice Superintendent of Chang Gung Memorial Hospital, sought to im-
prove the lives of his patients by gaining insight into the pathomechanisms involved in acute ex-
acerbations of SLE. Knowing that Chinese medicine had no framework for autoimmune disor-
ders per se, Dr. Chang sought to analyze the symptoms that erupted in hopes of finding successful
treatments to manage acute episodes. Because acute episodes are often marked by systemic heat
symptoms, Dr. Chang searched through classical texts for clues into how such profuse and sys-
temic heat signs could arise.
In ancient Chinese medicine, the pulse was taken at a variety of places other than the radial
pulse. Nine positions were used, three in the upper body, three in the center, and three in the
lower body. Each pulse identified disease of a given channel; the channels were not yet linked
together in a circuit. Over time, the use of the nine pulse locations faded and practitioners fo-
cused their pulse diagnosis upon the wrist pulse exclusively. It is speculated that changes in cul-
tural mores may have prohibited the use of palpation in sensitive areas such as the neck and groin;
consequently, theory needed to be devised to link the channels together so that the pulse could be
taken at a single, inoffensive location. The theory that made this possible was the theory of the
stomach is the sea of the twelve channels. This concept was put forth by the time of the Ni Jng;
it provided an explanation of how the channels were joined together and how the q of all the
channels was carried to the wrist pulse.
By investigating this ancient concept of the stomach is the sea of the twelve channels, Dr.
Chang was able to consult a variety of classical sources and devise a treatment for acute episodes
of lupus. Just as the ancient Chinese used the stomach is the sea of the twelve channels to ex-
plain the joining of all the channels, Dr. Chang used the stomach-is-the-sea theory to connect the
diverse constellation of symptoms seen in lupus. Lupus has a very clear definition and patho-
genesis in Western medicine. By researching the clinical signs seen in acute episodes of SLE, Dr.
Chang was able to find an approach that could explain and treat these signs through the use of
Chinese medicine.
Endometriosis: The modern recognition of endometriosis provides practitioners with useful
information that links up a variety of different symptoms and TCM diseases. In cases where uter-
ine tissue proliferates locally, extreme pain with menstruation is not uncommon; many such con-
ditions would thus be typically classified as painful menstruation in Chinese medicine.
 In an effort to develop effective treatments for endometriosis, practitioners at Chang Gung
Memorial Hospital investigated the appearance of proliferating endometrial tissue. By using a
microscope to examine the tissue, they were able to gather information that was not available to
practitioners in the past. One of their findings was that the tissue was typically red and inflamed.
Looking through the lens of Chinese medicine, this appeared to be a clear manifestation of heat
that may not have been visible via conventional intake methods. In cases where the tissue was
proliferating locally, the location of this heat could be placed on the liver channel. This knowl-
edge allowed practitioners to investigate pathomechanisms that could produce heat in the liver
channel in an effort to provide patients with lifestyle and dietary suggestions to minimize exacer-
bation of the disease. In addition to assessing contributing factors and recommendations to main-
tain patient health, this knowledge spurred many doctors to experiment with the use of lng dn
xi gn tng (Gentian Liver-Draining Decoction) in their patients with endometriosis. Practitio-
ners could then monitor the impact of their treatments by tracking symptoms as well as lab as-
sessments of the marker CA-125. By compounding different formulas, the cold nature of the
base formula may be adjusted for weaker patients by combining it with formulas such as xing
sh li jn z tng (Costusroot and Amomum Six Gentlemen Decoction). Practitioners who use
this Westernized method may use different base formulas depending on the patients constitution,
with a relatively minor quantity of lng dn xi gn tng (Gentian Liver-Draining Decoction)
added in.
A number of comments should be made regarding this approach. The method and thought
process outlined above is derived from the modern prescription style for integrated medicine in
Taiwan. One of the hallmark characteristics of the modern Taiwanese prescribing method is the
compounding of multiple granule formulas. Practitioners use several different formulas together
in different quantities, and they usually tailor their selections based upon pattern identification. It
must be stressed that endometriosis does not always manifest as a heat pattern, and the tissue pro-
liferation can occur on nearly any channel.
A successful clinical outcome depends upon thoughtful analysis of every individual case. If a
true presentation of liver channel fire is seen, then prescription of lng dn xi gn tng (Gentian
Liver-Draining Decoction) is appropriate. However, in the absence of this clinical picture, it may
yield poor results. Simply trying to use lng dn xi gn tng to treat an inflammatory condition
located on the liver channel is out of synch with TCM theory and has limited clinical utility. De-
spite increasing numbers of practitioners using Chinese medicinals based upon Western medical
logic, many practitioners feel that superior results can be achieved through pattern identification
and flexible use of pathomechanisms based upon traditional parameters of diagnosis. While the
ultimate goal of relieving symptoms and signs is universal, practitioners use very different ap-
proaches depending on their orientation.
For local proliferation of endometrial tissue, textbooks of integrated medicine in the Peoples
Republic of China recommend that if the proliferating tissue is smaller than a 50 day-old fetus,
medicinal therapy may be used. If there is no benefit from the prescription, surgery is recom-
mended. Following menstruation, they recommend 810 packs of the formula below (one pack
per day); the rest of the cycle passes without medication. By assessing their formula, it is clear
that the authors believe that liver depression and blood stasis are factors in the manifestations of
endometriosis.
 Base Formula:
chi h (Bupleuri Radix) 8 g yn h su (Corydalis Rhizoma) 15 g
bi sho (Paeoniae Radix Alba) 12 g xing f (Cyperi Rhizoma) 15 g
zh qio (k) (Aurantii Fructus) 12 g f lng (Poria) 15 g
r xing (Olibanum) 10 g m dn p (Moutan Cortex) 15 g
m yo (Myrrha) 10 g to rn (Persicae Semen) 15 g
gu zh (Cinnamomi Ramulus) 10 g kn b (Laminariae/Eckloniae Thallus) 15 g
xu ji (Daemonoropis Resina) 4 g hi zo (Sargassum) 15 g
dn shn (Salviae Miltiorrhizae Radix) 15 g
If the patient tends to have exuberant heat, with symptoms such as dry mouth and throat, heart
vexation, a bitter taste in the mouth, and a red tongue with yellow fur, remove gu zh (Cinna-
momi Ramulus) and add:
xi k co (Prunellae Spica) 30 g
xun shn (Scrophulariae Radix) 15 g
zh z (Gardeniae Fructus) (scorch-fried) 10 g

B ASIC PATHOMECHANISMS I N G YNECOLOGY

Pathomechanisms in gynecology may be broadly divided into the following categories:
Disharmony of q and blood
Irregularities in bowel and visceral function
In addition to these basic categories, some practitioners use different theoretical frameworks to
describe gynecological pathologies. Although these other frameworks relate data that is essen-
tially similar in meaning, some texts organize the pathomechanisms of gynecology around the
following factors:
Irregularities of tin-gu (the principle of reproductive viability, menstruation)
Damage to the thoroughfare (chng), controlling (rn), governing (d), and girdling (di) ves-
sels
Damage to the uterus, the uterine vessels, and the uterine network vessels

Disharmony of Q and Blood

The Ni Jng, S Wn (Inner Canon, Plain Questions) states: The hundred diseases change
and arise [when] q and blood are in disharmony. In the Lng Sh (Magic Pivot), we find the
statement: Womens lives have a superabundance of q and an insufficiency of blood. Har-
mony of q and blood is essential for womens health. Because of the close relationship between
blood and q, complex variations and mixed patterns of repletion and vacuity are very common in
the clinic. The primary types of basic disharmony are outlined below:
Pathomechanisms of the Blood
Blood vacuity: Blood vacuity refers to a pathological state of insufficiency of yn-blood that
results in a loss of bloods nourishing and moistening function. It primarily arises from three
mechanisms: 1) Blood may be damaged by profuse bleeding, menstruation, pregnancy, childbirth,
and breast-feeding. Profuse menstrual bleeding, flooding, and great bleeding during pregnancy or
childbirth are particularly significant causes of blood vacuity. 2) Blood vacuity may arise when
q fails to sufficiently form blood. This is generally due to either spleen-stomach vacuity or poor
nourishment. 3) Insufficiency of kidney-essence may cause blood vacuity because essence forms
blood.
When blood is vacuous, the thoroughfare (chng) and controlling (rn) vessels lack fullness.
This may lead to: delayed menstruation, scant menstruation, menstrual block, painful menstrua-
tion, abdominal pain during pregnancy, stirring fetus, habitual miscarriage, atrophied fetus, scant
breast milk, generalized postpartum pain, infertility, and pudendal itching.
Blood Stasis: Blood stasis may arise from cold, heat, vacuity, repletion, injury, surgery, bleed-
ing, and enduring illness. It may lead to a variety of gynecological diseases, which may be
grouped by the causative factors involved:
Blood cold leading to stasis: Cold congeals the blood; it may result from contracting external
cold when the blood chamber is open, i.e., during menstruation or after giving birth. It may
also arise from consumption of raw and cold foods, or from getting soaked in the rain or wading
through water.
Blood heat leading to stasis: Contraction of heat evil or consuming excessive quantities of
acrid, hot foods or yng-assisting medicinals leads to deep-lying heat in the thoroughfare (chng)
and controlling (rn) vessels. This heat scorches the blood and forms stasis.
Q vacuity leading to stasis: Vacuous q lacks the force to move the blood. This causes the
blood to flow slowly, leading to blood stasis.
Q stagnation and blood stasis: Q is the commander of blood; when q moves, the blood
moves. Internal damage by the seven affects inhibits the q dynamic and causes q stagnation,
which in turn gives rise to blood stasis.
When blood stasis is formed, it obstructs the uterus, the uterine vessels, the uterine network
vessels, and the thoroughfare (chng) and controlling (rn) vessels. It may lead to painful men-
struation, menstrual block, headache during menstruation, generalized pain, ectopic pregnancy,
postpartum abdominal pain, infertility, or concretions and conglomerations. Stasis accumulating
over a prolonged time can gradually lead to endometriosis or pelvic inflammatory disease.
Blood Heat: Blood heat refers to heat lying deep within the blood. It causes the blood flow to
accelerate, and in severe cases leads to frenetic movement of hot blood. Blood heat may arise
from constitutional exuberance of yng, from excessive consumption of acrid, hot or yng-
assisting foods, as well as from inappropriate use of yng-assisting and uterus-warming medici-
nals. When deep-lying heat in the thoroughfare (chng) and controlling (rn) vessels leads to
frenetic movement of hot blood, it manifests with profuse menstruation, advanced menstruation,
flooding and spotting, blood ejection or spontaneous external bleeding during menstruation, fetal
spotting, or postpartum heat effusion.
Heat flames upward by nature; if liver depression transforms into heat, it may lead to head-
ache during menstruation, moodiness during menstruation, or advanced menstruation. In patients
with constitutional yn vacuity or damage to yn-blood from menstruation, pregnancy, childbirth,
or breastfeeding, yn vacuity forms internal heat. This heat harasses the thoroughfare (chng) and
controlling (rn) vessels, leading to insecurity of the thoroughfare (chng) and controlling (rn)
vessels; this manifests as advanced menstruation, flooding and spotting, stirring fetus, and persis-
tent flow of the lochia following childbirth.
Blood Cold: When the blood and vessels contract cold, the blood becomes congealed and
moves slowly. Blood cold often results when insufficiency of right q allows contraction of cold
evil to occur during menstruation or after childbirth. It may also arise from constitutional yng
vacuity. Blood cold leads to painful menstruation, delayed menstruation, scant menstruation,
menstrual block, abdominal pain during pregnancy, abdominal pain or generalized pain following
childbirth, or infertility due to uterine cold.
Pathomechanisms of Q
Q vacuity: The impact of q vacuity on womens health varies depending on whether the vacu-
ity primarily affects the lung, spleen, or kidney. In lung q vacuity, insecurity of defensive q in
the outer body leads to common colds during menstruation, postpartum spontaneous sweating, or
postpartum heat effusion. By contrast, spleen q vacuity, center q fall, or kidney q vacuity can
all lead to insecurity of the thoroughfare (chng) and controlling (rn) vessels. These vacuities
may lead to advanced menstruation, profuse menstruation, flooding and spotting, fetal spotting,
uterine prolapse, or loss of breast milk.
Q stagnation: In binding depression of liver q, the free-coursing function of the liver is im-
paired, causing obstruction in the thoroughfare (chng) and controlling (rn) vessels. This gives
rise to menstrual irregularities, menstrual pain, menstrual block, advanced menstruation or men-
struation at irregular intervals, or infertility. When the movement of q is inhibited, the body flu-
ids collect and stagnate. This causes phlegm-damp to form, leading to pathoconditions of puffy
swelling during menstruation, pregnancy swelling, menstrual block, and infertility. Over time, q
stagnation transforms into fire; heat evil may ascend to harass the heart spirit or descend into the
sea of blood to affect the thoroughfare (chng) and controlling (rn) vessels. This causes moodi-
ness during menstruation or after childbirth, as well as visceral agitation. Additionally, when the
q dynamic is inhibited, irregularities in the functions of the liver, stomach, and spleen arise. This
can cause chest oppression with a desire to vomit during menstruation, as well as menstrual pain
or distention and pain in the lesser abdomen, chest, and breasts.
Q counterflow: The lung governs q and depurative downbearing. When lung q ascends
counterflow, it may cause pregnancy cough or pregnancy suspension (a condition of stirring fetus
with distention and fullness in the chest and heart). If liver q invades the stomach and causes
stomach q to counterflow upwards, it may result in vomiting during menstruation or vomiting
during pregnancy.