Missed Periods at 19, Rib Pain So Bad She Couldn’t Eat? Doctor Wu Jutong’s Case of Amenorrhea from Liver Constraint and Blood Stasis, Treated with Xuanfu Flower Decoction and Huazheng Huisheng Pills

What the patient was searching for: missed periods / periods stopped / periods getting lighter and lighter / rib pain / pain under the ribs / can’t eat / vomit as soon as eating / lower belly pain Medical terms: amenorrhea (bi jing) · liver qi constraint (gan yu) with qi stagnation and blood stasis · zheng jia (abdominal masses) · blood stasis in the liver channel

Opening: summer of 1830 — a 19-year-old girl whose periods had already stopped

On the 29th day of the sixth lunar month in the tenth year of the Daoguang reign (Gengyin year, 1830), a very young patient walked into the consulting room of the great Qing-dynasty physician Doctor Wu Jutong — a 19-year-old girl. But the moment he took her pulse and asked his questions, his heart sank. At this age a young woman’s qi and blood should be at their fullest — yet her periods had grown scanty, the blood darker and darker, until finally they stopped altogether. Just 19 years old, and she had amenorrhea. On top of that, both flanks (under the ribs) had been aching for two or three years; when the pain flared it was unbearable, and with each attack she would vomit and could eat nothing at all. Her lower abdomen (shao fu) was painful and distended too.

💬 Note from Doctor Luo: This case is recorded in extraordinary detail — from the first visit on the 29th of the sixth lunar month through the follow-ups on the 14th of the seventh month, the 28th of the seventh month, and the 17th of the eighth month — the timeline is crystal clear, first, second, third visit. Why? Because Qing-dynasty physicians kept remarkably thorough case records, often writing down the entire course of treatment, so we can see the whole picture. Earlier records were extremely terse, and you had to squeeze meaning out of every crack between the characters. Reading a complete record makes learning clearer — though also more complicated, because patients don’t get sick according to the textbooks. A cold in the middle of treatment gets treated as a cold, overeating gets treated as food stagnation — the great physicians all adjust as they go.

How did this illness come about? — Bad emotions, plus a dose of autumn dryness

The root of this girl’s illness is written plainly in the record, in four characters: gan yu jian shou zao jin — liver constraint plus the assault of dryness-metal.

First, “liver constraint.” The girl was young, but her emotions had long been unsettled — stifled, quick to anger, unhappy inside. Doctor Luo Dalun says that if you read enough classical case records, a pattern emerges: in women’s illnesses, the story almost always begins with liver constraint (gan yu). Emotional problems cause an enormous number of gynecological and other diseases — this is something every woman should take seriously.

Second, “dryness-metal.” Doctor Wu Jutong was a master of warm-disease (wen bing) theory. When he discussed external pathogens, his Systematic Differentiation of Warm Diseases (《温病条辨》) lays out with complete clarity how dryness evil invades and works its way inward step by step. Dryness qi belongs to autumn; autumn belongs to the lung and to metal; metal controls wood, and wood corresponds to the liver. Now take a woman whose emotions are unsettled and whose liver qi is already not flowing — in autumn she catches dryness evil. Dryness injures the yin fluids and attacks the lung-metal; traveling further inward, it follows the metal-controls-wood pathway and attacks the liver-wood. So external evil and constrained liver qi became tangled together; over two or three years it grappled with the blood, clumped together with it, and became blood stasis.

💬 Note from Doctor Luo: The key word here is “dryness.” Dryness evil is the ruling qi of autumn, and it is not like the cold or damp evils you usually hear about — it injures yin fluids and can dry up the blood bit by bit. When blood dries, it thickens, congeals, and forms clumps. In this case, dryness evil + liver constraint + blood stasis — all three present — is what made a 19-year-old girl this ill. Doctor Wu Jutong always pays special attention to this doctrine of “dryness” in his records, and the pill formula later in this case was designed precisely for blood-dried, clumped masses.

Why did her lower abdomen hurt too? — The roadmap of the liver channel

The girl’s lower abdomen (shao fu) was both painful and distended. Does that relate to the periods and the uterus? Yes — but Chinese medicine has an even more elegant way of explaining it: the liver channel’s pathway runs downward, encircles the genitals, then continues along the inner thigh. That is why problems of the lower abdomen, the genital region and menstruation are intimately tied to the liver channel.

💬 Note from Doctor Luo: This is the beauty of Chinese medical theory. The lower abdomen, the genitals, the menses — all are governed by the liver channel. When the liver channel is blocked, problems appear all along that entire line. So you see, one touch of the pulse and Doctor Wu Jutong had his verdict: the disease lies in the liver. In women’s illness, regulate the liver — that has been the master principle of gynecology from ancient times to the present.

The treatment: first unblock the liver collaterals, then dissolve with pills over time

Doctor Wu Jutong had his own fixed strategy for blood stasis of the liver channel — a specialty of his, Doctor Luo says:

💬 Note from Doctor Luo: Doctor Wu Jutong’s method for liver-channel blood stasis runs: first, spread and unblock the liver collaterals — open up the collateral vessels of the liver; then harmonize with a decoction — use a boiled formula to smooth out qi and blood; then slowly unblock the yin collaterals with pills — finally, use a pill formula to dissolve, little by little, the residual blood stasis hiding in the finest collaterals. He used this sequence again and again in his case records — the previous case (the liver constraint/collateral disease case, number 267) and this one use almost identical formulas. Why do I keep coming back to it? So that everyone can memorize the great physicians’ habitual methods.

First, the decoction — a formula built on Xuanfu Flower Decoction, Doctor Wu Jutong’s most common combination for liver disease: xin jiang sha (newly dyed silk), xuan fu hua (inula flower) and jiang xiang (Dalbergia heartwood) as the core, with tao ren (peach kernel), chuan jiao tan (charred Sichuan peppercorn), dang gui xu (angelica rootlet), su zi shuang (perilla seed frost), jiang ban xia (ginger-processed pinellia), qing pi (green tangerine peel), guang chen pi (aged tangerine peel) and sheng jiang (fresh ginger) — boiled down to three cups, taken in three doses.

The prescription unpacked: herb by herb, every choice deliberate

• Xin jiang sha (newly dyed silk) — the soul of the formula. What exactly is xin jiang? In the Essentials from the Golden Cabinet (《金匮要略》), Zhang Zhongjing wrote “a little xin jiang” for Xuanfu Flower Decoction — and scholars have argued about it for over a thousand years. Some say it is qian cao (madder root), some say hong hua (safflower) or Tibetan saffron; the most credible explanation is new silk fabric dyed with madder and similar plants. Silk itself can dissolve stasis and unblock the collaterals, and madder is a prime blood-moving herb — the two together are the perfect pairing for collateral work;
• Xuan fu hua (inula flower) — the ancients said “of all the flowers, all rise — only xuan fu hua descends” (zhu hua jie sheng, xuan fu du jiang). Every flower’s qi travels upward; only inula flower goes downward. Your liver qi is rushing upward? It presses downward — descending qi and transforming phlegm, exactly on target;
• Jiang xiang (jiang zhen xiang, Dalbergia heartwood) — a fragrant wood from Hainan, it enters the liver channel, dissolves stasis, regulates qi and stops pain. Note it is not the same as chen xiang (agarwood): agarwood enters the spleen-stomach-kidney channels and chiefly treats heart and abdominal pain; jiang xiang enters the liver channel and specializes in dissolving liver-channel blood stasis. Doctor Wu Jutong used it constantly;
• Tao ren (peach kernel) — dissolves formed, tangible blood stasis; a standing guest in Zhongjing’s blood-moving formulas;
• Chuan jiao tan (Sichuan peppercorn, charred) — Sichuan peppercorn burned into charcoal warms the liver. Before stasis can be dissolved, the liver must first be warmed up; charcoal is gentle, and once charred black it enters the blood aspect — this is a signature move of Doctor Wu Jutong’s that other physicians rarely used;
• Dang gui xu (angelica rootlet) — the fine root of dang gui: it moves blood, unblocks the collaterals, and also nourishes the blood;
• Su zi shuang (perilla seed frost) — perilla seed descends lung qi and regulates qi, but perilla oil lubricates the intestines and can easily cause diarrhea, so Doctor Wu Jutong pressed the oil out and made it into “frost” — the qi-descending, qi-regulating action remains, but the laxative side effect is gone. Another of his clever inventions;
• Jiang ban xia (ginger-processed pinellia) — pinellia dries dampness and transforms phlegm; processed with ginger it becomes warming, better at transforming cold phlegm. Qing pi + chen pi together regulate qi and transform phlegm (qing pi breaks qi with greater force), with sheng jiang (fresh ginger) to warm the stomach.

💬 Note from Doctor Luo: Look at this formula — unblocking collaterals, regulating qi, warming the liver, nourishing the blood — not a single cold herb anywhere; everything is warm. The qi-regulating herbs smooth the qi, the collateral-unblocking herbs dissolve the stasis, dang gui xu nourishes as it opens, and chuan jiao tan warms the liver up. This is Doctor Wu Jutong’s experience formula, appearing again and again across his series of liver-disease cases. He never gave it a name himself — if I had to name it, I would call it the “Warm-the-Liver, Dissolve-Stasis Decoction.”

The secret weapon: Huazheng Huisheng Dan — a grand 36-herb pill

The decoction alone was not enough. Doctor Wu Jutong had one more ace up his sleeve — Huazheng Huisheng Dan (the Mass-Resolving Resurrection Pill), taken every morning at dawn, one qian (about 3 g) dissolved in warm water. This formula was his proud creation, appearing again and again in his treatment of women’s disorders.

💬 Note from Doctor Luo: Why the name “Huazheng Huisheng” — resolving masses, returning life? Doctor Wu Jutong explained it himself: when dryness evil penetrates deep into the lower burner and grapples with the blood aspect, it dries up the blood drop by drop; with less blood, and drier blood, it congeals into clumps — these are the “zheng jia ji ju” (abdominal masses). Whenever blood-dried clumps form, especially in the lower burner, this formula applies. Thirty-six herbs in all — Doctor Wu Jutong recited nearly the entire list in his record: ren shen (ginseng), an nan gui (Annam cinnamon), liang tou jian, she xiang (musk), pian zi jiang huang, gong ding xiang (clove), chuan jiao tan (charred Sichuan peppercorn) — the yang-warming wing; meng chong (gadfly, working in the qi aspect), pu huang tan (charred cattail pollen), zang hong hua (Tibetan saffron), su mu (sappan wood), tao ren (peach kernel), su zi shuang (perilla seed frost), wu ling zhi, jiang zhen xiang (Dalbergia heartwood), dang gui wei (angelica tail root) — the blood-moving, collateral-unblocking wing; plus bai shao (white peony) and shu di huang (prepared rehmannia) to nourish yin and kidney essence, yi mu gao (motherwort paste) to nourish yin and disperse water accumulation, and bie jia jiao (turtle shell glue) to tonify liver qi and dissolve masses; then xing ren, wu zhu yu, shui zhi (leech, working in the blood aspect), a wei (asafoetida), xiao hui xiang tan (charred fennel), chuan xiong, ru xiang (frankincense), liang jiang (galangal) and ai tan (charred mugwort), and finally da huang (rhubarb) decocted in vinegar to guide the medicine to the seat of disease without harming other organs; the whole mass is then set into pills with turtle shell glue, motherwort paste and the vinegar-reduced rhubarb. Blood-eating insects plus vinegar-decocted rhubarb — penetrating everywhere, breaking what nothing else can break. Such compositional daring could only come from a master of warm-disease theory.

What does this formula treat? Doctor Wu Jutong listed 14 indications in one breath:

1. Zheng masses in the abdomen that neither disperse nor hurt;
2. Zheng masses with violent pain;
3. Blood bi — pain from blood stasis blocking the circulation;
4. Women’s gan xue lao (dry blood consumption) of the excess type — the “dry blood consumption” in which the blood is so depleted the person becomes skin and bones, wasting away as if consumptive; so long as there is a blockage inside, this formula applies — once the stasis opens and the blood flows, the person stops drying up;
5. Nue mu — a mass under the left ribs with alternating chills and fever;
6. Women’s pain before the period — menstrual cramps;
7. Women who run hot and cold as the period approaches — like a fever coming on, the “heat entering the blood chamber” type; the stasis must be dissolved before the heat can clear;
8. Women who, as the period approaches, eat something cold by mistake and get abdominal pain;
9. Women’s amenorrhea caused by blood stasis and accumulations;
10. Women whose menses come purple-black, even in clots — exactly this patient’s situation;
11. Low back pain from falls, sprains and knocks with dead blood inside;
12. Postpartum blood stasis, with lower abdominal pain that worsens on pressure (pain on pressing is ironclad evidence of stasis);
13. Fainting near death from a fall, unable to come around for half a day;
14. Sword wounds and beating wounds with stasis.

💬 Note from Doctor Luo: Some people ask — doesn’t treatment favor few herbs and large doses? Doctor Wu Jutong’s answer: that is for acute conditions. Dissolving a mass is different — think of a great block of ice: try to split it with one axe blow and you are asking for trouble; you can only melt it slowly. Hence many herbs, used over a long time, dissolving the mass day by day. Sadly, Huazheng Huisheng Dan never spread widely in later generations — with so many ingredients, no pharmaceutical factory was willing to make it, and today there is almost no major manufacturer producing it; only private hands make it, with quality hard to vouch for. By contrast, Doctor Wu Jutong’s other famous formula is known all over the world — Angong Niuhuang Wan (Bezoar Resurrection Pill), which genuinely works in phlegm-heat coma and stroke. But remember: it works only when there is genuine phlegm-heat. Some marketing nowadays claims that taking one pill at each solar term “regulates the body” — that is pure nonsense. Doctor Wu Jutong left far more than Angong Niuhuang Wan; it is a pity the rest of his formulas are not being made.

The twists of treatment: fourteen days, then another fourteen

The prescription was written and the girl began taking it — 7 doses of the decoction, spread over 14 days, with one qian (about 3 g) of Huazheng Huisheng Dan every morning on waking. Why at dawn? Doctor Luo explains:

💬 Note from Doctor Luo: In the morning, yang qi rises. Ride the momentum of rising yang to dissolve the blood stasis — half the work, twice the effect. That is why the pill was fixed for early morning, dissolved in warm water, one qian at a time — a small dose, but persistence is the key.

• Follow-up, 14th of the 7th lunar month: all symptoms reduced — everything was lighter. The original formula, 7 more doses over 14 days, with Huazheng Huisheng Dan every morning as before;
• Follow-up, 28th of the 7th lunar month: pain stopped, distension gone — the flanks no longer hurt and the bloated feeling vanished; appetite greatly increased — where she used to vomit at the first mouthful and eat nothing, now she ate better and better. But the menses still had not come. The pulse was stringlike and fine at all six positions, with the right pulse shorter and tighter.

Doctor Wu Jutong did not rush to force the menses. He saw a new problem: the right pulse governs qi and yang; a short, tight right pulse means the middle qi and yang qi are still insufficient. So he changed the formula — Huangqi Jianzhong Tang combined with Er Chen Tang (minus fu ling), boiled down to two cups taken in two doses, with Huazheng Huisheng Dan still one qian every morning.

Jianzhong Tang: the riverbed is cleared — but where does the water come from?

Why switch to Jianzhong Tang at this point?

💬 Note from Doctor Luo: Chinese medicine asks: where does blood come from? The spleen and stomach generate it. The spleen and stomach are the source of qi and blood production; when they are weak, the essence of food and drink cannot transform into blood, and the menses will not come. Doctor Wu Jutong’s sense of treatment layering is on display here: while stasis was blocking, he first unblocked the collaterals and dissolved the stasis — like clearing out a riverbed; with the riverbed clear, but the river empty — the water source is the spleen and stomach — now he had to tonify the spleen and stomach to bring the water in. Step one dissolves stasis, step two tonifies the spleen — one step at a time, perfectly clear.

Jianzhong Tang is Zhang Zhongjing’s formula: gui zhi (cassia twig), shao yao (peony), zhi gan cao (honey-fried licorice), sheng jiang (fresh ginger), da zao (jujube), plus yi tang (malt sugar). It strengthens the spleen and stomach, harmonizes the liver (bai shao astringes yin and softens the liver), and unblocks yang; the yi tang, made by boiling grains, itself tonifies the spleen and stomach and lets the medicine linger there a little longer — it cannot be omitted. I have discussed how Huangqi Jianzhong Tang works wonderfully for stomach disease and gastric ulcers — this is the same path. The Er Chen Tang (ban xia and chen pi) added to it is the ancestral formula for transforming phlegm, used here to transform the phlegm-dampness in the spleen and stomach — and Doctor Wu Jutong deliberately left out fu ling to lighten the spleen and stomach’s load.

• Follow-up, 17th of the 8th lunar month: after about ten doses of the new formula plus another ten-plus days of Huazheng Huisheng Dan — everything was excellent, and the menses flowed abundantly. Her whole condition was restored; her period came normally, freely and smoothly, with a normal volume.

What can we learn from this case?

From the 29th of the sixth lunar month to the 17th of the eighth lunar month — in under two months, a 19-year-old girl who had stopped menstruating and could not eat from rib pain was restored to pain gone, distension resolved, appetite soaring, menses flowing again. Doctor Wu Jutong observed finely and recorded finely; and what we learn is far more than one formula:

💬 Note from Doctor Luo: This case has three layers of skill worth savoring again and again. Layer one: at the start, regulate qi and unblock the collaterals, paired with Huazheng Huisheng Dan — nourishing the blood and dissolving stasis at the same time. You say your blood is deficient? I nourish it on one side while dissolving slowly on the other — the stasis melts without the blood being depleted. Layer two: once the pain stopped and the stasis dissolved, he immediately turned to tonifying the spleen and stomach, letting the essence of food and drink generate fresh blood — and only then did the menses flow. Layer three: throughout, treating the liver never meant forgetting the emotions — for women, the spleen-stomach and the emotions matter enormously. Deficient blood, stagnant blood, and constrained liver qi all at once — that is the most stubborn of diseases. Conversely, if you do not nurse anger, if your spleen and stomach are strong, if your blood is well nourished and your channels and collaterals stay open — you will never become this ill. This is the greatest harvest from watching a great physician at work: knowing what to protect and what to watch out for.

This case is a model of Doctor Wu Jutong’s treatment of blocked channels in women — regulating qi, dissolving stasis, nourishing blood, strengthening the spleen, each link joined to the next. It is worth saving and rereading.

Compiled from Doctor Luo Dalun’s commentary on the case records of Doctor Wu Jutong; the case is from Wu Jutong’s Case Records (《吴鞠通医案》).