Miscellaneous

According to The Merck Manual1 irritable bowel syndrome (IBS) is defined as a motility disorder of the small and large intestines associated with variable degrees of abdominal pain, constipation, and/or diarrhea largely as a reaction to stress. This syndrome represents approximately half of all GI referrals or initial GI complaints in both private practice and institutional care facilities. Women suffer from this condition three times more often then men. Other symptoms include abdominal bloating, flatulence, nausea, headache, fatigue, lassitude, depression, anxiety, and difficulty concentrating. Modern Western medicine divides this syndrome into two patterns: 1) spastic colon type accompanied by abdominal pain and 2) the painless diarrhea type. In this article, I am primarily discussing the spastic colon type of IBS.

IBS is a commonly discussed condition in modern Chinese medical journals from the People's Republic of China2. One of the interesting things about these articles is the degree of uniformity of Chinese opinion about the spastic colon type of this disease. Virtually all of the Chinese journal articles I have read and translated on this condition agree that it is due to a liver-spleen disharmony which then may be complicated by a number of other disease mechanisms. In this case, a liver-spleen disharmony means liver depression qi stagnation and spleen qi vacuity. The abdominal cramping, flatulence, pain, constipation, and emotional depression are due to liver depression, while the diarrhea, fatigue, lassitude, and poor concentration are due to the spleen qi vacuity. In terms of tongue and pulse signs, a bowstring pulse3 signifies the liver depression, and a swollen tongue with teethmarks on its edges and possible cracks on its surface indicate the spleen qi vacuity. In addition, women with liver depression typically have premenstrual or perimenstrual breast distention and pain and/or painful menstruation as well as other menstrual irregularities. Further, most women with spleen qi vacuity will have cold hands and nose, orthostatic hypotension, and may bruise easily due to the spleen qi not holding the blood within its channels.

In my own 22 years of clinical experience treating Western female patients with IBS, the overwhelming majority have suffered from liver-spleen disharmony complicated by damp heat in the stomach and intestines. In this case, the above signs and symptoms are complicated by bright yellowish (if spleen qi is most pronounced), greenish (if liver qi is most pronounced), or dark, odorous stools (if damp heat is most pronounced), burning around the anus, mouth and tongue sores, bleeding gums, thirst, and a tendency to damp heat vaginitis, damp heat cystitis, damp heat skin conditions, and damp heat impediment conditions. The pulse is bowstring and slippery (at least in some positions) and may be rapid (typically it is not slow), while the tongue fur is slimy and also possibly but not necessarily yellow, at least at the root. Although poor appetite is a textbook symptom of spleen qi vacuity, when there is heat in the stomach, the appetite may not be poor and may even be excessive. Due to damp heat in the yang ming, there is often yang ming channel premenstrual acne in women.

According to Chinese medical theory, women are more prone to spleen vacuity than men due to blood loss and consumption in turn associated with menstruation, gestation, and lactation. One of the functions of the spleen is to engender qi and blood. Therefore, if the spleen is vacuous and weak, blood may be scanty and insufficient. In women, the blood gathers in the uterus during the premenstruum. If their blood is scanty, this may leave the liver malnourished by blood during this time in the menstrual cycle. The Nei Jing (Inner Classic) says that all organs and tissues can only function when they obtain blood to nourish them. The liver's main function is the control of coursing and discharge. If the liver is malnourished premenstrually, the liver's function of coursing and discharging may be impaired, thus leading to or aggravating liver depression qi stagnation. If such a liver-spleen disharmony is not too serious, it commonly causes constipation with slow or difficult defecation, but not necessarily hard, dry stools. When this disharmony becomes more severe just before or at the onset of menstruation, such constipation commonly swings to loose stools or diarrhea.

In addition, dampness tends to accumulate in the lower burner during the premenstruum. This is explained by the following Chinese medical facts: Blood and fluids move together. The blood is sent down to the uterus by the heart via the bao mai. Blood is thicker than fluids. Therefore, fluids tend to arrive in the lower burner before the blood. Dampness then obstructs the free flow of yang qi, and thus damp depression may transform into damp heat. According to Li Dong-yuan, the heat of damp heat (i.e., yin fire) wafting upward may further damage the spleen qi.

The overwhelming majority of Chinese authors recommend Tong Xie Yao Fang as the guiding prescription for IBS of the spastic colon type. However, when complicated by damp heat, this must be modified by various additions and subtractions. Ban Xia Xie Xin Tang (Pinellia Drain the Heart Decoction) is also a harmonizing formula, but one which treats damp heat in the stomach and intestines. Likewise, the famous harmonizing formula, Xiao Chai Hu Tang (Minor Bupleurum Decoction) treats both a liver-spleen and a spleen-stomach and intestine disharmony. When these three formulas are combined, they form an especially good combination for the majority of Western IBS sufferers.

However, when there is spleen vacuity, liver depression, and damp heat, there is often also chong or parasites in the intestines, remembering that Candida albicans and other such yeasts and fungi are defined as chong in Chinese medicine. Heiner Fruehauf has published some very interesting research on Qing dynasty gu chong theory and therapy4. In this article, Dr. Fruehauf makes a case for some Chinese medicinals having a stronger regularizing effect on the intestinal fauna and flora than others. Dr. Fruehauf refers to these as special anti-gu medicinals. Some of these include Radix Angelicae Dahuricae (Bai Zhi), Radix Polygoni Multiflori (He Shou Wu), Fructus Forsythiae Suspensae (Lian Qiao), Folium Perillae Frutescentis (Zi Su Ye), Herba Menthae Haplocalycis (Bo He), and Fructus Pruni Mume (Wu Mei).

The Qing dynasty Yan Fang Xin Bian (A New Compilation of Tested Formulas) contains an anti-gu formula called Su He Tang (Perilla & Mentha Decoction). The ingredients in this formula include a number of the anti-gu medicinals described by Dr. Fruehauf above. If one looks at these from a standard modern Chinese medical perspective, these are either spleen supplements, blood supplements, exterior-resolvers/qi-rectifiers, anti-parasitics, or damp and heat clearing and eliminating medicinals, or, in other words, the very classes of Chinese medicinals indicated for a liver-spleen disharmony complicated by blood vacuity and damp heat with chong. Therefore, in designing the formula Modified Perilla & Mentha (Jia Jian Su He Tang), I have taken this prescription and modified it with ingredients from and the rationales behind the three other formulas discussed above. As Qin Bo-wei, one of the architects of modern Chinese medicine said, "When I say to use Liu Wei Di Huang Wan (Six Flavors Rehmannia Pills), I mean for you to use the idea of Liu Wei Di Huang Wan, not necessarily the ingredients of Liu Wei Di Huang Wan."

This formula has proven very effective in a number of Western clinics for treating IBS complicated by intestinal dysbiosis or altered bowel ecology and leaky gut syndrome in patients where the Chinese pattern discrimination is liver depression, spleen qi vacuity, and damp heat with gu or chong. However, in order to get a good effect with this formula, it is important that it be prescribed based on the Chinese pattern discrimination and not solely on Western diagnoses of candidiasis, leaky gut syndrome, parasites, or intestinal dysbiosis. Please see the Blue Poppy Herb catalog for further information on combining this formula with other commonly available Chinese ready-made or "patent" medicines in order to extend and modify its therapeutic range. Also, when using this formula, adherence to a clear, bland diet with no or extremely little sugar and sweets is essential to getting a fully satisfactory treatment effect. Without support by a hypoallergenic, yeast-free, sugar-free diet, simply taking this formula will not achieve either speedy or complete therapeutic results. I discuss the clear, bland diet of Chinese medicine and hypoallergenic, yeast-free foods in Blue Poppy Seminars' Distance Learning Program on Chinese Dietary Therapy as well as in my book, The Tao of Healthy Eating available from Blue Poppy Press.

For more information on key ingredients in this formula (Perilla & Mume), leaky gut syndrome, intestinal dysbiosis, candidiasis, parasites, gu, and yin fire, please see my other articles posted on these subjects at this same Web site.

For More Information...

Check Out these Blue Poppy Products:

The Treatment of Diseases in TCM, Vol. 6
Blue Poppy Seminars Digestive Diseases Distance Learning Program

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1 The Merck Manual of Diagnosis & Therapy, 15th Edition, Robert Berkow, ed., Merck Sharp & Dohme Research Laboratories, Rahway, NJ, 1987, p. 808-810

2 To sample English translations of a number of such Chinese IBS articles, please see the Blue Poppy Press Recent Research Report on Irritable Bowel Syndrome.

3 The xian mai, what Nigel Wiseman refers to as the stringlike pulse and which may Westerners refers to as the wiry pulse.

4 Fruehauf, Heiner, "Driving Out Demons & Snakes," Journal of Chinese Medicine, UK, #57, May, 1998, p. 10-17

Blue Poppy Herbs uses isopropyl alcohol in its liniments and tinctures for two reasons: 1) its price and 2) Alcohol, Tobacco & Firearms Bureau (ATFB) red tape. Over the years, we have tried to buy ethyl alcohol, so-called drinking alcohol, for use in the manufacture of our products. However, we have not be able to find a cost-effective wholesale source. In addition, because ethyl alcohol is "drinking" alcohol, there are numerous licenses and rules and regulations regarding its purchase and resale, even for remedies meant for external application only. Therefore, because isopropyl alcohol is easily available, cost-effective, and its repackaging and sale do not require Federal and/or State licensing and also because it is used in a number of other commonly sold products meant for external application, we have chosen isopropyl alcohol as the medium for our liniments and tinctures. Isopropyl alcohol is manufactured and sold for application to human skin for the express purposes of disinfection and as a rubifacient. Another name in trade for isopropyl alcohol is "rubbing alcohol." It is also found in various cosmetics. Isopropyl alcohol is sold for these purposes and in such products in grocery and drugstores without caution or limitation across America.

In Chinese medicine, alcohol, including isopropyl alcohol, is considered acrid, bitter, and hot. It enters all the channels and vessels of the entire body. It strongly moves the qi and quickens the blood. It also potentizes other medicinals that are combined with it. Therefore, alcohol has been used for thousands of years in Chinese medicine as a medium for external medications and especially for those intended for the treatment of pain and traumatic injury. In this case, the alcohol itself is considered not just the medium but an active ingredient in the formula.

Recently, Dr. Hulda Clark, ND, has raised concerns over isopropyl alcohol's safety even when ony used externally. Dr. Clark is the author of a popular book titled A Cure for All Cancers. In it, Dr. Clark says that she has found traces of isopropyl alcohol in the livers of numerous patients with cancers of various sorts. However, she does not explain how the isopropyl alcohol arrived in these patients' livers nor any causal relationship between it an these patients' cancers. As Dr. Clark herself admits, her research has been turned down as lacking merit by at least three juries of experts at major American medical journals. Dr. Clark's book title should cause concern in the mind of any professional health care practitioner.

Nevertheless, because of the concerns Dr. Clark has raised about the safety of externally applied isopropyl alcohol, we have tried to do our own independent research. What we have found is that, according to the best scientific data available at this time, isopropyl alcohol is not a carcinogen when used externally. Nasal cancers found in workers in factories where this type of alcohol is produced are due not to the isopropyl alcohol itself but to the strong acid used in its manufacture. The "Material Safety Data Sheet" on Hibiclens® (which contains isopropyl alcohol as a main ingredient) published by ICI Americas, Inc. states:

The manufacture of isopropyl alcohol by the strong acid process is associated with paranasal sinus and laryngeal cancer in man. No other information or data have linked isopropyl alcohol with cancer.1

Likewise, David Kailin, Lic. Ac. and Ph.D. in Public Health, unequivocally says, "There is no evidence that Isopropyl Alcohol is a carcinogen."2 Further, the lawyers at McGhee & Pianelli, L.L.P., corroborate that it is the production of isopropyl alcohol that is potentially carcinogenic,3 not its external use.

www.caretechlabs.com/MSDS/HIBICLENS_MSDS.htm, p. 4 Kailin, David, Acupuncture Risk Management, CMS Press, Corvallis, OR, 1977, p. 259 "Cancer Causing Agents, Exposure and Site of Cancer," McGhee & Pianelli, L.L.P., http://lawtx.com/cancer.html, p. 2

All Blue Poppy Herbs' products containing isopropyl alcohol are meant for external application only, and we believe these products are safe when used as instructed. Because isopropyl alcohol may cause skin irritation in some persons, it should only be applied to a small area at first in order to test the patient's personal reaction. It should then be applied to larger areas only if the patient does not have an adverse reaction. Patients who know they are adversely sensitive to isopropyl alcohol should not use these products.

We believe that Dr. Clark's suggestion that externally applied isopropyl alcohol is carcinogenic is scientifically unfounded, and we would certainly not manufacture our products with this ingredient if we thought it was carcinogenic. Nevertheless, we promise to keep an eye on this issue. Our customers can rest assured that we will discontinue the manufacture and sale of any product found to contain a proven carcinogen. Till then, we believe Blue Poppy Herbs' liniments and tinctures are safe when used as instructed. As the ever-increasing sale of these products suggest, many patients and practitioners alike are finding them very useful.

Keywords: Chinese medicine, liver depression

(From "The Treatment of 42 Cases of Meniere’s Disease with Ling Gui Zhu Gan Tang Jia Wei [Poria, Cinnamon, Atractylodes & Licorice Decoction with Added Flavors," by Xie Shou-liang, Hu Nan Zhong Yi Za Zhi [Hunan Journal of Chinese Medicine], #1, 2000, p. 26)

From Jun. 1984 to Jul. 1999, the author of this study treated 42 cases of Meniere’s disease with Ling Gui Zhu Gan Tang Jie Wei. The author then compared these outcomes with 30 cases of Meniere’s disease treated with 654-2 (an unidentified ready-made medicine in injectible form) combined with  Xi Bi Ling (an unidentified ready-made medicine in capsule form).

Cohort description:

Altogether, there were 72 patients in this study, with 42 in the treatment group and 30 in the comparison group. Of the 42 patients in the treatment group, 25 were male and 17 were female. The oldest was 65 and the youngest was 22 years old, with a median age of 46. The shortest course of disease was two days and the longest was 10 years. Of the 30 patients in the comparison group, 17 were male and 13 were female. They ranged in age from 68-20, with a median age of 48 years. The shortest course of disease in this group was three days and the longest was eight years. Therefore, there was no marked statistical difference in terms of sex, age, or disease duration between these two groups (P , 0.05). Diagnoses was based on history, clinical symptoms, and examination. Criteria for diagnosis were based on the Shanghai Medical University’s Shi Yong Nei Ke Xue (A Study of Practical Internal Medicine) published by the People’s Health & Hygiene Press.

Treatment method:

The treatment group received Ling Gui Zhu Gan Tang Jia Wei: Sclerotium Poriae Cocos (Fu Ling), 20g, Ramulus Cinnamomi Cassiae (Gui Zhi), 10g, Rhizoma Atractylodis Macrocephalae (Bai Zhu), 12g, Radix Glycyrrhizae (Gan Cao), 9g, Rhizoma Alismatis (Ze Xie), 30g, lime-processed Rhizoma Pinelliae Ternatae (Ban Xia), 18g, uncooked Rhizoma Zingiberis (Sheng Jiang), 12g, Pericarpium Citri Reticulatae (Chen Pi), 12g, uncooked Os Draconis (Long Gu), 30g, and uncooked Concha Ostreae (Mu Li), 30g. One ji of these medicinals was boiled in water two times and the two decoctions were then taken in three divided doses per day. If there was severe vomiting, electrolytes and fluids were intravenously replaced.

The comparsion group received Xi Bi Ling Jiao Nong (Xi Bi Ling Capsules), 10mg, each evening before going to bed. In addition, they received 10mg of 654-2 by intramuscular injection three times per day. If there was severe vomiting, electrolytes and fluids were intravenously replaced. Ten days equaled one course of treatment for both groups.

Treatment outcomes:

Cure meant that all the symptoms basically disappeared. Improvement meant that the clinical symptoms partially disappeared or improved. No effect meant that, after one course of treatment, there was no marked improvement in symptoms. Based on these criteria, in the treatment group, 33 cases were cured, eight improved, and only one experienced no effect. Thus the total amelioration rate in the treatment group was 97.6%. In the comparison group, 19 cases were cured, five improved, and six got no effect. Therefore, the total amelioration rate in that group was 80.0%. Hence statistical difference in outcomes between these two groups was marked (P + 0.05).

Author’s discussion:

According to the author, Meniere’s disease corresponds to the traditional Chinese disease category of "dizziness and vertigo." As Zhu Dan-xi said, "No phlegm, no dizziness." This clearly explains that most cases of this disease result from phlegm dampness obstructing and stagnating the clear orifices. The Jin Gui Yao Lue (Essentials from the Golden Cabinet) says, "For diseases [due to] phlegm rheum, one should use warm medicinals to harmonize them," and, "If one has slight rheum, one should expel this via urination." This formula uses Cinnamon Twigs, Poria, Atractylodes Macrocephala, Pinellia, Orange Peel, uncooked Ginger, and Licorice to warm yang and transform rheum, dry dampness and transform phlegm, rectify the qi and harmonize the center. In addition, the author uses large doses of Poria and Alisma to disinhibit water and seep or percolate dampness in order to clean the clear orifices. He then also adds uncooked Dragon Bone and Oyster Shell in order to settle, still, and quiet the spirit. When all these

medicinals are used together, their effect is to transform phlegm, harmonize the center, and quiet the spirit.

(From "The Treatment of 25 Cases of Meniere’s Syndrome with the Two Step Method," by Luo Shi-wei, Si Chuan Zhong Yi [Sichuan Chinese Medicine], #2, 2000, p. 34)

The authors of this article treated 25 cases of Meniere’s syndrome with the two step method with fully satisfactory treatment efficacy as described below.

Cohort description:

All 25 patients in this study were seen as out-patients. Of the 25, 11 were male and 14 were female. They ranged in age from 30-65 years old, and their course of disease had lasted from 1-6 years. All the patients had been diagnosed by Western medicine as having Meniere’s syndrome, and 20 patients had been previously treated with Western medicinals without marked treatment results.

Treatment method:

Step one consisted of taking Huo Chai Tang (Agastaches & Bupleurum Decoction) with additions and subtractions: Herba Agastachis Seu Pogostemi (Huo Xiang), Radix Bupleuri (Chai Hu), and Radix Angelicae Dahuricae (Bai Zhi), 10g each, Rhizoma Atractylodis Macrocephalae (Bai Zhu), Sclerotium Poriae Cocos (Fu Ling), Radix Platycodi Grandiflori (Jie Geng), lime-processed Rhizoma Pinelliae Ternatae (Ban Xia), Cortex Magnoliae Offiicinalis (Hou Po), and Radix Scutellariae Baicalensis (Huang Qin), 15g each, Radix Codonopsitis Pilosulae (Dang Shen), 30g, Folium Perillae Frutescentis (Zi Su Ye), Pericarpium Citri Reticulatae (Chen Pi), and uncooked Rhizoma Zingiberis (Sheng Jiang), 6g each. One ji was administered per day after being boiled in water and divided into three doses. This was continuously administered for 2-3 ji.

Step two consisted of taking self-composed Nei Er Xuan Yun Tang (Inner Ear Dizziness Decoction): Semen Plantaginis (Che Qian Zi), Radix Achyranthis Bidentatae (Niu Xi), and Spica Prunellae Vulgaris (Xia Ku Cao), 12g each, Sclerotium Poriae Cocos (Fu Ling), lime-processed Rhizoma Pinelliae Ternatae (Ban Xia), Fructus Lycii Chinensis (Gou Qi Zi), and uncooked Magnetitum (Ci Shi), 15g each, Flos Chrysanthemi Morifolii (Ju Hua) and Pericarpium Citri Reticulatae (Chen Pi), 10g each. One ji was administered per day after being boiled in water and divided into three doses. Seven days equaled one course of treatment, and typically two such courses were given before seeing treatment effects. During this treatment, patients were forbidden to eat acrid, peppery, uncooked, chilled, or oily, slimy, stimulating foods.

Treatment outcomes:

Using this protocol, 22 patients were cured. This meant that their dizziness and vertigo, tinnitus, and vomiting disappeared and there was no recurrence on follow-up after one year. The other four cases improved. This meant that their clinical symptoms markedly improved even though they did not disappear.

Author‘s discussion:

This disease is characterized by a prolonged course and frequent relapses. It is categorized in Chinese medicine as "dizziness" and "vomiting." Most Chinese doctors think that the disease mechanisms at work in this condition are a loss of regulation in the function of the liver, spleen, and kidneys with counterflow and chaos of the qi mechanism. This results in the qi of phlegm turbidity harassing above. However, the authr thinks that most cases are due to excessive taxation fatigue and psychoemotional stress allowing for external invasion. Therefore, he first gives Huo Chai Tang to A) dispel and eliminate external evils and B) regulate and rectify the liver-gallbladder and spleen-stomach qi mechanism, thus treating the branch condition. Then he uses Nei Er Xuan Yun Tang to level the liver and downbear counterflow, fortify the spleen, transform phlegm, and eliminate dampness to treat the root. After this treatment, if there is a liver-kidney insufficiency, he consolidates the treatment effects and prevents recurrence by prescribing Qi Ju Di Huang Wan (Lycium & Chrysanthemum Rehmannia Pills). If there is spleen-stomach insufficiency, he prescribes Bu Zhong Yi Qi Wan (Supplement the Center & Boost the Qi Pills) with Xiang Sha Yang Wei Wan (Auklandia & Amomum Nourish the Stomach Pills).

Functionally translated by Bob Flaws. Copyright © Blue Poppy Press, 2000. All rights reserved.

translated & abstracted by

Bob Flaws, Dipl. Ac. & C.H., FNAAOM, FRCHM

Keywords: Chinese medicine, Chinese herbal medicine, autoimmune disease, autoimmune fever, systemic lupus erythmatosus, myasthenia gravis, nephrotic syndrome, rheumatoid arthritis, Xiao Chai Hu Tang

(From Li Guang-wen’s “Experiences Treating Autoimmune Fever with Xiao Chai Hu Tang [Minor Bupleurum Decoction],” Zhe Jiang Zhong Yi Za Zhi (Zhejiang Journal of Chinese Medicine), #10, 2001, p. 450-451)

According to Dr. Li, autoimmune diseases are typically characterized by a systemic bodily vacuity with replete tips or branches. In addition, there is easy contraction of external evils. However, unwarranted and/or prolonged use of bitter, cold medicinals may greatly damage the righteous qi, leading to a worsening of the patient’s overall condition. Xiao Chai Hu Tang’s nature is mild, level (or neutral), and harmonious. Its function is to harmonize and resolve the shao yang, and its key point is that it clears and discharges heat from the pivot mechanism. Therefore, Dr. Li commonly uses this formula for the treatment of autoimmune fevers. Below are four case histories which exemplify Li’s use of this formula in the treatment of this sort of condition.

Systemic lupus erythmatosus (SLE)

The patient was a 29 year old female who was initially examined on Feb. 28, 2001. The patient had been diagnosed with SLE for nine years. During the last half year, she had stopped taking Prednisone, had begun using Chinese medicinals, and her disease condition was relatively stable. However, in the previous month, she had developed a sore throat accompanied by fever which was lower during the day but higher at night. This febrile condition had occurred secondary to the development of an infection in an acne lesion. The patient went to her local hospital where she was treated with bitter cold Chinese medicinals administered intravenously but without effect. When examined by Dr. Li, the patient’s temperature was 39.4E C. This was accompanied by generalized muscular aching, lassitude of the spirit, loss of strength, a dry mouth with a slightly bitter taste, torpid intake, dry stool, nose-bleeding, and slightly yellow urine. There were small red macules on either side of her nose as well as on the backs of both hands. In addition, there was bilateral submaxillary lymph node enlargement, a red throat, a red tongue with scanty fur, and a fine, rapid pulse. White blood cells were 16.7 x 10⁹, lymphocytes were 0.5, and blood sedimentation was 30mm/L.

Based on these findings, Dr. Li prescribed the following modification of Xiao Chai Hu Tang: Radix Bupleuri (Chai Hu), Radix Scutellariae Baicalensis (Huang Qin), and Rhizoma Polygoni Bistortae (Zhong Lou), 12g each, Rhizoma Pinelliae Ternatae (Ban Xia) and Radix Lithospermi Seu Arnebiae (Zi Cao), 15g each, Fructus Forysthiae Suspensae (Lian Qiao), Radix Puerariae (Ge Gen), Semen Plantaginis (Che Qian Zi), Radix Isatidis Seu Baphicacanthi (Ban Lan Gen), and Rhizoma Imperatae Cylindricae (Bai Mao Gen), 30g each, uncooked Gypsum Fibrosum (Shi Gao), 35g, and Radix Glycyrrhizae (Gan Cao), 3g. One ji of these medicinals was decocted in water and administered four times per day. After seven ji, the red macules on the patient’s face and back of her hands had faded in color, the nose-bleeding had stopped, the fever had abated, and all the other symptoms were less. In addition, all the blood levels had returned to normal. Therefore, Dr. Li used the methods of fortifying the spleen and boosting the kidneys, enriching yin and cooling the blood in order to treat the root.

According to Dr. Li, the disease mechanism of SLE is qi and yin dual vacuity with kidney essence insufficiency. In this patient’s case, infection of epidemic toxins secondary to a ruptured acne lesion had combined with internal vacuity fire to produce heat toxins which had harassed the patient’s constructive aspect or division, forcing the blood to move frenetically and thus resulting in the nose-bleed and the red skin macules. Therefore, treatment in this case should clear heat and resolve toxins, cool the blood and disperse macules which, in fact, resulted in eliminating the fever.

Myasthenia gravis

The patient was a 31 year old male who was first examined on Feb. 28, 2000. The patient had been diagnosed with myasthenia gravis for a number of years. In 1992, he had been treated with integrated Chinese-Western medicine and judged cured. In 1998, after a long period of drinking alcohol, his disease had relapsed and he was treated systemically again. At the time of being seen by Dr. Li, the man was caught a cold. He had a fever of 40.2E C accompanied by alternating fever and chills, head clouding, oppression, and pain, ptosis of the right upper eyelid, double vision, lack of strength in the extremities, sore throat, torpid intake, poor sleep, and yellow urine. His tongue was pale red with thin, white fur, and his pulse was deep, fine, and rapid.

Based on the above, Dr. Li prescribed the following modification of Xiao Chai Hu Tang: Radix Bupleuri (Chai Hu), Radix Scutellariae Baicalensis (Huang Qin), and Folium Bambusae (Zhu Ye), 12g each, Rhizoma Pinelliae Ternatae (Ban Xia), 15g, Fructus Forsythiae Suspensae (Lian Qiao), Radix Puerariae (Ge Gen), Semen Plantaginis (Che Qian Zi), Radix Isatidis Seu Baphicacanthi (Ban Lan Gen), and Herba Houttuyniae Cordatae Cum Radice (Yu Xing Cao), 30g each, Talcum (Hua Shi), 18g, uncooked Gypsum Fibrosum (Shi Gao), 60g, and Radix Glycyrrhizae (Gan Cao), 3g. Two ji of these medicinals were adminsitered per day in six divided doses. The next day, the patient’s temperature had returned to normal and all his other symptoms were decreased. Therefore, another ji of above medicinals were prescribed without Shi Gao but plus 25 grams of white Radix Panacis Ginseng (Bai Tiao Shen). These were administered in three divided doses. After three ji of these medicinals, he was treated with the principles of fortifying the spleen and boosting the kidneys to complete the cure.

The disease mechanisms of myasthenia gravis are typically a downward falling of the central qi plus liver-kidney insufficiency. In this case, the patient’s righteous qi was not able to overcome evils, and external evils had taken advantage of vacuity to enter. these evils resided in the exterior but had also reached the interior. Hence the shao yang pivot mechanism was inhibited and evil heat had become hyperactive and exuberant. According to Dr. Li, treatment in this case should clear heat and resolve toxins, harmonize and resolve the shao yang. Because the medicinals and the pattern mutually coincided, the man’s temperature returned to normal.    

Nephrotic syndrome

The patient was a six year old male who was first examined on Apr. 3, 2000. The patient had been diagnosed with nephrotic syndrome for three years for which he had been administered Prednisone and Chinese medicinals. Three days before, after catching cold, the patient had developed a fever of 40.5E C. This was accompanied by headache, a bland affect, fatigue, difficulty sleeping, a puffy, edematous face and limbs, torpid intake, a tendency to dry stool, and yellow, turbid, frothy urine. This tongue was red with thin, white fur and teeth-marks on its edges, while his pulse was deep and rapid. Urine examination revealed urinary protein (++), erythrocytes (+), and leukocytes (+++).

Based on the above, Dr. Li prescribed the following version of Xiao Chai Hu Tang: Radix Bupleuri (Chai Hu), Radix Scutellariae Baicalensis (Huang Qin), and Folium Bambusae (Zhu Ye), 10g each, Rhizoma Pinelliae Ternatae (Ban Xia), 12g, Fructus Forsythiae Suspensae (Lian Qiao), Radix Puerariae (Ge Gen), Semen Plantaginis (Che Qian Zi), Herba Leonuri Heterophylli (Yi Mu Cao), Rhizoma Imperatae Cylindricae (Bai Mao Gen), and Nodus Rhizomatis Nelumbinis (Ou Jie), 15g each, uncooked Gypsum Fibrosum (Shi Gao), 30g, and Radix Glycyrrhizae (Gan Cao), 3g. One ji of these medicinals was administered per day in four divided doses. After two ji, the patient’s temperature gradually descended. Therefore, 15 grams of Shi Gao were removed from the formula and 30 grams of Radix Astragali Membranacei (Huang Qi) were added. After five ji of this formula, the boy’s temperature returned to normal and all his other symptoms were greatly reduced. Urine examination showed protein (+) and WBCs slightly elevated. Therefore, the patient’s treatment was continued on the basis of boosting the qi and enriching the kidneys in order to treat the root disease.

According to Dr. Li, the disease mechanisms of nephrotic syndrome are spleen qi insufficiency with kidney yang vacuity weakness. In this case, there was a former heaven insufficiency with latter heaven malnourishment. The righteous was vacuity and evils had become attached. Additional cold evils had been contracted which had directly struck the center and transformed heat. Toxic evils had then blazed internally resulting in the manifestation of the boy’s signs and symptoms. In this case, Dr. Li felt that treatment should clear heat and resolve toxins, cool the blood and disinhibit urination and thus fever would be eliminated, which turned out to be the case.

Rheumatoid arthritis

The patient was a 42 year old female who was first examined by Dr. Li on Oct. 13, 2000. The patient had been diagnosed with rheumatoid arthritis for five years and had been treated with Chinese medicines. Until recently, all her symptoms had been in remission. However, three days earlier, she had developed a cough and expectorated phlegm. Then two days before she had developed a fever of 39E C. This was accompanied by headache, aching and pain of the small joints of her four limbs, torpid intake, restless sleep at night, and a slightly red throat. The following modification of Xiao Chai Hu Tang was, therefore, administered by Dr. Li: Radix Bupleuri (Chai Hu), Radix Scutellariae Baicalensis (Huang Qin), and Semen Pruni Persicae (Tao Ren), 12g each, Rhizoma Pinelliae Ternatae (Ban Xia), 15g, Fructus Forsythiae Suspensae (Lian Qiao), Radix Puerariae (Ge Gen), Semen Plantaginis (Che Qian Zi), Rhizoma Phragmitis Communis (Wei Jing), Semen Benincasae Hispidae  (Dong Gua Ren), Semen Coicis Lachyrma-jobi (Yi Yi Ren), and uncooked Gypsum Fibrosum (Shi Gao), 30g each, and Radix Glycyrrhizae (Gan Cao), 3g. One ji of these medicinals was decocted in water per day and administered in four divided doses. After five ji, the fever had receded, the joint pain had greatly decreased, and the cough and expectoration of phlegm had been eliminated. Therefore, treatment was continued in order to supplement and boost the liver and kidneys, regulate and rectify the qi and blood.

According to Dr. Li, the disease mechanisms of rheumatoid arthritis are mainly liver-kidney insufficiency and qi and blood disharmony. This patient’s lungs were not capable of controlling fluids and diffusion and downbearing had lost their regulation. External evils had entered the interior and transformed heat, and this had combined with deep-lying (or hidden) phlegm which bound together, become exuberant, and had congested. Therefore, the treatment principles were to clear heat and resolve toxins, transform phlegm and stop coughing first in order to treat the tips or branch. Once heat was eliminated and coughing stopped, then one could supplement and boost the liver and kidneys, regulate and rectify the qi and blood in order to treat the root.

Copyright © Blue Poppy Press, 2002. All rights reserved.

For more information on the Chinese medical treatment of autoimmune diseases, please see Bob Flaws & Philippe Sionneau’s The Treatment of Modern Western Medical Diseases with Chinese Medicine and Blue Poppy Institute’s Distance Learning program, Treating Allergies & Autoimmune Diseases with Chinese Medicine.  

(This article was originally published in the RCHM Newsletter. The RCHM is the Register of Chinese Herbal
Medicine in the U.K. Since then, I have slightly expanded it and reworded a few sentences.)

There is supposedly a Chinese saying that goes something to the effect that, "New practitioners use many formulas; old practitioners use only a few." This saying may or may not be apocryphal. However, in my case it is certainly true. After 20 years of practicing Chinese medicine and based on the theories and methodology of Li Dong-yuan, I find that I use various combinations and modifications of four basic formulas for 90% of my patients with chronic conditions. These four formulas are Bu Zhong Yi Qi Tang (Supplement the Center & Boost the Qi Decoction), Xiao Chai Hu Tang (Minor Bupleurum Decoction), Xiao Yao San (Rambling Powder), and Ban Xia Xie Xin Tang (Pinellia Drain the Heart Decoction). Although I do not have a favorite from among these four, I would like to discuss Xiao Chai Hu Tang, the most commonly prescribed Chinese medicinal formula in the world.

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Xiao Chai Hu Tang (Minor Bupleurum Decoction)

Radix Bupleuri (Chai Hu), 9g
Radix Scutellariae Baicalensis (Huang Qin), 9-12g
Radix Panacis Ginseng (Ren Shen), 6-9g
Rhizoma Pinelliae Ternatae (Ban Xia), 9g
mix-fried Radix Glycyrrhizae (Gan Cao), 3-6g
Fructus Zizyphi Jujubae (Da Zao), 3-5 pieces
uncooked Rhizoma Zingiberis (Sheng Jiang), 2-3 slices

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This formula is recorded in Zhang Zhong-jing's late Han dynasty Shan Han Lun (Treatise on Cold Damage) and is the prototypical formula for harmonizing the defensive and constructive in a shao yangpattern of cold damage. However, this formula has a much broader scope of application than that classical description implies. As a harmonizing formula, it not only harmonizes the defensive and constructive but also the liver and spleen, liver and stomach, spleen and stomach, and stomach and intestines. Since exterior-resolvers and qi-rectifiying medicinals are often interchangable, both up-bearing and tending to effuse clear yang, this formula can be used to treat liver depression qi stagnation with concomitant spleen vacuity and dampness. In addition, since out-thrusting is another way of clearing internal heat (especially depressive heat), this formula may be used to clear heat in the liver, gallbladder, stomach, and/or lungs.

Li Dong-yuan, author of the Pi Wei Lun (Treatise on the Spleen & Stomach) and arguably the most famous of the Four Great Masters of Medicine of the Jin-Yuan Dynasties, was an expert at treating complex, multi-pattern conditions where there was spleen qi vacuity, depression of the qi mechanism, and some sort of heat. In such cases, the evil heat involved is engendered from the middle or lower burners and only secondarily wafts up to collect in and disturb the upper burner or body. Li called this type of evil heat "yin fire." He called it yin is because A) it develops from the lower or yin part of the body, B) it is often damp or yin in nature, and C) it is pathological.

Li's five principles for treating yin fire conditions, i.e., complicated conditions where there is spleen vacuity, an inhibited qi mechanism, upward counterflow, and evil heat (damp heat, depressive heat, vacuity heat, or upward stirring of ministerial fire), are to:

1. Fortify the spleen and boost the qi while harmonizing the stomach and intestines.
2. Rectify the qi mechanism, upbear the clear and downbear the turbid.
3. Clear heat of whatever kind from wherever necessary.
4. Do whatever elese needs doing depending upon the presenting condition (e.g., quicken the blood, transform phlegm, eliminate dampness, moisten dryness, etc.) .
5. Prioritize the above four necessities and apply in appropriate order of precedence and proportion.

Within Xiao Chai Hu Tang, Bupleurum courses the liver and rectifies the qi, upbears the clear and disinhibits the qi mechanism. Ginseng, mix-fried Licorice, and Red Dates fortify the spleen and supplement the qi (as well as nourish the heart spirit). Pinellia and uncooked Ginger harmonize the stomach, downbear turbidity, eliminate dampness and transform phlegm. And Scutellaria clears heat from the liver, gallbladder, stomach, large intestine, and lungs. Likewise, because Bupleurum is bitter, acrid, and cool, it also has some ability to clear both damp and depressive heat from the liver/gallbladder. Therefore, this formula embodies Li Dong-yuan's five principles of treating yin fire conditions -- in this case, eliminating dampness and transforming phlegm in terms of principle number four, and relatively equally supplementing the spleen, rectifying the liver, and clearing heat in terms of principle number five.

As the great mid-century architect of modern Chinese medicine, Qin Bo-wei said,

"When I say to use Liu Wei Di Huang Wan (Six Flavors Rehmannia Pills), I do not mean
to use the ingredients of Liu Wei Di Huang Wan but rather the idea of Liu Wei Di Huang Wan."

Thus, in clinical practice, I rarely use this formula in its standard, textbook form. If I need to regulate the blood in addition to coursing the liver and rectifying the qi, fortifying the spleen and supplementing the qi, transforming phlegm and eliminating dampness, and clearing heat from the lungs, stomach, liver/gallbladder, or large intestine, I typically will add Radix Angelicae Sinensis (Dang Gui) and/or Radix Albus Paeoniae Lactiflorae (Bai Shao) or maybe even all of Si Wu Tang (Four Materials Decoction).

For instance, when women catch a cold or manifest fluey symptoms before or with each menstruation, this usually indicates a constructive and defensive disharmony complicated by blood vacuity. In that case, the blood, which is the mother of the qi, is insufficient to nourish and root the defensive qi. The defensive qi thus does not do its duty of securing and astringing the exterior, leaving the body easily invaded by external wind evils. Prior to the menses, the blood is downborne viathechong mai/bao mai from heart to uterus. If there is a blood vacuity, there may not be sufficient blood left over to nourish the liver during the premenstruum. In that case, there will be the engenderment or worsening of liver depression qi stagnation. Since exterior-resolving is associated with upbearing and out-thrusting, if the qi mechanism is depressed due to lack of blood to nourish the liver premenstrually, then any external evils invading the body may also not be efficiently out-thrust. Instead, they may linger in the body as hidden or retained evils waiting for the right set of circumstances to become pathologically active once again. In addition, since the spleen is the root of phlegm engenderment, if the liver becomes depressed, the spleen becomes vacuous and weak, and the lungs are fettered by external evils, then accumulation of phlegm dampness is all the more likely. To top this all off, liver depression complicated by phlegm and damp depression is all the more likely to transform into depressive heat and heat, which is yang, tends to float upwards to accumulate in the lungs, the florid canopy. The combination of Minor Bupleurum and Four Materials treats this complicated but commonly seen gynecological scenario.

If I need to moisten dryness (due to persistent heat), I typically add Tuber Ophiopogonis Japonici (Mai Dong) and/or Radix Trichosanthis Kirlowii (Tian Hua Fen) and may change Ginseng to Radix Pseudostellariae (Tai Zi Shen). If I need to rectify the qi more, I might add Rhizoma Cyperi Rotundi (Xiuang Fu), Radix Linderae Strychnifoliae (Wu Yao), and/or Radis Auklandiae Lappae (Mu Xiang) depending on where the qi stagnation is manifesting and how serious it is. If there is more phlegm, I might add Sclerotium Poriae Cocos (Fu Ling), Pericarpium Citri Reticulatae (Chen Pi), and/or Bulbus Fritillariae (Bei Mu). If the phlegm is in the chest annd/or throat, I will probably add Radix Playtcodi Grandiflori (Jie Geng). If there is phlegm nodulation, I will probably add some or all of Radix Scrophulariae Ningpoensis (Xuan Shen), Spica Prunellae Vulgaris (Xia Ku Cao), Concha Ostreae (Mu Li), Herba Sargassii (Hai Zao), Thallus Algae (Kun Bu), and Semen Citri Reticulatae (Ju He). If there is more dampness due to spleen vacuity, I might add Sclerotium Poriae Cocos (Fu Ling) and Rhizoma Atractylodis Macrocephalae (Bai Zhu). If the spirit is not quiet, I might add Os Draconis (Long Gu) and Concha Ostreae (Mu Li). If there is more qi vacuity, I will usually add Radix Astragali Membranacei (Huang Qi). If there is more heat, which medicinals I add will depend on the nature of the heat and where it is located. For instance for either damp heat or heat in the heart, stomach, and/or intestines, I will typically add Rhizoma Coptidis Chinensis (Huang Lian). If there is depressive heat causing vexation, I might choose Fructus Gardeniae Jasminoidis (Shan Zhi Zi). While if there is damp heat affecting the skin with itching, then Radix Sophorae Flavescentis (Ku Shen) and Cortex Radicis Dictamni Dasycarpi (Bai Xian Pi) might be good choices. And for wind heat evils affecting the throat, Fructus Arctii Lappae (Niu Bang Zi) and Radix Isatidis Seu Baphicacanthi (Ban Lan Gen) are often good choices.

In other words, this formula can be modified in numerous ways to fit large numbers of presenting situations. Since most patients with chronic diseases suffer from liver depression (The Heart Transmission of Medicine says, "In general, depression is part of any disease. If depression endures, it will generate disease. If a disease has endured, depression will be generated."), spleen vacuity ("Enduring disease damages the spleen."), and some kind of evil heat (viz. the theories of Liu Wan-su, Li Dong-yuan, and Zhu Dan-xi), this formula is an extremely useful one beyond just harmonizing the shao yang division.

Caveat: Although Minor Bupleurum is the most commonly prescribed Chinese medicinal formula in the world today and is extremely safe for a wide range of patients and conditions, it should not be used in tandem with Interferon therapy, as in certain types of cancer and chronic active hepatitis. Recently, several patients in Japan died from this combination due to liver failure. Until the exact mechanisms of this complication and all its co-factors are ascertained, I believe this caveat should be considered absolute.

by David Kailin, Lic. Ac., M.P.H.,  Ph.D. candidate, Public Health

You’ve been treating a woman throughout her pregnancy, first for morning sickness and later for a variety of minor complaints. The woman has really come to trust you and acupuncture/Oriental medicine. While getting this patient ready for delivery, she asked you if acupuncture could help reduce the pain of labor or speed up a stalled delivery. You told her that, depending on the situation, it could. So the woman’s asked you to attend her delivery. However, she’s going to deliver in a hospital, and the hospital won’t let you attend (at least not as a health care provider) since you don’t have hospital privileges. What to do?

Depending on the hospital and its policies, there may not be anything you can do for this particular patient. However, if you don’t want to be faced with this same situation in the future, you might want to consider applying for hospital privileges now. I can think of any number of situations where an acupuncturist might be able to help their patients with acupuncture and/or Oriental medicine even after they’ve had to be hospitalized. These situations range from acupuncture anesthesia for minor surgery, to post-operative pain control, to treating nausea as a reaction to chemotherapy.

Also consider the services you can offer to the hospitals’ Western medical providers, many of whom have patients with problems amenable to treatment with traditional Oriental medicine. That represents a major opportunity, not only in terms of market, but also for the advancement of integrative care.

What are hospital privileges?

Simply put, hospital privileges mean the right to work within a particular hospital as a professional health care provider. In general, there are two levels of hospital privileges: full medical staff privileges and affiliate staff privileges. The former allows one to admit, treat, and discharge patients from the facility.  The latter grants permission to provide services to patients who have been admitted to the facility but not to independently admit or discharge patients. A provider with affiliate privileges can work in conjunction with a provider with full privileges to have the affiliate’s patients admitted and discharged under the name of the fully privileged provider. Hence affiliate staff privileges will adequately meet the needs of most acupuncturists.

Steps in applying for hospital privileges

The standards of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) allow hospitals to grant privileges to non-physician licensed health care providers, but they do not require hospitals to do so. Most hospitals have granted affiliate privileges to a variety of allied health care providers but not specifically to acupuncturists. Therefore, the first step involves educating the medical staff office about acupuncture and acupuncturists. Provide answers to the questions that you know will be of concern: What are acupuncture’s indications, contraindications, benefits, and risks? What is the research basis? What training do you have? What techniques will you use? It helps at this point to have a champion or two on the hospital staff who can vouch for both you and acupuncture/Oriental medicine.  You will need the support of providers in the medical department you intend to work in. In general, I have found greater initial support from the medical staff than from hospital administrators and executives.

You will need to obtain and fill out the hospital’s staff privileges application form. Review the application with the hospital’s medical staff office if you have any questions about the specific nature of requested  information and also to confirm that the form is relevant to assessing the qualifications of an acupuncturist. This application will ask for documentation which you must provide, such as your personal and academic history (including continuing education, research, and teaching), board certification, copies of your current licenses as a health care practitioner, your Social Security number, and proof of current malpractice insurance. If you already have (or previously have had) staff privileges elsewhere, you will probably be required to show that you remain in good standing or that your privileges were not adversely revoked. You will need to respond to questions about your physical and mental health, drug or alcohol addictions, any criminal history, and previous or pending malpractice lawsuits. In addition, you will be required to provide personal and professional references, and, of course, you can expect to pay a fee.

After you have submitted all the above materials in support of your application, the hospital will verify the information you have supplied. Next, you will probably be asked to appear in person before the credentialing committee for an oral interview. This provides you with a formal opportunity to educate the committee about acupuncture and Oriental medicine as well as to introduce yourself. Depending on the outcome of that interview, the medical staff credentialing committee typically makes a recommendation to the medical staff executive committee or directly to the hospital’s board of governors, where a final decision is made. If your application is denied and you wish to appeal the hospital’s decision, you can find out about the hospital’s appeals process from the medical staff office. The JCAHO requires that accredited hospitals have an appeals process.

Clinical privileges

Once you have been granted affiliate (or associate) staff privileges, you will then be given clinical privileges. Clinical privileges specify exactly what procedures a practitioner can and cannot perform while treating patients in that hospital. Clinical privileges are determined primarily by the hospital, although they are delimited by your state acupuncture law’s definition of scope of practice and by JCAHO accreditation standards. The hospital may not have previously defined clinical privileges for acupuncturists. Therefore, after ascertaining the nature of their particular concerns, you should attempt to help resolve this problem by presenting a proposal of the clinical privileges you seek. That proposal should define precisely what procedures and tools you will be limited to using. It might also define limits to your herbal materia medica and/or circumstances requiring consultation with an MD.

For instance, an acupuncturist might be allowed to do acupuncture but not moxibustion, or acupuncture but not Chinese herbal medicine. Or they may be allowed to treat patients with certain diagnoses but not others. Some restrictions placed on practitioners in terms of their clinical privileges may be negotiable and others may not. In some cases, it may only be a matter of educating the committee members in charge of drafting your clinical privileges. However, being forbidden to do moxibustion due to smell, the potential fire hazard, and the potential for setting off of smoke alarms and/or sprinkler systems usually cannot be negotiated away. Instead, the acupuncturist can adapt to the needs of the institutional setting by using infra-red or other smokeless heating devices.

Many types of medical providers with hospital staff privileges have strictly defined clinical privileges, including nurse practitioners and even general practitioner MDs. For instance, GPs are often required to consult specialists in certain circumstances or with certain diagnoses. So acupuncturists seeking staff privileges should not feel singled out by the limits of clinical privileges. They are not meant to be discriminatory; they are meant to protect both the patient and the hospital. They also serve to protect the practitioner by ensuring that they do not do anything dangerous or for which they are not qualified. In addition, clinical privileges are not necessarily set in stone. Once you have gotten into the system and have shown your professionalism, competence, and therapeutic effectiveness, the hospital may be willing to expand your privileges over time. The first issue is getting your foot in the door. Then later, when you have built strong working relationships, you will be in a better position to negotiate.

Malpractice insurance

Whether or not your state requires all acupuncturists to carry malpractice insurance, you can be certain that the hospital to which you are applying for privileges will. They need to know that they will not be solely financially responsible for the defense and outcomes of any malpractice suits resulting from your actions on their premises. In my experience, the amounts of coverage hospitals require for obtaining privileges are larger than those required by those states which mandate acupuncturist malpractice insurance (such as Colorado, New Mexico, and Florida). For instance, Colorado requires a minimum of $500,000 coverage per single incident, but Denver General Hospital requires $1 million. Therefore, if you are applying for hospital privileges and you do not yet have malpractice insurance, be sure you purchase the right kind in the right amounts to meet the requirements of the hospital to which you are applying.

Conclusion

Acupuncture/Oriental medicine is appropriate for many in-patients as well as ambulatory care patients. The hospital door should no longer be seen as a glass wall denying entry to non-physician acupuncturists.  Granted, at times, this is still a heavy door to open, but some of that weight is due to our own reluctance to open it. In fact, I have found my acupuncture practice simpler, more rewarding, and, in certain regards, of higher quality when working as a team player inside those doors than when working as a solo practitioner in private practice.

Although obtaining hospital staff privileges may seem like a stressful and time-consuming hassle, it is a great boon to our patients when they are seriously in need. Some of the other benefits of obtaining hospital privileges include heightened visibility within your community, increased credibility with patient and other health care providers, and the ability to give and get advice and support from other health care providers. However, perhaps the greatest benefit of obtaining hospital privileges is the ability to actively participate in the creation of a new integrative medicine for the 21^st century.

Introduction

For the past 18 months, I have been teaching a Postgraduate TCM Gynecology Certification Program through Blue Poppy Press Inc.'s Seminar & Distance Learning Division. Approximately 70 students enrolled in the first section of this program with another 50 students in the second section. In order to get into this program, students had to be either A) a licensed professional acupuncturist or NCCA diplomate who had already formally studied Chinese materia medica and formulas and prescriptions or B) a third year student currently enrolled in a recognized acupuncture school who had completed their materia medica course and were currently enrolled in or had completed their formulas and prescriptions course. In fact, the great majority of students in this postgraduate program have been professional practitioners. These practitioners have graduated from a wide variety of schools from all areas of the United States. Therefore, I feel this group of students is a representative cross-section of American acupuncturists also prescribing Chinese medicinals for internal administration. If this group is atypical of American acupuncturists practicing Chinese medicine in general, it is that they are a self-selected group of high achievers who were interested in and willing to pay for extensive continuining education.

In addition, this course was designed and advertised as specifically a TCM gynecology program, not a generic Chinese medical or Oriental medical gynecology course. In the program prospectus, we specifically mentioned that this program was based on the TCM style of gynecology. By TCM, we meant that style which is the standard of care (soc) taught to undergraduates at prvovincial Chinese medical colleges in the People's Republic of China (prc). The basic metholodology of this style is described in Chinese as bian zheng lun zhi, the basing of treatment on pattern discrimination. This methodology is then further elucidated by the saying:

Yi bing, tong zhi
Tong bing, yi zhi

One disease, different treatments
Different diseases, same treatment

This means that, in TCM as a specific style of Chinese medicine, two patients with the same named disease diagnosis may receive different treatments if their TCM patterns are different, while two patients diagnosed with different named diseases may receive the same treatment if their TCM pattern is the same. In other words, in TCM, treatment is predicated primarily on one's pattern discrimination, not on one's named disease diagnosis. Therefore, the ability to discriminate patterns accurately and then erect treatment plans on the basis of that pattern discrimination is vital if one is going to practice TCM according to Chinese standards of care.

As part of our bpp Postgraduate TCM Gynecology Certification Program, students have been required to hand in at least one dozen written case histories. Each of these case histories has had to include 1) the patient's signs and symptoms and other pertinent information in order to make and substantiate a TCM pattern discrimination, 2) a statement of the TCM treatment principles necessary to remedy the imbalance inherent in the pattern discrimination, 3) the treatment plan derived from these principles, and 4) the effect of this treatment on the patient, its subsequent modification (with substantiating signs and symptoms and the restatement of new treatment principles if necessary), and the case's final outcome. Reading all these case histories and answering students questions in class, over the phone, and by fax and e mail has underscored my perception as a continuing education teacher that American practitioners are obviously passing their schools' exit examinations and the NCCA exams, but the majority are not very clear about the actual clinical application of TCM methodology at least by my perceptions of Chinese standards of care. Therefore, in order to help our BPP students understand TCM methodology and standards of care, I have written the following explanations. Because our BPP students have told me how much these materials have helped them clarify their clinical process, I would like to share these clarifications for what they are worth with our profession at large.

TCM methodology

In TCM, signs and symptoms are gathered by the four examinations. These signs and symptoms, including tongue examination and pulse examination signs, are compared and analyzed into various professionally named and agreed upon or standardized patterns. Typically, real-life patients do not exhibit the simple patterns most TCM textbooks emphasize for beginners. However, the complex patterns of real-life patients are made up of nothing other than combinations of these simple patterns. After 18 years of clinical practice, it is my opinion that all Western patients can be described according to TCM pattern discrimination as long as one understands how complex scenarios are made up from simple building blocks.

After stating the pattern or patterns which the patient's signs and symptoms add up to, then the TCM practitioner should write down the treatment principles one believes will logically remedy the imbalance inherent in the nomenclature of the pattern discrimination. In general, each element of the pattern discrimination is mirrored in a treatment principle. For instance, if one says that the patient is exhibiting a pattern of liver depression qi stagnation, then the treatment principles are to course the liver (liver depression) and rectify the qi (qi stagnation). If one says the pattern is one of spleen qi vacuity, then the treatment principles are to fortify the spleen (spleen vacuity) and supplement the qi (qi vacuity). If one says the pattern is one of damp heat, then the treatment principles are to clear heat and eliminate dampness. While if one says the pattern is one of blood stasis, then the treatment principles are to quicken the blood and transform or dispel stasis. Within TCM as s system, there are professionally agreed upon principles correlated to different patterns, and one may not add or subtract principles which are not logically derived from the stated pattern discrimination. Although this process may seem self-evident to anyone reading the Chinese TCM literature, my experience with Western students is that few have become habituated to following this process in a step by step way.

It is said in TCM texts that the treatment principles are the bridge between the pattern discrimination and the treatment plan. As such, they are extremely important and should not be overlooked or omitted. Depending on the first element of the patient's stated TCM pattern discrimination, one chooses a basic guiding formula. For instance, if the first element in the patient's pattern discrimination is spleen qi vacuity, then the first treatment principles written down should be to fortify the spleen and supplement or boost the qi. In this case, one should (my Chinese teachers would probably say must) pick a guiding formula from the qi supplementing category of formulas. In looking through the formulas listed under this category, one looks for a formula which is known to specfically supplement the spleen, as opposed to some other viscus. All other concomitant or complicating patterns are then considered secondary. Hence, once one has picked one's basic guiding, spleen qi supplementing formula, one can add medicinals in order to modify that guiding formula for any other secondary patterns and their treatment principles. If there is also damp heat, then one can add ingredients which clear heat and eliminate dampness. If there is concomitant qi stagnation, one can add qi-rectifying, qi-moving medicinals. If there is concomitant phlegm, one can add medicinals which transform phlegm. If there is blood stasis, one can add medicinals which quicken the blood and transform or dispel stasis.

Because it is the first stated element in the pattern discrimination and, therefore, the first stated treatment principle which determines the choice of guiding formula, it is very important to write down the patient's pattern discrimination in a logical progression from most important element to least important element. If one says liver depression qi stagnation first, then one must choose a guiding formula from the qi-rectifying category. If one says blood stasis first, then one must choose a guiding formula from the blood-rectifying category. If one says phlegm first, then one must choose a guiding formula from the phlegm-transforming or portal-opening category.

Thus the TCM methodology is like a snake entering a bamboo tube. If the snake goes in one end, it must come out at the other end. Or it may be likened to pouring liquid through a funnel. One begins with a diverse body of signs and symptoms. First one groups this seemingly unrelated welter of information into a pattern or patterns. This narrows down this wide variety of bits and pieces of information into a coherent, focused stream all going in one direction. Then one states one's treatment principles in the same order as the pattern is stated. Next one chooses a guiding formula from the category of formulas corresponding to the first or main pattern and it treatment principles. And finally, one modifies this formula for the other secondary patterns and their principles as well as for the patient's major complaints.

Because there are agreed upon norms or standards for what signs and symptoms do and do not add up to a given pattern, other mentors and peers may review one's pattern discrimination to determine if it is indeed correct. Because there are professionally agreed upon correspondenced between these patterns and their treatment principles, one's mentors and peers can critique the rectitude (or precision) of one's stated treatment principles. And because there are standards between medicinals and formulas and treatment principles, our mentors and peers can critique to rectitude (or precision) of our treatment plans. Thus this basic TCM methodology of moving from pattern discrimination to treatment principles to guiding formula with modifications can be professionally critiqued at every step of the way. Therefore, there are definite standards of care in TCM as a system.

The key to doing this system well is the following of this process or methodology in a step by step manner. Secondly, one's outcome very much depends on the correctness of one's initial pattern discrimination. If one's pattern discrimination is correct and one states the correct treatment principles for remedying that imbalance, then one should ipso facto be led to the correct treatment plan, as long as one follows this step by step methodology each step of the way. In order to do a correct pattern discrimination, one must have a very firm grasp of all the basic statements of theoretical fact of Chinese medicine coupled with a careful memorization of the signs and symptoms of each simple pattern. Then one must search for those signs and symptoms in a focused way. In other words, if a sign or symptom suggest that the patient may be exhibiting a certain pattern, one should immediately remember the rest of the signs and symptoms of that pattern. One then questions, looks, listens-smells, and feels to corroborate the existence of a modicum of those signs and symptoms. If there is substantiating evidence, voila!, the patient may be said to exbihit that pattern. If those other typical, cooroborating signs and symptoms are absent, then the patient is not exhibiting that pattern. In that case, one must think what other pattern may exhibit that symptom and then examine in a focused way to confirm or deny that working hypothesis.

This means that a pattern is never established based on a single sign or symptom alone. A pattern by its very name means that it includes more than a single thing. There must be a critical mass of other corroborating signs and symptoms before we can say that a patient is exhibiting a particular pattern. For instance, if there is diarrhea, this by itself means nothing. If the diarrhea occurs after meals, includes undigested food, has no foul odor, and if there are cold hands and feet, fatigue, and lack of strength, then, as a pattern or gestalt, this adds up to spleen vacuity. However, if there is foul-smelling, dark colored, explosive diarrhea which feels burning hot or acidic around the anus as it comes out and if there is a red tongue with slimy, yellow coating and a slippery, rapid pulse, then this group of signs and symptoms adds up to damp heat.

In complex, i.e., real-life, cases, because there is more than a single pattern or disease mechanism producing the signs and symptoms, one will not usually see all of the signs and symptoms listed under the textbook descriptions of simple patterns. Rather, one will see a selection of signs and symptoms, some of which add up to one pattern or element in the overall discrimination and some of which add up to other elements. For instance, if there is spleen vacuity at the same time there is stomach heat, the tongue is probably not going to be pale and even more probably will not have white coating. Likewise, the pulse may not be deep, slow, or weak. Rather, it may only be the swollen nature of the tongue with many small cracks on its surface, the loose stools several times a day, the fatigue, and the lack of warmth in the hands and feet that alert one to the spleen vacuity.

The following case histories all present complicated patterns in which there is more than a single disease mechanism at work and are meant as examples of how one builds complex pattern discriminations and, therefore, complex treatment plans in order to treat the typical real-life patient we see in the West.

Case histories

The following case histories and their analyses are based on actual cases in my clinical files. However, in their present form, they were designed as questions on test given to our bpp Postgraduate TCM Gynecology Certification Program students after their having studied dai xia bing (vaginal discharge diseases), wai yin yin dao bing (external genital & vaginal tract diseases), and za bing (miscellaneous diseases). After giving the answers to the questions about each case, I have then given a brief analysis and explanation of the case.

1. The patient is a 39-year-old female. She has had genital herpes since she was in her early 20s. These erupt as several, small slightly red papules, which eventually do rupture and then are wet. These occur on her perineum. They can occur before, during, or after her menstruation. They may also occur if she gets overtaxed (i.e., fatigued). The lesions tend to linger but are not very painful. In addition, the patient has a diminished appetite, fatigue, lack of strength, lack of warmth in her four limbs, and a a tendency to loose stools. Her tongue fur is thin and white, while the tongue substance is pale and swollen with teeth marks on its edges. Her pulse is soggy in the right bar and fine and wiry overall. It is neither fast nor slow.

Questions:

A. Please give the pattern discrimination for when the patient is having an outbreak.
B. Please state the treatment principles during an outbreak.
C. Please write a guiding formula, using a standard formula as a basis, to be administered during an outbreak.

Answers:

A. Spleen vacuity complicated by damp heat in the lower burner
B. Fortify the spleen and supplement the qi, clear heat and eliminate dampness
C. Dan Zhi Xiao Yao San Jia Wei (Moutan & Gardenia Rambling Powder) with added flavors, i.e., Rhizoma Smilacis Glabrae (Tu Fu Ling), Radix Sophorae Flavescentis (Ku Shen), Cortex Radicis Dictamni Dasycarpi (Bai Xian Pi), Radix Isatidis Seu Baphicacanthi (Ban Lan Gen)

Analysis

The patient was 39 years old. Therefore, you should know that her condition was probably a mixed repletion- vacuity one. The spleen typically begins to become vacuous if not already so around 35 years of age, while the kidneys become vacuous in women sometime after that, based on the interdependency of the former and latter heaven roots. Therefore, I would be looking for evidence of spleen and kidney vacuity. She had had genital herpes since her early 20s. This means that her condition is a recurrent, chronic one. That means that, although the branch manifestation may be a repletion, the root condition is a vacuity one. Small lesions suggest vacuity as opposed to repletion. Slightly red lesions also suggest not very strong heat. That they do rupture and then are wet indicates the presence of dampness. So, up to this point, we know that the woman's condition probably involves a mixture of repletion and vacuity, that there is dampness and heat, but that the heat is not as important as the dampness. That the lesions occur on the perineum is linked to dampness being a yin evil which is heavy and turbid and tends to sink downward. The fact that they may occur before during, or after menstruation indicates that the condition is also not a simple repletion. Since women are relatively empty and vacuous after menstruation, repletions are not so common then. As stated above, women in their late 30s typically suffer from some element of spleen vacuity. The spleen is the latter heaven root of qi and blood engenderment and transformation. It is the decline and vacuity of spleen qi and kidney yang cyclically each month which result in the onset of the menses. We also know that the spleen is the single most important viscera in the engenderment of dampness. The fact that these attacks also occur when she gets overtaxed shows that they are due to vacuity. Fatigue is a main symptom of qi vacuity and the spleen is the main viscus involved in the engenderment and transformation of the qi. The facts that the lesions linger and are not very painful show that they are associated with vacuity. In repletion patterns, the disease course is usually short but dramatic. Since replete evils obstruct the qi and in repletion patterns there is a lot of qi and blood to obstruct, thus there is more pain. In this case, there was very little.

So up till now, we know that there is some qi vacuity associated with dampness and heat and that the heat is not very severe. Now here come the signs and symptoms that confirm that we are dealing with a spleen qi vacuity as the source of the dampness. Poor appetite, lack of or diminished, scanty appetite, fatigue, lack of strength, lack of warmth in the four limbs, and a tendency to loose stools, when taken together as a pattern, are the standard signs and symptoms of spleen qi vacuity. Thin, white tongue fur is considered normal in Chinese medicine. It shows there is no obvious repletion and little if any heat. If there is heat, it is not affecting the yang ming. The tongue substance being pale suggests blood vacuity. Immediately we should think that the spleen is the main viscus associated with the engenderment and transformation of blood. In that case, we should then immediately think that the spleen is responsible for engendering and transforming not only the blood but also the qi. The fact that the tongue is swollen with teeth marks on its edges shows that the qi is vacuous and is not moving and transforming body fluids. Since the tongue is pale, pointing to the spleen, a swollen, indented tongue tells us that it is spleen qi vacuity which is not moving and transforming fluids which are then gathering and producing water dampness. This is further confirmed by the soggy pulse on the right bar. The soggy pulse is defined as a floating, fine, and forceless pulse. The right bar corresponds to the spleen and stomach. A soggy pulse in the right bar, therefore, indicates spleen qi vacuity with spilling over of water dampness. The fact that the pulse is fine and wiry confirms that we are dealing primarily with a vacuity condition. Fine means finer than normal. The fine pulse means that there is not as much qi and blood flowing through the vessels as there should be. Based on all the other signs and symptoms, this points back again to spleen vacuity. That the pulse is wiry shows that the qi and blood are not freely and uninhibitedly flowing. Based on Zhu Dan-xi's six depressions, we can easily understand that dampness is blocking the free flow of qi.

If one also put down liver depression qi stagnation based on the wiry, bowstring pulse, because of the liver's role in maintaining the free and smooth flow of the qi, that is not absolutely wrong. If the qi is hindered from freely and smoothly flowing, this will eventually affect the liver's function vis a vis coursing and discharging. However, as written here, there were no other symptoms to confirm this. The fact that the pulse was not either fast or slow shows that there is not heart or yang vacuity (a slow pulse) nor prominent heat (a fast pulse).

Ergo, the case is one of spleen qi vacuity with dampness and heat with more dampness than heat. If one said damp toxins just because the condition is one of herpes genitalia, I will belabor that point. However, as given, there are no particular signs or symptoms which add up to toxins in TCM. Toxic lesions tend to be purulent, reddish purple, and locally quite severe.

Hence the treatment principles in the case are to supplement the spleen and boost the qi assisted by clearing heat and eliminating dampness with dampness being more prominent than heat. If one says that there are toxins in their diagnosis, then you would have to add resolve toxins in your treatment principles and, further, you would then have had to included toxin-resolving medicinals in your formula. In this case, it is debatable whether this is necessary.

The formula, Dan Zhi Xiao Yao San, is based on the harmonizing formula, Xiao Yao San (Rambling Powder), which harmonizes the liver and spleen, supplements the spleen, and eliminates dampness. With the addition on Cortex Radicis Moutan (Dan Pi) and Fructus Gardeniae Jasminoidis (Shan Zhi), it clears heat and eliminates dampness at the same time as it resolves depression. Although this formula is usually used for liver depression-depressive heat with an element of spleen vacuity, I have chosen it as my guiding formula not because there is obvious liver depression per se but because the external genitalia are traversed by the foot jue yin liver network vessels and Radix Bupleuri (Chai Hu) is capable of guiding the other heat-clearing medicinals to that area of the body at the same time as it helps fortify the spleen by upbearing clear yang. Smilax, Dictamnus, Sophora Flavescens, and Radix Isatidis are added to clear heat and eliminate dampness more effectively. In particular, Isatis is known to possess an antiviral effect and is chosen because of herpes genitalia being due to a viral infection.

2. The patient is a 35-year-old female with external vaginal itching and profuse or excessive vaginal discharge. The discharge is a creamy, opaque white. It does not have any particularly bad smell. This discharge is worse if the patient eats sugar or sweets. She is also fatigued, tends to have loose stools, and tends to have cold hands and feet. She frequently gets dizzy when she stands up rapidly. She also often experiences white, clear to opaque nasal phegm after eating sweets or dairy. Her tongue is somewhat swollen with thin, white fur. Her right bar is soft. Otherwise, her pulse tends to be fine and just a little wiry or bowstring. She does not have much pms. She does tend to have two to three bowel movements per day which occur after meals.

Questions:

A. Please give the patient's pattern discrimination.
B. Please state the treatment principles.
C. Please write a guiding formula using a standard formula as the basis.

Answers:

A. Spleen vacuity leading to dampness pouring downward, possibly with a slight element of heat
B. Fortify the spleen and boost the qi, eliminate or transform dampness and stop dai (vaginal discharge)
C. Bu Zhong Yi Qi Tang Jia Wei (Supplement the Center & Boost the Qi Decoction) with added flavors, i.e., Rhizoma Dioscoreae Hypoglaucae (Bi Xie), Semen Coicis Lachryma-jobi (Yi Ren), Rhizoma Acori Graminei (Shi Chang Pu), Fructus Tribuli Terrestris (Bai Ji Li)

Analysis:

The patient was 35. "At 35 years, the yang ming declines in women and so they get wrinkles on their face." So says the Nei Jing (Inner Classic), or at least something very close to that. The woman has external vaginal itching and excessive vaginal discharge. Let us leave the itching alone for the moment. Excessive vaginal discharge always involves dampness. The discharge is creamy and opaque white. White usually means that there is no heat. However, because it is somewhat thick and opaque, we cannot rule heat out altogether yet. It does not have any particularly bad smell. Offensive odor is mostly associated with heat. That this discharge is worse if the woman eats sweets shows immediately that it is associated with excessive dampness in turn associated with the spleen. The sweet flavor inherently engenders fluids and enters the spleen channel. A little sweet supplements the spleen, but concentrated, excessive sweet damages the spleen causing vacuity detriment. She is also fatigued. This is always a symptom of qi vacuity. Her stools are loose and she tends to have cold hands and feet. Taken together, these are standard TCM textbook symptoms adding up to spleen qi vacuity. She frequently gets dizzy when she stands up too rapidly. This is spleen qi not upbearing the clear. Thus the brain loses its clarity and dizziness occurs. She also experiences

(From "A Brief Summary of Wu Long Tang [Black Dragon Decoction] in the Treatment of Paralysis Agitans," by Wang Jian-guo et al., Hu Nan Zhong Yi Za Zhi [Hunan Journal of Chinese Medicine], #1, 2000, p. 13-14)

From Nov. 1996 to Jun. 1999, the authors of this study compared a specific Chinese medicinal protocol to a specific Western medical protocol for the treatment of paralysis agitans or Parkinson’s disease. A total of 41 patients were divided into two groups, a so-called treatment group which received Chinese medicinals and a comparison group which was treated with Western medicines.

Cohort description:

The treatment group was comprised of 13 males and nine females. The oldest member of this group was 69 and the youngest was 53, with a median age of 60.30 ± 7.45 years. The longest course of disease in this group was 6.7 years and the shortest was six months, with a median duration of 3.20 ± 0.48 years. In the comparison group, there were 12 males and seven females whose ages ranged from 71-52, with a median age of 59.87 ± 7.21 years. The longest course of disease in this group was 6.3 years and the shortest was eight months, with a median duration of 3.41 ± 0.75 years. Based on criteria set forth in Zhong Yi Lao Nian Zhan Zheng Gong Neng Zhang Ai Ji Fen (Chinese Medicine Geriatric Tremor Condition Functional Impairment Rating Score), three cases in the treatment group were considered to have light or slight impairment, 17 to have moderate impairment, and two cases to have heavy or severe impairment. In the comparison group, three cases had slight impairment, 15 had moderate impairment, and one had severe impairment. Thus there was no marked statistical difference between these two groups (P , 0.05).

The diagnostic criteria used in this study were based on those found in Shen Jing Bing Xue (A Study of Neurological Diseases): 1) main symptoms: decreased motility, tremor, muscular tension, and abnormal bodily position; 2) accompanying symptoms: a torpid affect, forehead bent forward, difficulty speaking, seborrhea, drooling from the corners of the mouth, psychological disturbance, decreased ability to control one’s daily activities, and inability to coordinate one’s upper extremities; 3) onset during middle or old age, 4) slow arising of disease and progressive worsening.

Treatment method:

The treatment group was internally administered Wu Long Tang: Zaocys Dhumnades (Wu Shao She), 15g, Os Draconis (Long Gu), 30g (cooked first), Rhizoma Gastrodiae Elatae (Tian Ma), 10g, Ramulus Uncariae Cum Uncis (Gou Teng), 10g, Radix Angelicae Sinensis (Dang Gui), 15g, Radix Ligustici Wallichii (Chuan Xiong), 10g, Radix Albus Paeoniae Lactiflorae (Bai Shao), 15g, cooked Radix Rehmanniae (Shu Di), 20g, Scolopendra Subspinipes (Wu Gong), 2 strips, Radix Glycyrrhizae (Gan Cao), 5g.

If there was simultaneous blood stasis, 10g of Semen Pruni Persicae (Tao Ren) and 15g of Radix Salviae Miltiorrhizae (Dan Shen) were added. If there was simultaneous yin vacuity, 20g each of Fructus Ligustri Lucidi (Nu Zhen Zi) and Fructus Mori Albi (Sang Zhen Zi) were added. If there was simultaneous yang vacuity, 15g of Fructus Psoraleae Corylifoliae (Bu Gu Zhi) and 20g of Herba Cistanchis Deserticolae (Rou Cong Rong) were added. If there was simultaneous phlegm heat, 10g each of bile-processed Rhizoma Arisaematis (Dan Nan Xing) and Bulbus Fritillariae Thunbergii (Zhe Bei Mu) were added. One ji was decocted in water per day and administered internally in two divided doses.

The comparison group was internally administered Artane (trihexyphenidyl hydrochloride), 2mg 3 times per day which was subsequently increased each week to 4mg and eventually to 6mg per day 3 times per day. Two months equaled one course of treatment for both groups, and treatment effects were assessed after one course.

Treatment outcomes:

The criteria for judging the treatment outcomes were also derived from Zhong Yi Lao Nian Zhan Zheng Gong Neng Zhang Ai Ji Fen (Chinese Medicine Geriatric Tremor Condition Functional Impairment Rating Score). Based on these criteria, eight cases in the treatment group experienced marked improvement, nine experienced improvement, two experienced slight improvement, and three experienced no effect. Thus the total amelioration rate in the treatment group was 86.36%. In the comparison group, four experienced marked improvement, five experienced some improvement, two experienced slight improvement, and eight experienced no effect. Therefore, the total amelioration rate in the comparison group was 57.89%. This meant that there was a significant statistical difference in outcomes between the treatment and comparison groups (P + 0.05). There was also a marked difference in degree of decrease in functional impairment from before to after treatment in these two groups (P + 0.05), the treatment group experiencing a greater degree of decrease. In addition, the treatment group experienced no uncomfortable side effects. In the comparison group, six cases experienced blurred vision, and 11 cases experienced dizziness and oral dryness. In all cases, these symptoms stopped when the patients stopped their medication.

Authors’ discussion:

According to the authors, Parkinson’s disease is called "geriatric tremor condition" in Chinese medicine. It is mostly due to yin and blood decline and vacuity not having the power to emolliate the liver and subdue yang. Hence wind and yang stir internally, thus leading to the onset of this disease. Within Wu Long Tang, Zaocys and Dragon Bone are the sovereigns which nourish the blood, emolliate the liver, subdue yang, and extinguish wind. Gastrodia and Uncaria level the liver, extinguish wind, and subdue yang. Dang Gui, White Peony, and cooked Rehmannia enrich and nourish yin and blood. Scolopendra extinguishes wind and stops tetany. Ligusticum quickens the blood, moves the qi, and dispels wind. And Licorice regulates and harmonizes all the often medicinals in the formula. In addition, when combined with Peony, its sweetness and Peony’s sourness transform yin. When all these medicinals are combined together, they have the function of nourishing blood and emolliating the liver, subduing yang, extinguishes wind, and stopping tetany. This promotes yin and blood’s obtaining fullness, the liver’s obtaining moistening and nourishment, and yang’s obtaining subduing and downbearing. Hence wind is leveled and tetany is stopped. Because the ingredients in this formula match the vacuity and repletion disease mechanisms of this disease, it cuts to the center of these disease mechanisms and so gets a good treatment effect in clinical practice.

Functionally translated by Bob Flaws. Copyright © Blue Poppy Press, 2000. All rights reserved.  

Keywords: Chinese medicine, Chinese herbal medicine, disease diagnosis, pattern discrimination, classical formulas

Keywords: Chinese medicine, Chinese herbal medicine, dermatology, chronic urticaria (CU)

Just because something is written by a Chinese doctor from China, it does not mean that what that doctor is saying is necessarily good Chinese medicine. Although I believe it is impossible to really understand this system without reading the Chinese medical literature from China (preferably in Chinese), nevertheless, when reading this literature, it is extremely important not to accept everything written by a Chinese as equally valid or commendable.

As I have written elsewhere and often, I believe that the system of Chinese medicine as taught at the major Chinese medical colleges in the People’s Republic of China is extremely dependent on the proper use of technical terms. If one understands these key technical terms, one can navigate this system and employ it in clinical practice with clear-cut standards of diagnosis and treatment. For instance, if one says that their patient is suffering from spleen qi vacuity, then the treatment principles requisite for remedying this pattern are to fortify the spleen and supplement the qi. Having said this, one knows that one must find their guiding prescription (whether Chinese medicinal, acupuncture, or tui na) under the qi-supplementing category, subcategory: supplementing the spleen. In other words, once one has used the words qi and supplement, one is guided directly to the chapter or section in their clinical manual where they will find the appropriate formula or protocol. The technical words one uses, when used in their proper way and order, funnel one directly to the proper treatment plan.

Conversely, if one uses the wrong words, one will be funneled to the wrong treatment. Since what we do in clinical practice has very real consequences for the health and well-being of our patients, we should use every means at our disposal to arrive at the correct treatment plan. This is what the systematic prescriptive methodology of professional Chinese medicine seeks to do. However, the correct application of this systematic methodology primarily hinges on the correct use of certain key technical terms, and if one uses those words incorrectly, one may easily, no, will probably be led astray.

Since these technical words play such an important role in the professional practice of Chinese medicine, it is very important that the precision of their use be maintained. If one becomes sloppy in their use, then the system itself becomes less precise, and it is the system which insures proper treatment. The following Chinese journal article is an example of a Chinese author’s using one of the technical terms in Chinese medicine in what I believe to be a technically erroneous way. Perhaps the author is simply trying to be clever and novel. Perhaps the author is trying to stimulate discussion by "throwing a spanner into the works." I am willing to consider that the author does themself understand the implications of what they are saying. However, if a Western reader reads this article uncritically, it may blur the importance of using the technical terminology of Chinese medicine in a technically precise way.

The term which I take issue with in the following article is the word se which Nigel Wiseman translates as "astringent" or "astringing." Astringing as a treatment principle is used when the lungs and/or kidneys have lost their power of "restraining, containing, astringing, and securing." This is a function of the qi, and is mostly a function of the kidney qi. It is the kidneys which govern opening and closing, sealing and storing. Usually the principle of astringing is used when either there is enduring coughing due to lung qi vacuity or enduring diarrhea, spermatorrhea, urinary incontinence, and/or abnormal vaginal discharge due to kidneys loss of securing.

Here, the emphasis is on the word "enduring." It is said in Chinese medicine that "enduring disease reaches the kidneys." If the kidney qi is damaged and becomes vacuous and weak, it loses its ability to carry out its proper functions. One of the kidneys’ functions is to govern the opening and closing of the two yin, A) the vaginal and urethral meatuses and B) the anus. Therefore, prolonged, enduring discharges from either of these two yin may be due to and/or cause lose of the kidney qi restraining, containing, astringing, and securing.

If either the lung qi loses its astringing and securing or the kidney qi loses its astringing and securing, one must pick a guiding formula from the se ji or astringent category of formulas or they must at least include astringent medicinals in their formula. The two main subcategories of astringing formulas are those which se jing zhi yi, astringe the essence and stop involuntary discharge (of semen, urine, or vaginal fluids), and those which se chang zhi xie, astringe the intestines and stop diarrhea. However, when using such astringing and securing formulas and medicinals, one must be sure that either 1) all replete evils have been eliminated or 2) the treatment also does contain medicinals for draining such replete evils at the same time as astringing and securing. If not, one will close the avenues of drainage and discharge of such evils, trapping them inside the body where they may brew and ferment. In particular, one must be careful not to mistakenly use astringing medicinals when enuresis, spermatorrhea, diarrhea, and leukorrhea are due to damp heat in the lower burner.

In the following Chinese article, the author asks the reader to consider Xiao Yao San (Rambling Powder)’s effects as an astringing formula. Xiao Yao San is one of Chinese medicine’s famous harmonizing formulas, harmonizing the liver and spleen. Therefore, the ususal treatment principles indicating this formula’s use in clinical practice are to course the liver and rectify the qi at the same time as fortifying the spleen and eliminating dampness. This combination of treatment principles can then simply be and often is abbreviated to harmonizing the liver and spleen. Therefore, speaking of Xiao Yao San as an astringent formula is a startlingly non-standard approach, and one which, ultimately, I think does more harm than good.

At this point, let’s take a look at the article itself:

From "A Personal Understanding Based on Experience of Using Xiao Yao San As An Astringing Prescription" by Zhu Sheng-kui, Zhe Jiang Zhong Yi Za Zhi (Zhejiang Journal of Chinese Medicine), #7, 1998, p. 321

Xiao Yao San (Rambling Powder) comes from the He Ji Ju Fang ([Tai Ping Benefit the People] Harmonizing Prescriptions Collection of Formulas). It is a famous formula for coursing the liver, rectifying the qi, and resolving depression. The author has used this formula flexibly in clinical practice for the treatment of seminal emission, enuresis, and abnormal vaginal discharge, changing this prescription into an astringing formula, and has gotten good results. The following representative case histories show the key points they have learned from their experience.

1. Seminal emission

[The patient] was a 40 year old male worker. He was first examined on Jun. 15, 1994. He had had seminal emission for six months. At the least, [this occurred] once every 4-5 days. At most, [it occurred] once every 2-3 days. When serious, seminal emission would occur night [after] night. [The patient] had already taken Chinese and Western medicinals, but without seeing any treatment effects. When examined, there was heart vexation, a tendency to sigh greatly, tension and agitation, a bitter [taste in] the mouth, insomnia, profuse dreams, lassitude of the spirit, torpid intake, and stools which were sometimes dry and sometimes loose. His tongue had a red tip and edges with yellowish white fur. His pulse was bowstring. [Thus, his] having to work without mistake and under great pressure had resulted in seminal emission.

Based on [the patient’s] pattern discrimination, the treatment [principles] were to course the liver, resolve depression, and fortify the spleen. [Therefore,] Xiao Yao San with additions and subtractions was used: Radix Bupleuri (Chai Hu), Radix Gentianae Scabrae (Long Dan Cao), Radix Angelicae Sinensis (Dang Gui), Rhizoma Atractylodis Macrocephalae (Bai Zhu), and Sclerotium Poriae Cocos (Fu Ling), 10g @, Radix Pseudostellariae (Tai Zi Shen), Radix Albus Paeoniae Lactiflorae (Bai Shao), and Radix Achyranthis Bidentatae (Huai Niu Xi), 15g , Os Draconis (Long Gu), decocted in advance, and Concha Ostreae (Mu Li), decocted in advance, 30g @, and Radix Glycyrrhizae (Gan Cao), 3g. One ji was administered per day after being decocted in water. At the same time, the patient was advised not to be disturbed by thinking and worrying about making mistakes at work.

After one week, [the patient] was examined again. After having taken these medicinals, all his symptoms had greatly decreased. His intake of food had gradually improved and his defecation had gradually regularized. During the time he took these medicinals, he had only had seminal emission one time. The formula’s medicinals matched the pattern, and so he was given another seven ji. On his third examination, the patient’s affect and form both had color, there had been no further seminal emission since the last examination, and his essence spirit [i.e., mood] had gradually become fine. Therefore, Gentiana Scabra was removed from the above formula and another seven ji were administered in order to consolidate the treatment effect. On follow-up recently, there had been no further recurrence.

Author’s discussion:

This is a case of poor emotions [resulting in] liver qi depression and binding. This then harassed and stirred [the patient’s] essence resulting in seminal emission. Therefore, [I] used Xiao Yao San with additions and subtractions for treatment. Within this formula, Bupleurum, Gentiana Scabra, Peony, Dang Gui, Dragon Bone, and Oyster Shell [all either] course the liver, drain the liver, or level the liver. Dragon Bone and Oyster Shell also have the function of restraining, astringing, and stopping involuntary emission. Atractylodes, Poria, Pseudostellaria, and Licorice fortify the spleen and calm the spirit.

2. Enuresis

[The patient] was a five year old male who was first examined on Aug. 5, 1996. He had had enuresis for one year and had been treated a number of times with Chinese and Western medicines without a cure. The child had been born normally. At three years of age, due to high fever, he had had convulsions. He was commonly a picky eater and his stools were sometimes dry and sometimes loose. During the day, his movement and intelligence were listless and fatigued. At night, he was commonly frightened by things and had nightmares. His tongue was pale red with thin, white fur, while his pulse was bowstring and moderate [i.e., relaxed or slightly slow]. All these were symptoms of liver-spleen loss of regulation. [Therefore,] treatment should fortify the spleen, course the liver, and astringe the urine.

Xiao Yao San with additions and subtractions was used: Radix Bupleuri (Chai Hu) and Radix Angelicae Sinensis (Dang Gui), 5g @, Radix Albus Paeoniae Lactiflorae (Bai Shao), Rhizoma Atractylodis Macrocephalae (Bai Zhu), Sclerotium Poriae Cocos (Fu Ling), Ramulus Uncariae Cum Uncis (Gou Teng), and Radix Pseudostellariae (Tai Zi Shen), 10g @, Periostracum Cicadae (Chan Yi), 3g, and Radix Glycyrrhizae (Gan Cao), 2g. One ji was decocted in water and administered each day. At the same time, he was advised to exercise more but before sleep at night to slow down and do less.

After one week, [the patient] was re-examined. His night-time fright and nightmares had markedly decreased. During the time he took the medicinals, he had only had enuresis one time. He was given another seven ji of the above formula, all his symptoms disappeared, and his enuresis stopped. On follow-up after half a year, no recurrence had been seen.

Author’s discussion:

Children’s viscera and bowels are tender and weak. Their livers commonly have a surplus, while their spleens commonly are insufficient. In this case, the child’s enuresis was related to his previous high fever. This manifested as night-time fright of things and nightmares, [hence we] know that the liver had involuntary emission heat. [Due to] the picky eating and sometimes dry, sometimes loose stools, [we] know there was spleen disharmony and that liver wood was assailing it. Therefore, Bupleurum, Peony, Dang Gui, Unaria, and Cicada Moutlings [either] coursed the liver, emolliated the liver, or leveled the liver, while Atractylodes, Poria, Pseudostellaria, and Licorice fortified the spleen.

3. Abnormal vaginal discharge

[The patient] was a 33 year old female worker. Her first examination occurred on Feb. 8, 1995. She had had vaginal discharge for more than a half a year. Due to an in-law’s problems with lack of success in business and a wife’s [having to speak from] the corner [of her] mouth, her white vaginal discharge had gradually become profuse in amount. [However,] it did not have any foul odor. Although it never stopped, on days that she was particularly vexed, it was even more severe. She had already taken Flagyl and Fluconazole as well as Chinese medicinals without effect. Examination showed taciturnity and scanty speech, vexation and agitation, easy anger, weakness and fatigue of the four limbs and lack of strength, torpid intake, loose stools, abdominal distention and discomfort, nausea, and a desire to vomit. Her tongue was pale red with thin, white fur, and her pulse was bowstring and moderate [i.e., relaxed or slightly slow]. Her pattern discrimination was liver depression & spleen vacuity, and treatment was in order to course the liver, fortify the spleen and astringe vaginal discharge.

[Therefore,] Xiao Yao San with additions and subtractions was used: Radix Bupleuri (Chai Hu), Rhizoma Pinelliae Ternatae (Ban Xia), and Radix Angelicae Sinensis (Dang Gui), 10g @, Radix Dioscoreae Oppositae (Huai Shan Yao) and Radix Albus Paeoniae Lactiflorae (Bai Shao), 20g @, Rhizoma Atractylodis Macrocephalae (Bai Zhu), Sclerotium Poriae Cocos (Fu Ling), and Radix Codonopsitis Pilosulae (Dang Shen), 15g @, Concha Ostreae (Mu Li), decocted in advance, 30g, and Radix Glycyrrhizae (Gan Cao), 3g. One ji was decocted in water and administered per day. She was also advised to correct her thinking in order to resolve and eliminate her worry and anxiety.

[The patient] was re-examined after one week. Her leukorrhea had greatly decreased. Her vexation and agitation and easy anger had also diminished. Her intake of food were increasing daily and her stools had become formed. Since the medicinals already matched the pattern, she was given another seven ji. On follow-up after four months, no recurrence had been seen.

Author’s discussion:

Because, as a wife, she was not [supposed] to know [i.e., be involved in her husband’s family’s business], her seven affect [or emotions] were not satisfied. [Therefore, her] liver had lost its orderly reaching. The liver and stomach had become disharmonious and the spleen had lost its fortification and movement. This had then resulted in abnormal vaginal discharge. Hence, [I] used Xiao Yao San to course the liver and fortify the spleen. Codonopsis, Dioscorea, and Oyster Shell were added to fortify the spleen and stop vaginal discharge, while Pinellia was in order to eliminate counterflow, harmonize the stomach, and dry dampness.

Bob’s discussion:

In my opinion, the author has not at all succeeded in making a case for Xiao Yao San being able to be used as an astringing formula. In all three cases, the patient’s pattern was liver depression with spleen vacuity. In case number one, liver depression additionally had transformed into heat and spleen vacuity had engendered dampness. This depressive heat had bound with the dampness and transformed into damp heat. It was damp heat in the lower burner which was harassing the essence chamber and forcing the essence to be discharged. In cases two and three, dampness due to spleen vacuity was simply pouring downward to the lower burner. In cases of liver-spleen disharmony, the correct standard treatment principles are to course the liver and fortify the spleen or to harmonize the liver and spleen for short. That means that one must choose a formula from the harmonizing category of formulas, which is exactly what the author of this article did.

While it is true that all three of the disease categories exemplified by these case histories are diseases which might be treated by astringing and securing, it is also important to note that loss of astringency and failure to secure is only one disease mechanism resulting in these three diseases. The central statement of contemporary professional Chinese medicine as taught and practiced in the People’s Republic of China is, "Bian zheng lun zhi." This means that treatment should be given on the basis of each person’s individualized pattern discrimination. Therefore, although seminal emission, enuresis, and abnormal vaginal discharge might be treated by astringing in certain particular cases, astringing and securing are not, ipso facto, the treatment principles for these diseases.

At best, all really the author should be saying is that one can add astringing and securing medicinals to a base of Xiao Yao San when liver-spleen disharmony has resulted in long-term, enduring discharge which has then become complicated by loss of astringing and securing. For instance, the author adds astringing medicinals (Dragon Bone and/or Oyster Shell) to Xiao Yao San in cases number one and three. And even in these cases, these ingredients are not listed in the astringing and securing category of Chinese medicinals. Rather, they are heavy spirit-quieters which also happen to astringe yin. In case, number two, the only modifications are wind-extinguishing and qi-supplementing medicinals.

The point I am trying to make is that, in patient’s with these conditions due to liver-spleen disharmony, one should not be thinking about the principles of astringing and securing. One should first and foremost be thinking about coursing the liver and fortifying the spleen. Then, if enduring discharge has damaged the kidney qi’s ability to seal and store, open and close, then one might choose to add one or more appropriate medicinals from the astringing and securing category.

I think that probably the author wrote this article and titled it so that it would purposively raise some eyebrows. In other words, I think it is deliberately provocative, and maybe most Chinese readers will not be confused by it. However, here in the West, it is my experience that, as a profession, we are having a very hard time really learning how to do the bian zheng lun zhi methodology in a logically consistent, step by step manner. As an internationally known teacher, the most common question I hear is, "How do you treat this or that disease with Chinese medicine?" This is actually the wrong question. The question should be, "How do you treat a patient with this disease and that pattern?"

In large part, this problem in the West exists because the logic inherent in the Chinese technical terms is lost or at least blurred when translated into English. (This is even more so when linguistically incorrect, non-standard terms are used.) The logic of the bian zheng lun zhi diagnostic and prescriptive methodology primarily hinges on the correct and conisistent use of technical terms. Therefore, it is especially dangerous for us relative neophytes when a Chinese uses these terms in a non-standard way. It means that Western readers must read this literature actively and critically. Caveat emptor. "Let the buyer beware!"

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Translated & with an introduction by
Bob Flaws

Introduction:

Below are functionally translations of several recently published articles on the Chinese medical treatment of insomnia. All appeared in Chinese medical journals published in the People's Republic of China. There are approximately 30 such journals published in the PRC on a monthly or bimonthly basis, and each journal typically publishes between 40-60 articles per issue. The articles presented below are all describe what has fashionably been called "outcome-based research." Basically, they are retrospective clinical audits statistically analyzing the clinical efficacy of particular protocols in a self-selected cohort of patients. Although this type of research is often not considered "up to par" here in the U.S. where double-blind, randomly controlled, prospective clinical trials are the "gold standard", nevertheless, they do measure patient satisfaction. Since our patients are self-selected and we do not treat in even a single-blind environment, I believe such clinical audits do provide a real-life assessment of the efficacy and appropriateness of specific protocols.

Clinical manuals and textbooks on the treatment of disease typically only give treatments for various patterns under various diseases without necessarily commenting on the actual clinical efficacy of those treatments. If one only has access to such beginner's textbooks and clinical manuals, one may think that all one has to do is prescribe the right formula under the right pattern and, voila!, the patient will get better. Alas, that is often not the case. In my experience, being able to tell patients (when they ask) what the statistical probability of response is to a particular protocol helps patients have realistic expectations. I find my patients like to know that a group of x number of patients with the same disease of the same age, sex, etc. got a particular percentage of effect using a particular protocol. For beginning practitioners, having this information also helps prevent them from having unrealistic expectations that are then followed by confusion, guilt, and insecurity when a patient fails to be cured by our ministrations.

Further, such Chinese articles often provide insights into new ways to think about certain patterns, diseases, and treatments. No standard Chinese clinical treatment manual in my possession lists blood stasis as a pattern of insomnia. Yet below is an article on the treatment of insomnia by primarily quickening the blood and dispelling stasis. Therefore, if one does not have access to this type of research, one will tend to have a lop-sided view of the practice and possibilities of Chinese medicine.

If readers find the information below of interest and value, I urge them to begin learning how to read modern medical Chinese for themselves. This is not as hard as it sounds. I have taught myself how to do this; so I know it can be done. Likewise, I strongly encourage all American schools of acupuncture and Chinese medicine to teach required classes in reading modern medical Chinese. Without such ability, however slow and imperfect, one cannot access and research the main source of professional literature on acupuncture and Chinese medicine, and, without such research, one cannot have a doctoral level of information on the clinical practice of Chinese medicine.

#1"The Treatment of 22 Cases of Insomnia in Young Adults Mainly by Acupuncturing Si Shen Cong (M-HN-1)" by Piao Ming-hua, Hei Long Jiang Zhong Yi Yao (Heilongjiang Chinse Medicine & Medicinals), 1995, #6, p. 38-39

All 22 patients in this clinical audit were seen as out-patients. There were 12 females and 10 males. The youngest was 11 years old and the oldest was 28. The shortest course of disease was seven days and the longest was four years. Eighteen cases had already been administered Western sedatives. Either these had not produced a markedly good effect or they had caused side effects. The author mentions that insomnia in young adults is mostly due to overtaxation and thinking too much.

The treatment method mainly consisted of needling Si Shen Cong (M-HN-1). If there was heart-spleen detriment and decline, Xin Shu (Bl 15), Pi Shu (Bl 20), and Jue Yin Shu (Bl 14) were added. If heart and kidneys were not interacting, Xin Shu (Bl 15), Shen Shu (Bl 23), and Tai Xi (Ki 3) were added. If there was heart-gallbladder vacuity and timerity, Xin Shu (Bl 15), Dan Shu (Bl 19), and Da Ling (Per 7) were added. If there was spleen-stomach disharmony, Wei Shu (Bl 21) and Zu San Li (St 36) were added. And if there was ascendant hyperactivity of liver yang, Gan Shu (Bl 18), Jian Shi (Per 5), and Tai Chong (Liv 3) were added. The needles were left in place for 30 minutes and were stimulated once every 10 minutes. One treatment was given per day and 10 treatments equalled one course of therapy. After one course, the patient was allowed to rest for 3-5 days before starting a new course of therapy.

Supplementally, in order to strengthen the treatment effect and depending on the patient's pattern and signs and symptoms, small seeds or pellets were taped to one or more of the following ear acupuncture points: Shen Men (Spirit Gate), Subcortex, Heart, Liver, Spleen, or Kidneys. Up to six of these ear points were selected. The patient was instructed to press each of these pellets four times each day in order to stimulate these points. The points were pressed before sleep, after waking, in the morning, and in the afternoon. Both ears were treated at the same time.

Cure was defined as being able to go to sleep easily and staying asleep for seven hours or more. Marked effect meant that one could go to sleep relatively easily and could stay asleep for more than five hours. Some effect meant that the symptoms were decreased but the condition relapsed. No effect meant that the condition was the same as before treatment. Based on these criteria, after two whole courses of therapy, 14 cases or 63.64% were cured; five cases or 22.73% got a marked effect; and three cases or 22.73% got some effect. Therefore, the total effectiveness rate was 100%. Further, more than half these cases took an obvious turn for the better after a single treatment.

#2 "Joining Needling at Nei Guan (Per 6) in the Treatment of 202 Cases of insomnia" by Liu Bing-quan, Xin Zhong Yi (New Chinese Medicine), #5, 1996, p. 34

Of the 202 patients studied in this clinical audit, 82 were male and 120 were female. Their ages ranged from 18-65, with the majority being between 30-45 years old. In 54 cases, their course of disease has lasted six months to one year. In 128 cases, it had lasted one to three years. And in 20 cases, it had lasted for more than three years. Eighty-five percent of these patients continued to take or intermittently took sleeping medications. These 202 patients were divided into two groups of 101 patients each for comparison purposes.

In terms of their diagnostic criteria, these patients all suffered from inability to go to sleep, difficulty going to sleep, sometimes sleeping and sometimes being aroused, difficulty sleeping after being aroused, or sleep diminished by 40%. In some cases, they could only go to sleep after taking sleeping medication. Most of these patients also had varying degrees of dizziness, headache, heart palpitations, impaired memory.

In one group, called the Needling Nei Guan Group, the treatment method consisted of acupuncturing Nei Guan (Per 6) to a dept of 0.8-1 inch deep along with the points Shen Men (Ht 7) and Tai Chong (Liv 3). In the second group, called the Joining Needling Nei Guan Group, Nei Guan was needled deeply through to Wai Guan (TB 5) but without breaking the skin on the opposite side of the forearm. After obtaining the needling sensation the needles were stimulated one time every 10 minutes with even supplementing/even draining technique. The needles were retained for 30 minutes per treatment with one treatment given per day. Thirty such treatments equaled one course of therapy.

Patients were considered cured if their sleep increased to 70-80% per night or more and they could stop taking sleeping medication. Marked effect meant that sleep increased to 60-70% and they could stop taking sleeping medication. Some effect meant that sleep increased to 50-60% per night and they could stop taking sleeping medication. No effect meant that sleep per night was only 40% or below and patients had to continue taking their sleep medication.

Based on these criteria, in the Joining Needling Group, 35 cases were cured, 34 got a marked effect, 20 got some effect, and 12 got no effect. Thus the total improvement rate for this group was 88.1%. In the Nei Guan Group, 20 were cured, 16 got marked effect, 40 got some effect, and 25 got no effect. Therefore, the total improvement rate in this group was 75.2%. Thus both these treatments were considered statistically significantly effective.

#3 "A Survey of the Treatment Efficacy of Treating Recalcitrant Insomnia with Xue Fu Zhu Yu Tang (Blood Mansion Dispel Stasis Decoction)" by Zhan Guo-tong, Xin Zhong Yi (New Chinese Medicine), 1996, #8, p. 32-33

Of the 31 patients in this clinical audit, 26 were out-patients and five were in-patients. There were 11 males and 20 females. Three were between 15-30 years of age; eight were between 31-40; eight were between 41-50; nine were between 51-60, and three were 61 years old or older. Their course of disease had lasted six months to one year in five cases, from one to five years in 17 cases, from five to 10 years in seven cases, and for more than 10 years in two cases.

All the patients in this study exhibited varying degrees of blood stasis, such as piercing pain in the head, dizziness, static macules on their tongues, and a choppy pulse. In addition, four other patterns were also discriminated: qi vacuity and blood stasis (11 cases), blood vacuity and blood stasis (8 cases), yin vacuity and blood stasis (6 cases), and phlegm heat and blood stasis (6 cases).

Based on everyone in this study suffering from blood stasis as at least part of the mechanisms of their insomnia, Xue Fu Zhu Yu Tang (Blood Mansion Dispel Stasis Decoction) was used as the guiding prescription. This was them modified for each of the four complicating patterns. The basic formula consisted of: Semen Pruni Persicae (Tao Ren), Flos Carthami Tinctorii (Hong Hua), Radix Angelicae Sinensis (Dang Gui), Fructus Citri Aurantii (Zhi Ke), Radix Rubrus Paeoniae Lactiflorae (Chi Shao), Radix Platycodi Grandiflori (Jie Geng), 10g each, uncooked Radix Rehmanniae (Sheng Di), 15g, Radix Achyranthis Bidentatae (Niu xi), 6g, Caulis Polygoni Multiflori (Ye Jiao Teng), 30g, Succinum (Hu Po), 1.5g, uncooked Radix Glycyrrhizae (Gan Cao), 3g.

If there was concomitant qi vacuity, Radix Codonopsitis Pilosulae (Dang Shen), 10g, and mix-fried Radix Astragali Membranacei (Huang Qi), 50g, were added. If there was concomitant blood vacuity, cooked Radix Rehmanniae (Shu Di), 25g, and Gelatinum Corii Asini (E Jiao), 10g, were added. If there was simultaneous yin vacuity, Fructus Lycii Chinensis (Gou Qi Zi), 15g, Fructus Corni Officinalis (Shan Zhu Yu), 12g, Rhizoma Acori Graminei (Shi Chang Pu), 6g, Radix Polygalae Tenuifoliae (Yuan Zhi), 5g, Radix Glehniae Littoralis (Bei Sha Shen), and Tuber Ophiopogonis Japonici (Mai Dong), 10g @, were added. If there was simultaneous phlegm heat, Pericarpium Citri Reticulatae (Chen Pi), 10g, Rhizoma Pinelliae Ternatae (Ban Xia) and processed Rhizoma Arisaematis (Nan Xing), 12g each, and Radix Scutellariae Baicalensis (Huang Qin) and Tuber Curcumae (Yu Jin), 10g each, were added. These were decocted in water and administered, one packet per day in two divided doses, morning and evening.

Cure meant that the patients were able to easily fall asleep each evening and sleep for eight hours or more. In addition, all their other symptoms disappeared. Marked effect meant that patients could sleep for at least six hours each evening and the major part of their accompanying symptoms disappeared. Some effect meant that the patient's sleep each night was longer than before. However, it still remained less than six hours. Or it meant that some of their symptoms disappeared. No effect meant that there was no change for the better in sleep and no improvement in symptoms.

Based on the above criteria, of the patients in the qi vacuity pattern group, six were cured, three registered marked improvement, and two got some effect. In the yin vacuity group, three were cured, two registered marked improvement, and one got some effect. Of the patients in the blood vacuity group, six were cured and two registered marked improvement. And of those in the phlegm heat group, one was cured, three got some effect, and two got no effect. Therefore, using this protocol, those patients in the blood vacuity/blood stasis group got the best results and those in the phlegm heat/blood stasis group got the worst. Twenty-four cases were followed up from one to three years, and only two cases had relapses. The cure rate was 51.6% and the total effectiveness rate was 93.5%.

#4"The Treatment of 12 Cases of Recalcitrant Insomnia by Tapping the Governing Vessel" by Zhuang Dan-hong, Hei Long Jiang Zhong Yi Yao (Heilongjiang Chinese Medicine & Medicinals), 1996, #3, p. 47

Eight of the patients in this study were male and four were female. All were young, seemingly healthy adults. Ten cases suffered from overtaxation due to too much study and "brain work." Two cases were workers. The treatment method consisted of first disinfecting the skin over the vertebrae from the neck to the sacrum. Then a small hammer with several small needles embedded in its head was used to tap up and down over the governing vessel on the midline of the back. This tapping was continued until either the area tapped was flushed red or there was very, very slight bleeding. This was done one time each day. All the patients in this study were cured using this technique.

By way of example, the author gives a case history. The patient was a 34 -year old male who worked as a teacher. He had suffered from recurrent insomnia for four years which was lately even more severe. He had difficulty falling asleep, dizziness, heart palpitations, lack of strength of his entire body, poor appetite, constipation, reddish colored urine, a red tongue with yellow fur, and a fine, rapid pulse. He had previously been administered a couple of different Chinese herbal decoctions which had not proven particularly effective. This had been combined with oral administration of Western sleep medication, which had put him to sleep. When he decided to come to the hospital for acupuncture treatment he had stopped taking these sleep medications and he was only sleeping approximately three hours per night. After being treated with the above protocol two-three times, his sleep increased to four to five hours. He stopped taking the Chinese medicinals and his treatment was stabilized after three more treatments, at which time he was discharged from the hospital.

The author says that insomnia is mostly due to yin vacuity with yang hyperactivity. Tapping the governing vessel like this regulates yin and yang, rectifies the qi and blood, harmonizes the viscera and bowels, and frees the flow of the channels and network vessels. When the tapping causes a little bleeding, it further drains yang heat, which is hyperactive and exuberant. This then has the effect of levelling or calming yin and secreting yang. As it is said, "When yin is levelled and yang secreted, the essence spirit [i.e., the mind] is treated [i.e., cured]."

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Curing Insomnia Naturally with Chinese Medicine
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Keywords: Chinese medicine, Chinese herbal medicine, autoimmune disease, multiple sclerosis (MS)

Keywords: Chinese medicine, history, Ding Gan-ren, Qin Bo-wei, Cheng Men-xue, Zhang Ci-gong

Almost 10 years ago, beginning with my book, Nine Ounces:A Nine Part Program for the Prevention of AIDS in HIV Positive Persons (Blue Poppy Press, 1992), I suggested that the Chinese medical concept of hidden or deep-lying warm evils (fu wen xie) deserves more consideration than this idea typically receives in contemporary Chinese medicine. According to Wiseman and Feng, something that is deep-lying in Chinese medicine is "present in the inner body, [but] latent, or barely perceptible."[1] Hidden or deep-lying evils describe types of evil qi which enter the body at one time, but do not manifest until some time later when provoked by other factors. In addition, hidden evils are primarily associated with warm diseases. According to Jiang Wen-zhai in his Yi Lue Shi San Pian (Thirteen Sheet Summary of Medicine), "Hidden evils... mostly make heat conditions." The locus classicus of the concept of hidden evils is the Nei Jing (Inner Classic) where it says, "[If in] winter [one] is damaged by cold, in spring [this] must [result in] warm disease." However, most of the premodern writings on hidden evils, such as the Fu Xie Xin Shu (Hidden Evils New Book), stem from the Qing dynasty and are considered part of the wen bing xue or warm disease literature. Recently, a number of Western practitioners of Chinese medicine, such as Z’ev Rosenberg and Heiko Lade, have speculated on the use of the concept of hidden warm evils in terms of viral diseases and their sequelae. Although I am not as enthusiastic about the clinical utility of this concept as I once was, I would like to share the some of the opinions of Tang Nai-guang as they recently appeared in an article titled, "Hidden Qi Warm Diseases & Miscellaneous Diseases."[2]

First of all, Tang Nai-guang feels that this concept may be of use in the treatment of certain "miscellaneous diseases." Miscellaneous diseases (za bing) refer to the indeterminate list of traditional Chinese diseases that comprise the Chinese medical specialty of nei ke or internal medicine. Some of the specific conditions that Tang suggests may often be associated with hidden evils include cholecystitis, laryngitis, gynecological inflammatory diseases, prostatitis, and appendicitis. Tang postulates that, due to lowered immunity, pathological germs or viruses may invade the body and lie hidden or latent until they are provoked and activated by some later occurrence, such as psychological injury, poisoning, surgery, or parturition. These events may further weaken the immune system, thus allowing the hidden evils to become overtly active. In such cases, there are no initial defensive aspect symptoms. In conditions such as sudden onset encephalitis and epidemic hemorrhagic fever, these begin directly as interior heat patterns. Thus Tang thinks that hidden warm evils may play a role in a number serious, sudden onset, acute conditions. However, Tang also thinks fu wen xie may also play a role in other, not so serious conditions, such a herpes zoster. As Tang points out, most herpes zoster patients present few defensive aspect symptoms; whereas, interior heat symptoms are typically marked. Another condition Tang thinks may be associated with hidden warm evils is viral pneumonia, especially the heavy type which initially begins as a qi and yin vacuity pattern.

Secondly, Tang Nai-guang thinks that hidden warm evils are often associated with diseases which Chinese medicine regards as difficult to treat. Here he refers to retained evils as a potential source or species of hidden warm evils. Retained evils (yu xie) refer to disease evils which remain after treatment which was not forceful enough. As Tang says, "If treatment is not forceful [enough], evil qi may fall internally."[3] Explaining this process in greater detail, Tang quotes an unidentified ancient:

[If] treatment has already [been given in order] to cure but [this] was no able to completely eliminate the disease root, these evils may lie deeply [or hide] internally and afterwards break out again. These are also called hidden evils.[4]

These retained evils may become hidden for an indeterminate length of time and then, when other factors comes together, they may result in the onset of some other disease. As examples of this process, Tang says that glomerulonephritis may be associated with retained evils from incompletely treated tonsillitis, scarletina, or erysipelas, and he thinks that most cases of viral myocarditis are due to various types of viral upper respiratory tract infections that have not been effectively treated. Other diseases Tang thinks may be associated with hidden or retained evils include a number of autoimmune disorders, such as scleroderma, systemic lupus erythmatosus (SLE), and rheumatoid arthritis RA), which have periods of remission and recurrence. All these are considered by Chinese medicine as difficult to treat diseases.

Unfortunately, Tang does not give any examples of how such hidden evil theory might be applied to the clinical treatment of the diseases he suggests may be associated with hidden evils. Although he thinks that an investigation of this theory may lead to improved Chinese medical treatment of the difficult to treat diseases he mentions, he fails to present a single case history showing this theory’s applicability in real-life practice or to even suggest a hypothetical treatment strategy for such hidden warm evils.

Since hidden warm evils often lie deeply in the blood aspect, there are at least two treatment strategies which are logical possibilities. These are cooling and clearing the blood and upbearing and out-thrusting evils, as in the treatment of measles. Of these two strategies, I think the first one holds the greatest potential for benefit with the least potential for adverse reactions. This is because, the medicinals used for out-thrusting evils are acrid, windy natured medicinals which can damage yin, and many patients with the kinds of conditions Tang mentions above already manifest yin vacuity patterns, or at least mixed yin vacuity patterns.[5]

Cooling and clearing the blood means to clear heat from the blood using such medicinals as Radix Lithospermi Seu Arnebiae (Zi Cao), Radix Scrophulariae Ningpoensis (Xuan Shen), Cortex Radicis Moutan (Dan Pi), Cortex Radicis Lycii Chinensis (Di Gu Pi), Radix Cynanchi Atrati (Bai Wei), and Radix Stellariae Dichotomae (Yin Chai Hu). Interestingly, Hong Qing-xiang, writing in "A Clinical Survey of the Treatment of 12 Cases of Sjögren’s Syndrome," notes that, although this autoimmune condition mostly manifests as a yin vacuity pattern, "taking clearing heat and resolving toxins as the root and nourishing yin and moistening dryness as the tip [or branch] gets better results in clinical practice" than just nourishing yin and moistening dryness.[6] In fact, Hong says that simply nourishing yin and moistening dryness gets only small results in this condition. In the case of Sjögren’s syndrome, overt symptoms of heat toxins are not usually present, but Hong and his teacher, Dr. Fu, seem to think such heat toxins, or at least heat evils, are present in most, if not all, cases of this particular autoimmune disorder. If hidden warm evils do, in fact, play a role in this and other autoimmune diseases, then this approach might be of benefit in those other conditions. Although heat-clearing, blood-cooling and heat-clearing, toxin-resolving medicinals are contraindicated in spleen-stomach vacuity conditions and most patients with autoimmune and other difficult to treat disease do present spleen vacuity symptoms, when these medicinals are combined in formulas which contain ingredients that supplement the spleen and harmonize the stomach, it is my experience that they do not typically provoke side effects. Therefore, I believe their cautious addition to standard formulas for these conditions warrants further investigation.

Copyright © Blue Poppy Press, 2001. All rights reserved.   

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Introduction

The Chinese medical technical term "blood ejection (tu xue)" is defined in Wiseman and Feng's A Practical Dictionary of Chinese Medicine as "ejection of blood through the mouth" and "vomiting or expectoration of blood." [1]   As such, it can refer to the Western medical diseases of hemoptysis (coughing of blood) as well as  hematemesis (vomiting of blood). Hence, this Chinese medical term does not differentiate if the ejected blood originated in the lungs or in the upper gastrointestinal (GI) tract. In Western medicine, upper GI tract bleeding is most commonly due to gastric or duodenal ulcers or erosions, varices, Mallory-Weiss tears, and erosive esophagitis. As a rule, hematemesis must be considered a medical emergency until proven otherwise. Bleeding of the respiratory tract giving rise to hemoptysis, on the other hand, is most commonly due to upper respiratory infections (URI) and bronchitis coughs. However, it may also be due to pulmonary tumors and pulmonary infarction secondary to thrombo-embolization of the lungs; or it may occur at the time of menstruation due to endometriosis. Hemoptysis, if due to URI's or bronchitis, manifesting as blood-streaked sputum is a common and nonthreatening condition. However, if hemoptysis involves a large quantity of blood or is recurrent, it requires an immediate search for its cause.

In Chinese medicine, blood ejection includes all of the above scenarios: blood-streaked sputum, gross hemoptysis, and hematemesis. Therefore, it may describe diseases which, in Western medicine, require emergency intervention. Thus, the following Chinese medical discussion of blood ejection needs to be prefaced by the statement that patients presenting with vomiting or expectoration of blood need to be first referred to and evaluated by a Western medical physician before any further Chinese medical therapy is prescribed. Thereafter, if the cause is not life-threatening and/or does not respond well to Western treatments, Chinese medicine could and should be combined with Western medical intervention.

In modern Chinese medicine, blood ejection is sometimes compared to retching of blood (ou xue) which specifically refers to bleeding only from the upper GI tract. However, retching of blood is not identical to blood ejection. Rather, retching of blood is a subtype of blood ejection. Nevertheless, since standard professional Chinese medicine primarily bases its treatment on pattern discrimination as opposed to disease diagnosis, the origin of bleeding in Chinese medicine is of less importance than the fact that blood is ejected from the mouth.

Blood ejection belongs to the category of bleeding conditions (xue zheng) in Chinese medicine. As such, it must have one of the four Chinese medical disease mechanisms of bleeding at its core. These four, as identified and taught by Bob Flaws, are: 1) heat (repletion or vacuity) stirring the blood and causing it to frenetically move outside the vessels; 2) static blood obstructing the flow of blood and hence forcing blood to leave the vessels; 3) qi vacuity not containing the blood within the vessels; and 4) trauma leading to damage of the vessels and hence causing blood to flow outside its pathways.

Below, I present a functional translation of an article by Tian Wei-jun that appeared in the December 1998 edition of  Xin Zhong Yi (New Chinese Medicine) and was titled "Pattern Discrimination and Treatment of Blood Ejection." [2]   However, in the introduction to his article, Dr. Tian says: "Blood ejection, also called retching of blood, is a bleeding disease in which blood from the stomach is ejected at the mouth." Hence, his discussion focuses on the blood ejection subtype of retching of blood, or, in modern Western medical terms, on hematemesis. [3] Following this translation, I list a number of Chinese medicinal prescriptions that are commonly used in modern China for various types and patterns of blood ejection.

Dr. Tian’s Discussion of Blood Ejection

Dr. Tian, combining his many years of clinical experience with existing theories on this subject, discriminates eight patterns of retching of blood, four repletion patterns and four vacuity patterns. The repletion patterns are intense exuberance of stomach heat, liver fire assailing the stomach, accumulation and stagnation damaging the stomach, and stasis obstructing the stomach network vessels. The vacuity patterns are central qi vacuity and weakness, qi vacuity-blood depletion, yin vacuity-fire effulgence, and middle burner cold depression. Furthermore, it is Dr. Tian's opinion that the early acute stages of this disease are most commonly characterized by heat causing the blood to frenetically move, ascend, and be ejected, and that the vacuity patterns are commonly a result of a prolonged duration of this disease and/or the loss (i.e., ejection) of profuse amounts of blood. 

A) Repletion Patterns

1) Intense exuberance of stomach heat

The Ji Sheng Fang (Aiding Life Formulas) says:

As for frenetic movement of the blood, this is always due to heat effusion, [leading to] hot blood [which] seeps [outside the vessels]. Blood and qi both become hot, and blood follows ascending qi, thus leading to spontaneous ejection of blood. 

Its causes are usually drinking excessive amounts of alcohol or indulgence in spicy, hot, greasy, and oily foods. Heat then amasses in the stomach. Similarly, alcohol's heat injures the stomach. Both assist fire and stir the blood. External damage by summerheat heat harassing the constructive and blood may also lead to an accumulation of heat which then turns into fire and leads to frenetic movement of the blood and thus blood ejection. Clinically, one can see sudden ejection of profuse amounts of blood which is fresh red or purple in color and mixed with food. Initially, ejection of blood is often accompanied by vexatious heat, thirst, a feeling of heat ascending and surging in the stomach duct or stomach duct pain, chest and duct glomus and oppression, clamoring stomach, and acid regurgitations. The attack may be brought on by drinking of alcohol; the stools are bound and constipated and black like lacquer; the urine is reddish; the lips are red; the mouth is malodorous (i.e., there is bad breath); the tongue is red with yellow fur; and the pulse is surging, slippery, and rapid. 

According to Dr. Tian, the suitable treatment principles for this pattern of blood ejection are to clear and discharge stomach heat, cool the blood and stop bleeding. The formula Dr. Tian recommends is San Huang Xie Xin Tang (Three Yellows Drain the Heart Decoction) which is bitter and cold and thus clears and discharges stomach fire. Within this formula, Radix et Rhizoma Rhei (Da Huang) is an especially important medicinal since it addresses both repletion heat in the stomach and ejection of blood (i.e., it clears heat and stops bleeding).  The Xue Zheng Lun (On Bleeding Conditions) says:

Da Huang is a flavor [i.e., medicinal] which pushes out the stale so as that the new [can be engendered]...it not only is quick at precipitating and downbearing but also does not leave any lodged evils behind. 

The above prescription should be combined with Si Sheng Wan (Four Uncooked [Ingredients] Pills): uncooked Folium Nelumbinis Nuciferae (He Ye), uncooked Folium Artemesiae Argyi (Ai Ye), uncooked Cacumen Biotae Orientalis (Ce Bai Ye), and uncooked Radix Rehmanniae (Sheng Di). These medicinals cool the blood and stop bleeding. If summerheat heat lead to blood ejection, then Dr. Tian thinks the correct formula is Qing Ying Tang (Clear the Constructive Decoction) which cools the blood and discharges heat. Dr. Tian combines this prescription with Cortex Radicis Moutan (Mu Dan Pi), Radix Rubrae Paeoniae Lactiflorae (Chi Shao), Herba Taraxaci Mongolici Cum Radice (Pu Gong Ying), and Radix Lithospermi Seu Arnebiae (Zi Cao) which cool the blood and resolve toxins. Dr. Tian also says one may consider adding fresh Nodus Rhizomatis Nelumbinis Nuciferae (Ou Jie) juice, fresh Folium Menthae Haplocalycis (Bo Ye), and Exocarpium Citrulli (Si Gua Cui Yi), which together clear summerheat, cool the blood, and stop bleeding. If there is blood ejection because damp heat has damaged the stomach, manifesting with slimy and yellow tongue fur and a soggy and rapid pulse, then Dr. Tian says the correct formula is Zhi Shi Dao Zhi Wan (Immature Aurantium Abduct Stagnation Pills) combined with Si Sheng Wan so as to clear heat and transform dampness, cool the blood and stop bleeding.

2) Liver fire assailing the stomach

If depressed anger damages the liver, liver qi counterflows transversely and depression leads to transformative fire. Thus the stomach network vessels are scorched and damaged. Or there may simply be stomach heat which is exacerbated by liver depression causing depressive fire in the liver channel which extends (i.e., increases) the stomach heat's strength, leading to frenetic movement of the blood with ejection of red or purple blood. In this case, the mouth is bitter and there is rib-side pain, vexation and agitation, irascibility, insomnia, profuse dreaming, a crimson red tongue, and a bowstring, rapid pulse. For Dr. Tian, the appropriate treatment principles are to drain the liver and clear the stomach, cool the blood and stop bleeding. The applicable formula is Zhang Xi-chun's Xie Gan Jiang Wei Tang (Drain the Liver & Downbear the Stomach Decoction) which consists of: Haematitium (Dai Zhe Shi), Radix Albus Paeoniae Latiflorae (Bai Shao), Concha Haliotidis (Shi Jue Ming), Semen Trichosanthes Kirlowii (Gua Lou Ren), Radix Gentianae Scabrae (Long Dan Cao), Pulvis Indigonis (Qing Dai), and Radix Glycyrrhizae (Gan Cao).  To this, Dr. Tian would add Rhizoma Imperatae Cylindrica (Bai Mao Gen), Ou Jie, and Radix Rubiae Cordifoliae (Qian Cao Gen) to cool the blood stop bleeding. If there is simultaneous chest and duct fullness and oppression and thirst without a desire to drink, Dr. Tian says there is often static blood. In that case, one can combine the above with Hua Rui Shi San (Ophicalcite Powder) or add Radix Pseudoginseng (San Qi) in order to transform stasis and stop bleeding.

3) Accumulation & stagnation damaging the stomach

The Zhong Yi Nei Ke Xue (Chinese Internal Medicine) says: "Fulminant drinking and eating can also [cause] detriment and damage the stomach network vessels and lead to ejection of blood." Fulminant eating and drinking leads to food stagnation obstructing internally which impedes the spleen’s movement, causes detriment and damage to the stomach network vessels, and thus leads to ejection of fresh red blood mixed with undigested food, stomach duct distension and fullness, and, if severe, [stomach] pain, putrid belching, acid regurgitations, non-crisp stools, slimy tongue fur, and a slippery pulse. The suitable treatment principles according to Dr. Tian are to disperse accumulation and guide out stagnation, harmonize the stomach and stop bleeding. The applicable formula is modified Bao He Wan (Harmony Preserving Pills).  Within this formula,  Fructus Crataegi (Shan Zha) and Massa Medica Fermentata (Shen Qu) disperse food and guide out stagnation. Rhizoma Pinelliae Ternatae (Ban Xia), Pericarpium Citri Reticulatae (Chen Pi), and Sclerotium Poriae Cocos (Fu Ling) transform dampness and harmonize the stomach. Fructus Forsythiae Suspensae (Lian Qiao) clears heat and dissipates bindings. The particularly great herb in this formula is Semen Raphani Sativi (Lai Fu Zi) which not only disperses food but also has the ability to open phlegm congestion and downbear the qi, loosen the chest and disinhibit the diaphragm. To this, Dr. Tian suggests adding Qian Cao Gen, Herba Ecliptae Prostratae (Han Lian Cao), and Ou Jie so as to cool the blood and stop bleeding. He also adds Mu Dan Pi, Chi Shao, and San Qi in order to stop bleeding and transform stasis.

4) Statis obstructing the stomach network vessels

The Lin Zheng Zhi Nan Yi An (Medical Guidebook for Clinical Patterns) says: "If there is accumulation and stasis in the network vessels, there is stirring of the network vessels with blood counterflow." The Xue Zheng Lun also says that, "If there is stasis, the qi pathways are obstructed and congested, obstructing and stagnating the qi mechanism." If the qi mechanism is congested and obstructed, then qi counterflow is engendered. Qi counterflow stirs the network vessels, and static blood, following the upward counterflow of qi, runs frenetic and seeps outside the vessels, thus engendering ejection of blood which is purplish-black and contains static clots. There is accompanying stabbing pain in the stomach duct which is fixed and refuses pressure, a blackish facial complexion, thirst with a desire to rinse the mouth but not to rinse the throat, a purplish-black tongue or a tongue with static macules and static speckles, and a rapid, bowstring pulse. The suitable treatment principles according to Dr. Tian are to quicken the blood and transform stasis, stop bleeding and downbear counterflow. The applicable formula is modified Hua Yu Zhi Xue Tang (Transform Stasis & Stop Bleeding Decoction) from the Zhong Yi Bing Zhuan Jian Bie Zhen Duan Xue (Differential Diagnosis of Chinese Medical Diseases). The medicinals in this formula include: Radix Salviae Miltiorrhizae (Dan Shen) to nourish and quicken blood; Qian Cao Gen "to quicken blood and move blood" (Ben Cao Gang Mu [Detailed Outline of the Materia Medica]); Chi Shao "to free the blood vessels and dissipate malign blood...govern the treatment of blood and stop pain" (Ben Cao Pin Hui Jing Yao [The Converging Essence of the Substances of the Materia Medica]); San Qi "to stop bleeding, dissipate blood, and settle pain" (Ben Cao Gang Mu); and Lignum Dalbergiae Odoriferae (Jiang Xiang) to move stasis, stop bleeding, and settle pain. Dr. Tian says that one can also use modified Xue Fu Zhu Yu Tang (Blood Mansion Expel Stasis Decoction) with additions and subtractions in the treatment of this pattern. Within that formula, Si Wu Tang (Four Materials Decoction) quickens blood and dispels stasis; Si Ni San (Four Counterflows Powder) courses the liver and resolves depression; Radix Platycodi Grandiflori (Jie Geng) opens the qi of the chest and diaphragm; and Radix Achyranthis Bidentatae (Niu Xi) guides the blood downward. Thus, one upbears (although it does not state this above, Jie Geng upbears qi) and one downbears, thereby regulating the qi mechanism's upbearing and downbearing. In clinic, one can also add Qian Cao Gen and San Qi to increase the strength of stopping bleeding and dispelling stasis.

B) Vacuity Patterns

1) Central qi vacuity weakness

The central qi is the qi of the spleen and stomach. If there is excessive taxation fatigue causing detriment and damage to the spleen and stomach, or if there is prolonged illness leading to spleen vacuity, the qi may not be able to contain the blood and the blood may move erroneously into the mouth and is ejected. It is said that, "The spleen controls [the blood], and if excessive thought damages the spleen, then there is ejection of blood" (Yi Fang Lei Ju [Gathering of Medical Methods).  In this case, the color of the ejected blood is red. There are sloppy and black stools as well as stomach pain which sometimes manifests and sometimes does not. In addition, this pain typically desires pressure. Further, there is shortness of breath, fatigued spirit, a pale red tongue with thin, white fur, and a vacuous, weak pulse. The suitable treatment principles are to supplement the qi and contain the blood. The applicable formula is modified Bu Zhong Yi Qi Tang (Supplement the Center & Boost Qi Decoction). Within this formula, Radix Codonopsitis Pilosulae (Dang Shen), Rhizoma Atractylodis Macrocephalae (Bai Zhu), Fu Ling, and mix-fried Gan Cao boost the qi and fortify the spleen. Radix Astragali Membranacei (Huang Qi) and stir-fried Radix Angelicae Sinensis (Dang Gui) supplement the qi and engender the blood. Radix Bupleuri (Chai Hu) and Rhizoma Cimicifugae (Sheng Ma) upbear and lift the clear yang and thus upbear the descended and fallen qi. Gelatinum Corii Asini (E Jiao) and Rhizoma Bletillae Striatae (Bai Ji) nourish the blood and stop bleeding. Chen Pi rectifies the qi and arouses the spleen. For severe and profuse blood ejection with a bright white facial complexion, heart palpitations, shortness of breath, spontaneous perspiration, and cold limbs, a critical condition in which qi follows deserting blood, one must quickly use Du Shen Tang (Solitary Ginseng Decoction) so as to boost the qi and stem desertion. Yu Nan Bai Yao (Yunan White Medicine) or San Qi Fen can be added to stop bleeding. A 10% glucose solution with an injection of Shen Fu Tang (Ginseng & Aconite Decoction) can be used as well if one wants to combine Chinese and Western medicine.

2) Qi vacuity blood depletion

As Dr. Tian says, there are many causes leading to qi vacuity and blood depletion. If the qi is vacuous, then the blood is not governed, and managing and containing lose their ability. If the blood is vacuous, then the qi is not carried. A dual vacuity of both qi and blood leads to the ejection of only a little blood which is hard to bring up. Other symptoms include continuous and unstoppable ejection of blood of a pale, not fresh, color. There is dull stomach duct pain which desires pressure, shortness of breath, fatigued spirit, lack of strength, heart palpitations, scant sleep, a bright white facial complexion, sometimes black stools, pale lips and tongue, and a fine or choppy [4] pulse. The suitable treatment principles for this pattern according to Dr. Tian are to fortify the spleen and boost the qi, nourish the blood and stop bleeding. The applicable formula is modified Gui Pi Tang (Return the Spleen Decoction) stemming from the Ji Sheng Fang. Within this formula, Si Jun Zi Tang (Four Gentlemen Decoction) fortifies the spleen and boosts the qi so as to bank the source of engenderment and transformation of qi and blood. Dang Gui Bu Xue Tang (Angelica Supplement the Blood Decoction) supplements the qi and engenders the blood. Further, Arillus Euphoriae Longanae (Long Yan Rou), Semen Ziziphy Spinosae (Suan Zao Ren), and Radix Polygalae Tenuifoliae (Yuan Zhi) supplement the blood and nourish the heart. E Jiao and Bai Ji nourish the blood and stop bleeding; Da Zao boosts the spleen; and Mu Xiang arouses the spleen. Dr. Tian says that clinical experience demonstrates that this formula is used with good effect.

3) Yin vacuity-fire effulgence

Fire is divided into vacuity and repletion fire. Qi is divided into insufficiency and surplus. Vacuity fire is yin vacuity with fire effulgence. If there is recurrent blood ejection of the repletion type without a cure, if excessive sexual activity damages the kidneys, or if excessive alcohol is consumed, then essence blood is caused detriment and damage. If the yin aspect is greatly depleted, then vacuity fire floats upward and surging qi counterflows upward. Blood follows the upwardly surging and counterflowing qi. Hence, there is ejection of blood. It is said that:

Yang usually has a surplus, [while] yin is usually insufficient. If yin qi is damaged, there is frenetic movement to the above and there is spontaneous ejection of blood (Guo Yi Zhong Zhi [National Medicine Ancestral Decree]).

In this case, the ejected blood is copious in amount and fresh red in color. There is also scorching pain in the stomach duct, vexation and agitation, thirst, tidal reddening of the facial complexion, night sweats, dizziness, heart palpitations, scant sleep, black or dry and black stools, a red tongue with scant liquids, and a fine, rapid pulse. For this pattern, Dr. Tian thinks that the suitable treatment principles are to enrich yin and downbear fire, cool the blood and stop bleeding, and he thinks that the applicable medicinals are Gypsum Fibrosum (Shi Gao) and Rhizoma Anemarrhenae Asphodeloidis (Zhi Mu) to clear and discharge stomach fire; Sheng Di Huang and Tuber Ophiopogoni Japonici (Mai Dong) to nourish yin and clear heat; and Niu Xi to lead fire downward and to downbear vacuity fire of the stomach so as to stop blood ejection’s ascending counterflow. He says one can also add Bai Mao Gen, Ou Jie, Mu Dan Pi, Ce Bai Ye,  and Folium Callicarpae (Zi Zhu Cao) in order to nourish yin and stop bleeding. If there is qi and yin dual vacuity, add Radix Panacis Quinquefolii (Xi Yang Sheng) to boost the qi and nourish yin. For heart vexation with scant sleep, add Suan Zao Ren, Cortex Albizziae Julibrissinis (He Huan Pi), and Caulis Polygoni Multiflori (Ye Jiao Teng) to eliminate vexation and quiet the spirit.

4) Middle gong cold depression [a.k.a. middle burner cold depression; gong is the note of spleen earth]

Middle gong refers to the spleen and stomach. If taxation fatigue damages the spleen or if blood ejection lasts for a prolonged period of time, qi follows the blood and yang follows the qi. Hence, spleen yang becomes insufficient and control of the blood loses its duty. Thus it is said, "If yang is vacuous, yin certainly wanders." (Jing Yue Quan Shu [The Complete Book of Jing-Yue]). Yin and blood are the same. Thus, if yang is vacuous and loses its control over the blood, the blood may seep outside of its vessels. It is also said, "Blood wanders [i.e., penetrates] and is discharged into the stomach" (Xue Zheng Lun). Therefore, it comes out at the mouth in the form of blood ejection. If the yang of the spleen and stomach is vacuous, then recurrent intake of chilled liquids, cold depression of the middle gong, and further damage to the spleen and stomach lead to recurrent detriment of middle yang. "If yang is vacuous, the blood cannot be controlled." (Yi Zong Zhai Yao [Selected Essentials from Ancestral Medicine]). To sum up the above, ejection of blood due to cold depression in the middle gong is not without involvement of the spleen and stomach. Its symptoms are ejection of pale, purplish blood, sloppy and black stools, dull stomach pain, possible upflow of clear water, declined intake with scant eating, fear of cold with cold hands and feet, a pale tongue with white fur, and a fine, weak pulse. The suitable treatment principles are to warm the middle and support yang, nourish the blood and stop bleeding. The applicable formula is Huang Tu Tang (Yellow Earth Decoction). Within this formula, Terra Flava Usta (Zao Xin Tu) warms the middle and stops bleeding; Shu Di and E Jiao nourish the blood and stop bleeding; stir-fried Bai Zhu, Radix Lateralis Praeparatus Aconiti Carmichaeli (Fu Zi), and mix-fried Gan Cao warm yang and fortify the spleen so as to restore middle yang’s duty of controlling the blood. Why is bitter and cold Radix Scutellariae Barbatae (Huang Qin) in this formula? For one, this is to prevent Fu Zi’'s acrid heat stirring the blood, and two, this substance (i.e., Huang Qin) also has a stop-bleeding function. This clearly illustrates the opposing assistant (fan zuo) principle of medicinal combination. Clinically, if this formula is used, Dr. Tian thinks one should add blast-fried Rhizoma Zingiberis (Pao Jiang) to warm the channels and stop bleeding and Bai Ji Fen to astrict and stop bleeding. Dr. Tian says this further improves the treatment effect. If there is blood ejection without stopping (i.e., continuous blood ejection) with signs of static blood, add San Qi and Ophicalcitum (Hua Rui Shi) to transform stasis and stop bleeding.

C) Dr. Tian’s Discussion

Blood ejection is a an acute disease in Chinese medicine, especially when part of a critical condition. It is said: "If one obtains blood, life is preserved." (Xue Zheng Lun) Thus, clinically, treat it after differentiating the patterns of cold and heat and vacuity and repletion. If stomach heat is intensely exuberant, use San Huang Si Sheng Wan with modifications. For liver fire assailing the stomach, use Xie Gan Jiang Wei Tang. If accumulation and stagnation damages the spleen and stomach, use modified Bao He Wan. For static blood obstructing the network vessels, use Hua Yu Zhi Xue Tang. For vacuity weakness of the central qi, use modified Bu Zhong Yi Qi Tang. For qi vacuity with blood weakness, use modified Gui Pi Tang. For yin vacuity-fire effulgence, use Yu Nu Jian (Jade Maiden Brew) with added flavors. For cold depression in the middle gong, use Huang Tu Tang. For qi desertion following blood desertion, use Du Shen Tang, Shen Fu Tang, or a combination of Chinese and Western medicine.

Clinically, in the treatment of blood ejection, it is most important to accurately discriminate the pattern and prescribe medicinals on the basis of that pattern discrimination. However, regardless of the complexity or simplicity of the formula, a number of empirical formulas have good effects in stopping bleeding. Some of these formulas are: Zhi Xue San (Stop Bleeding Powder: San Qi, Bai Ji, and calcined Hua Rui Shi), Zhi Xue Fang (Stop Bleeding Formula: Bai Ji, Os Sepiae seu Sepiellae (Hai Piao Xiao), charred Ce Bai Ye, Herba Seu Radix Cirsii Japonici (Da Ji), Herba Cephalanoplos Segeti (Xiao Ji), Fu Ling, Bai Zhu,and Gan Cao), Zhi Xue Fen (Stop Bleeding Powder: Bulbus Fritillariae Cirrhosae (Chuan Bei Mu), E Jiao, and San Qi). Dr. Tian himself regularly uses charred Da Huang, 3g, and powdered Bai Ji, 10g, added to formulas prescribed according to pattern discrimination. These medicinals’ stop-bleeding function is good and rapid. Because Da Huang contains tanic substances, it astringes and contracts the blood vessels. Bai Ji contains Bletilla glues which are extremely sticky and are also astringing, thus stopping bleeding as well as engendering the flesh. These gluey substances in Bai Ji also promote RBC coagulation and artificial thrombus formation, thus further aiding hemostais.

After ejecting blood, there is usually stasis collecting and stagnating. If static blood is not removed, then new (i.e., fresh) blood cannot be engendered. This then frequently leads to recurrent bleeding. To suitably treat this condition, one needs to follow the basic pattern discrimination above, but Dr. Tian says to certainly add one or two medicinals from the following list: San Qi, Dan Shen, Dang Gui, Tuber Curcumae (Yu Jin), Flos Carthami Tinctorii (Hong Hua), and Da Huang. These medicinals help to disperse stasis, quiet the blood, and supplement vacuity. Furthermore, according to the cause leading to blood ejection, one needs to take good care of oneself so as to prevent a recurrence of the illness. This is very important. One should stay at home, regulate their eating and drinking, suitably adjust cold and warm foods, avoid emotional stimulation, and stay away from eating hot and spicy foods. While one is suffering from blood ejection, one should stay in bed, have a calm and settled mood, and eliminate fear and anxiety so as to prevent recurrence or aggravation of blood ejection. If blood ejection is severe, one must abstain from foods. After the bleeding has stopped, one should only eat a little food and preferably drink liquid foods or semi-liquid foods. This is so as to maintain the spleen and stomach’s physiological function.

Blood Ejection Treatment Formulas

The following is a list of treatment formulas which stem from modern clinical manuals and research articles published in the People's Republic of China. These formulas are indicated not only for retching of blood but rather for blood ejection, including the Western medical conditions hemoptysis and hematemesis. However, as indicated in the indications section under each formula, some prescriptions are more appropriate to treat bleeding from the GI tract, whereas other formulas are more appropriate to treat bleeding from the lungs. Nevertheless, the discrimination of the patient’s pattern is, ultimately, more important than the differentiation of the site of bleeding. For example, a formula indicated for upper GI bleeding and having the function of supplementing qi and c

Introduction:

In the April edition of the Blue Poppy Online Journal, I outlined the treatment of the remission stage and long-term effects of chronic gout.[1]  This present article is an extension of that paper and primarily focuses on the treatment of acute gout. Together, these two papers are a comprehensive report on the Chinese medical treatment of gout, an as yet practically unavailable topic in the English language literature of Chinese medicine. The information below has been compiled from more than 20 research reports on gout that appeared in recent professional journals of Chinese medicine in the People’s Republic of China.  Besides giving a detailed description of the Chinese medical disease causes and disease mechanisms, more than 15 medicinal formulas and various external therapies are discussed. The value of all these treatment formulas or modalities is that they are not simply textbook advice or theoretical concepts but rather have been found, through clinical studies, to be effective in the treatment of gout and its associated symptoms and complications.

Why is the treatment of gout with Chinese medicine even necessary? Current biomedical treatments of gout are fairly effective and often quickly lead to the subsiding of symptoms. However, all Western medicines carry a relatively high risk of debilitating side effects. Chinese medicine, on the other hand, treats this disease without the debilitating side effects but with approximately equal effectiveness. In a clinical audit by Zhang Ming and Tiao Rong[2], the outcomes of both the treatment group receiving Chinese medicinals and the control group receiving standard Western medicines was essentially equal (94.2% vs. 94%).  The only notable difference between the two groups was that the control group which received the Western medicine suffered from many side effects, whereas the treatment group did not. Hence, assuming that Chinese medicine treats gout as effectively as does modern Western medicine, Chinese medical treatment is much more desirable due to the fact that it free of side effects when administered correctly by a professional practitioner of Chinese medicine.

At this point, I need to note that I have also found one clinical audit in which the author explicitly states that he does not think that Chinese medicine by itself is a sufficiently adequate treatment for gout. Sun Yu-qin, in his article titled "The Combination of Chinese & Western Medicine in the Treatment of 11 Cases of Gout" says:

Western medicines, such as allopurinol and tong feng (gout) li xian (?), can help lower blood uric acid levels but cannot efficiently resolve the diseases symptoms. Medications such as anti-inflammatories, ibuprofen, and colchicine, can resolve symptoms but lead to gastrointestinal side effects, such as abdominal discomfort, nausea, and vomiting, or even bleeding of the upper gastrointestinal tract.  Hence, these drugs cannot be taken long-term and, when they are discontinued, symptoms of gout often reappear. The simple use of Chinese medicinals can resolve symptoms, but it is not effective for lowering blood uric acid levels. Therefore, Western medicine and Chinese medicine must be combined to effectively treat and prevent the recurrence of gout.[3]

Sun Yu-qin’s opinion that Chinese medicine is effective for treating the symptoms of gout is backed by all other references used in this report. His opinion that Chinese medicine is not effective for lowering blood uric acid levels, however, seems to be his own. Many reports clearly point out the relationship between taking Chinese medicinals and lowered blood uric acid levels. Hence, Chinese medicine seems to be an effective and side effect free alternative to modern Western medicine for the treatment of gout which can either be used alone or in combination with Western medications.

Western medical disease explanation:

Gout represents a recurrent acute arthritis of peripheral joints that results from the deposition of urate crystals secondary to an increased serum uric acid level (hyperuricemia). This arthritis may become chronic and deforming.[4] Uric acid is produced from the catabolism of purines. Purines, if not derived from diet, may stem from increased cell turn-over with a high nucleoprotein (RNA/DNA) breakdown (which occurs in such diseases as lymphoma, leukemia, or hemolytic anemia) or may occur in cases where cellular proliferation and cell death is increased (such as in psoriasis). Furthermore, ethanol consumption accelerates ATP catabolism and slightly decreases glomerular filtration rate, thus increasing uric acid levels in the blood. When such an underlying cause for hyperuricemia can be determined, one refers to this as secondary gout. If purines are synthesized de novo or if an unexplained decrease in urinary clearance of uric acid leads to hyperuricemia, gout is called primary gout (i.e., no underlying disease is present). A decreased urinary clearance of uric acid is by far the most common cause of primary gout, and 75-90% of all cases suffering from primary gout “result from an as yet unexplained impairment of uric acid excretion by the kidneys.”[5] 

At 37.0EC, plasma is saturated with uric acid at levels above 7.0mg/dL. Urate solubility at 30EC is 4mg/dL. Therefore, urate crystals precipitate and deposit in the distal peripheral joints and in cooler tissues such as the ears. Crystals may also deposit in the kidneys and lead to renal failure (leading to an even further decrease of uric acid clearance) and urate stones.

Clinically, gout is divided into four stages: asymptomatic hyperuricemia often precedes acute attacks of gout and does not manifest with any symptoms. During acute gouty arthritis – the second stage – the joints of especially the metatarsophalangeal joint of the big toe but also of the ankles, knees, and possibly upper arm joints are involved. The attacks commonly start at night and are very painful. The involved joint or joints are swollen, red, and exquisitely tender. The overlying skin is often tense, warm, shiny, and red or purplish. Acute gout may be precipitated by a large and rich meal (lots of fats and purine-containing foods), alcohol, trauma, emotional stress, and medical stress. The third stage is the inter-critical period (henceforward referred to as the chronic period) during which no acute attacks occur and which can last up to 10 years. However, subsequent attacks “tend to be increasingly severe, prolonged, polyarticular, and even febrile.”[6]  Initial acute attacks last only a few days, but later untreated attacks may persist for weeks.  The fourth and last stage is termed tophaceous gout. This appears in patients with uncontrolled gout in whom the uric acid levels are not stabilized at normal or only slightly elevated levels. Tophi appear in the cartilage, synovial membranes, tendons, and soft tissues. These represent crystal aggregates which, during the later stages of gout, can be felt as subcutaneous nodules. If they rupture, a chalky white mass of urate crystals may be discharged. The bursa walls and tendon sheaths are frequently affected, and chronic joint symptoms with joint deformity and limitation of motion may develop during the later stages of disease when acute attacks are more frequent. Crystal deposits in the kidneys lead to urate stones which account for 10% of all renal calculi. Up to 25% of patients with gout are affected by this ailment. Furthermore, renal failure secondary to urate deposits in the renal interstitium account for 10% of deaths in patients suffering from gout.[7] 

Western medical treatment of gout is threefold. First, acute attacks need to be relieved. Colchicine is the drug of choice and is often immediately effective. However, the side effects of vomiting and diarrhea frequently prohibit or at least complicate administration. Second, serum urate levels must be lowered and dissolution of urate deposits increased. Besides avoiding foods high in purines and abstaining from alcohol, drugs which inhibit uric acid synthesis, such as allopurinol, and uricosuric drugs which inhibit urate resorption by the renal tubules, such as probenecid and sulfinpyrazone, are frequently administered during the chronic period. Allopurinol can actually dissolve established calculi. However, it causes GI distress, skin rashes, and leukopenia. Third, future attacks may be prevented by administering colchicine prophylactically during the chronic stages. Furthermore, nonsteroidal anti-inflammatory drugs (NSAIDs) are often administered for 2-3 days during acute attacks. Here, it is important to avoid salicylates as they antagonize uricosuric drugs. Acetaminophen provide comparable analgesia without interfering with uricosuric drug actions.

Chinese medical disease explanation

Gout belongs to the Chinese medical disease categories of impediment (bi), joint-running wind (li jie feng), and white tiger joint-running (bai hu li jie).[8] As we have seen above, gout can be divided into an acute stage and a chronic stage.  Characteristic symptoms during the acute stage are red, hot, swollen, and severely painful joints. The chronic stage is marked by elevated blood levels of  uric acid, urinary calculi, stiffness, and deformities of the joints as well as gouty nodules (tophi) all over the body but particularly around the joints and on the ears. Understanding the clinical manifestations of this disease in these two stages helps explain how and why Chinese medicine ascribes the diseases causes and mechanisms it does to this condition.

The underlying problem in most patients suffering from primary gout is a disorder of the purine metabolism. In Chinese medicine, this disorder is attributed to a natural endowment insufficiency with a general weakness of bodily qi. Furthermore, in old people, the population most commonly affected by gout, qi and blood become more debilitated day by day. Weak bodily qi combined with unregulated eating and drinking over time damages the spleen and stomach and leads to an inability to separate the clear from the turbid. Hence, dampness accumulates and pours into the joints, skin, and flesh externally and into the five viscera and six bowels internally. Further attacks of internal dampness or external evils may then, according to the mechanisms explained below, lead to recurrent gout.

 

Acute attacks arise after non-regulation of food and drink. The consumption of rich and excessively sweet foods leads to smoldering of dampness and phlegm internally. Smoldering phlegm and dampness obstruct the free flow of the inherently warm qi and thus may transform heat. Such heat transformations are aggravated if alcohol or fried foods are consumed. Damp heat then pours into the sinews and bones and phlegm obstructs the vessels and network vessels. Hence, an initial, possibly mild, impediment arises. Thereafter, repeated irregularities of food and drink or further assailment by different external wind evils lead to more severe congestion and blockage of the blood vessels, channels and network vessels. Thus, qi and blood become stagnant and static, and their free flow is inhibited. If there is no free flow, there is pain. Furthermore, due to the inherently warm nature of qi, prolonged lodging and depression of any evil will transform more heat. Hence, the joints become red, swollen, and painful, and their movement becomes inhibited.

Prolonged diseases or recurrent diseases lead to static blood obstructing the free flow of qi. Static blood may also bind with phlegm and turbidity to give rise to phlegm stasis. This leads to deformities of the joints and the characteristic gout nodules (tophi).

Chinese medicine has no concept of uric acid and does not measure its levels. However, it attributes the bean-curd like excretions of urate crystals from ulcerated gout nodules to phlegm dampness and considers the high blood uric acid levels, measured by Western medical devices, to be due to damp turbidity. Hence, the addition of phlegm-transforming or dampness-eliminating and turbidity-resolving medicinals to gout prescriptions has the effect of helping to dissipate nodules (gout tophi) and lower the blood uric acid level.

All acute attacks of gout are commonly discriminated as a damp heat impediment pattern. However, phlegm stasis and an underlying spleen vacuity and former heaven insufficiency are, as explained above, very commonly part of recurrent gout patterns. Hence, treatment must not only focus on clearing heat and disinhibiting dampness but also on quickening the blood and transforming phlegm, separating the clear from the turbid, and fortifying the spleen and supplementing the former heaven.

In between acute attacks of gout, during the chronic stages, heat and toxins are not as pronounced and the flow of qi and blood is not as obstructed as during acute attacks. However, the predisposing factor to gout, an underlying vacuity of the spleen and kidneys and the smoldering of at least some dampness, is still present. If external evils assail or if food and drink are not properly regulated, excessive dampness again accumulates and transforms heat and another acute attack is initiated. Hence, treatment during the chronic stages must focus on supplementing the kidneys, fortifying the spleen, and eliminating residual dampness.  Furthermore, according to the principle that prolonged and uncured diseases lead to phlegm stasis which leads to the deformities and gouty nodules, it is also important to quicken the blood and resolve phlegm.

Treatment based pattern discrimination:

Damp heat smoldering & obstructing

Main symptoms: Red, hot, swollen, and severely painful joints, shiny skin of the local area, sudden onset of pain, pain more severe at night, recurrent attacks, joint stiffness and deformities. The most commonly affected joint is the first metatarsophalangeal joint, but the ankle, knee, or finger joints may also be affected. There is difficulty walking and possible engenderment of tophi and nodules which may ulcerate and excrete a white, bean-curd like substance. Attacks are precipitated by eating greasy, fatty, and rich foods, drinking alcohol, being excessively active, or injuring the affected area. These attacks are possibly accompanied by headache, fever, aversion to cold, vexation and agitation, thirst, and reddish and scant urine or stone strangury.[9] The tongue is red or pale red with white or yellow, thin and slimy fur, and the pulse is slippery, bowstring, and possibly rapid.

Treatment principles: Clear heat and disinhibit dampness, quicken the blood and transform stasis, disperse swelling, stop pain, separate the clear from the turbid, dispel wind, boost the kidneys and fortify the spleen, and possibly transform stones

Formulas:

Si Miao Wan Jia Wei (Four Wonders Pills with Added Falvors)[10]

Rhizoma Atractylodis (Cang Zhu), stir-fried Cortex Phellodendri (Huang Bai), Radix Achyranthis Bidentatae (Huai Niu Xi), Caulis Akebiae (Mu Tong), Radix Stephaniae Tetrandrae (Han Fang Ji), Fructus Liquidambaris Taiwaniae (Lu Lu Tong), Semen Coicis Lachrymae-jobi (Yi Yi Ren), Caulis Lonicerae Japonicae (Ren Dong Teng), uncooked Radix Rehmanniae (Sheng Di), Rhizoma Smilacis Glabrae (Tu Fu Ling), Radix Glycyrrhizae (Gan Cao) 

This formula, combined with Xin Guang (?) Pian (New & Expanded [?] Tablets), [11] led to a drastic improvement in symptoms in 49 out of 50 cases suffering from gout within two weeks.

Tong Feng Tang (Pain Wind [i.e. Gout] Decoction)[12]

Gypsum Fibrosum (Shi Gao), Herba Oldenlandiae Diffusae Cum Radice (Bai Hua She She Cao), Ramulus Mori Albi (Sang Zhi), Radix Stephaniae Tetrandrae (Fang Ji), Rhizoma Alismatis (Ze Xie), Semen Plantaginis (Che Qian Zi), Radix Et Rhizoma Rhei (Da Huang), Cortex Phellodendri (Huang Bai), Sclerotium Poriae Cocos (Fu Ling), Herba Pyrolae (Lu Han Cao), Fructus Corni Officinalis (Shan Zhu You), Radix Dioscoreae Oppositae (Shan Yao), Semen Cuscutae Chinensis (Tu Si Zi), Radix Glycyrrhizae (Gan Cao)

This formula, besides clearing heat and disinhibiting dampness, also boosts the kidneys and resolves toxins. 

Wu Teng Wu Pi Yin (Five Vine & Five Skin Brew)[13]

Caulis Et Rhizoma Sinomenii Seu Sabiae (Qing Feng Teng)[14], Caulis Piperis Futokadsurae (Hai Feng Teng), Ramulus Uncariae Cum Uncis (Shuang Gou Teng), Caulis Polygoni Multiflori (Ye Jiao Teng), Caulis Aristolochiae (Tian Xian Teng), Cortex Erythrinae Variegatae (Hai Tong Pi), Cortex Radicis Dictamni Dasycarpi (Bai Xian Pi), Cortex Radicis Moutan (Mu Dan Pi), Cortex Radicis Lycii Chinensis (Di Gu Pi), Cortex Radicis Mori Albi (Sang Bai Pi)

Modifications:

During the acute phase with red, hot, swollen, and painful joints, add Gypsum Fibrosum (Shi Gao), Herba Taraxaci Mongolici Cum Radice (Pu Gong Ying), and Radix Et Rhizoma Polygoni Cuspidati (Hu Zhang).  For pronounced swelling, add Rhizoma Dioscoreae Hypogalucae (Bi Xie) and Radix Stephaniae Tetrandrae (Han Fang Ji). For pronounced pain, remove Qing Feng Teng and add Radix Albus Paeoniae Lactiflorae (Bai Shao) and Radix Glycyrrhizae (Gan Cao). For accompanying renal calculi, add Endothelium Corneum Gigeriae Galli (Ji Nei Jin) and Herba Lysimachiae Seu Desmodii (Jin Qian Cao). For gouty tophi, add Squama Manitis Pentadactylis (Chuan Shan Jia), Lumbricus (Di Long), and Radicis Extremitas Aneglicae Sinensis (Dang Gui Wei).

Tong Feng Xiao (Pain Wind [i.e. Gout] Disperser)[15]

Rhizoma Atractylodis (Cang Zhu), stir-fried Cortex Phellodendri (Huang Bai), Radix Achyranthis Bidentatae (Huai Niu Xi), Semen Coicis Lachrymae-jobi (Yi Yi Ren), Rhizoma Dioscoreae Hypoglaucae (Bi Xie), Rhizoma Smilacis Glabrae (Tu Fu Ling), Rhizoma Alismatis (Ze Xie)

Modifications:

During the acute inflammatory phase manifesting with local redness, swelling, heat, and pain, add Radix Stephaniae Tetrandrae (Han Fang Ji), Radix Gentianae Macrophyllae (Qin Jiao), Caulis Lonicerae Japonicae (Ren Dong Teng), Excrementum Bombycis Mori (Wan Can Sha), and Ramulus Mori Albi (Sang Zhi). For pronounced heat, add Rhizoma Anemarrhenae Asphodeloidis (Zhi Mu) and uncooked Radix Rehmanniae (Sheng Di). If the inflammation has dispersed but the pain has not been eliminated and there is accompanying stiffness and dark red skin, add Radix Rubrus Paeoniae Lactiflorae (Chi Shao), Cortex Radicis Moutan (Mu Dan Pi), and Radix Salviae Miltiorrhizae (Dan Shen). For pronounced elevation of the blood uric acid level, add Radix Et Rhizoma Rhei (Da Huang) and Stylus Zeae Maydis (Yu Mi Xu). For swelling and stiffness of the local area that does not disperse and begins to nodulate, add Radix Scrophulariae Ningpoensis (Xuan Shen), Radix Angelicae Sinensis (Dang Gui), and Flos Carthami Tinctorii (Hong Hua).

Xiao Tong Yin (Disperse Pain Brew)[16]

Radix Angelicae Pubescentis (Du Huo),  Radix Stephaniae Tetrandrae (Han Fang Ji), Rhizoma Alismatis (Ze Xie), Fructus Chaenomelis Lagenariae (Mu Gua), Cortex Phellodendri (Huang Bai), Rhizoma Atractylodis (Cang Zhu), Concretio Siliceae Bambusae (Tian Zhu Huang), Bombyx Batryticatus (Jiang Can), Caulis Lonicerae Japonicae (Ren Dong Teng), Radix Rubrus Paeoniae Lactiflorae (Chi Shao), Radix Achyranthis Bidentatae (Niu Xi), Lumbricus (Di Long)

Modifications:

For pronounced redness and swelling, add Herba Scutellariae Barbatae (Ban Zhi Lian), Sclerotium Rubrum Poriae Cocos (Chi Fu Ling), and Caulis Akebiae (Mu Tong). For pronounced pain, add Radix Pseudoginseng (San Qi), Rhizoma Corydalis Yanhusuo (Yan Hu Suo), and Herba Asari Cum Radice (Xi Xin). For dry and bound stools, add Radix Et Rhizoma Rhei (Da Huang). For swollen and big joints with deformities, add Squama Manitis Pentadactylis (Chuan Shan Jia), Buthus Martensis (Quan Xie), and prepared Rhizoma Arisaematis (Nan Xing).

It is important to note that the authors of this formula point out that, after the symptoms have dispersed, one should persist in taking this prescription at a frequency of 3 ji per week (in contrast to 7 ji per week during the acute phase) for at least another two months so as to remove dampness, prevent the engenderment of phlegm, and transform stasis.

Shang Zhong Xia Tong Yong Tong Feng Fang (Upper, Middle & Lower Body General Use Pain Wind [i.e. Gout] Formula)[17]

Cortex Phellodendri (Huang Bai), Rhizoma Atractylodis (Cang Zhu), prepared Rhizoma Arisaematis (Nan Xing), Radix Clematidis Chinensis (Wei Ling Xian), Ramulus Cinnamomi Cassiae (Gui Zhi), Radix Stephaniae Tetrandrae (Fang Ji), Semen Pruni Persicae (Tao Ren), Flos Tinctorii Carthami (Hong Hua), Radix Gentianae Scabrae (Long Dan Cao), Radix Ligustici Wallichii (Chuan Xiong), stir-fried Radix Angelicae Dahuricae (Bai Zhi), Radix Et Rhizoma Notopterygii (Qiang Huo), Massa Medica Fermentata (Shen Qu)

Zeng Wei Wu Bi Tang Jia Jian (Modified Increase Flavor Five Impediments Decoction)[18]

Herba Ephedrae (Ma Huang), Ramulus Cinnamomi Cassiae (Gui Zhi), Flos Carthami Tinctorii (Hong Hua), Radix Angelicae Dahuricae (Bai Zhi), Radix Puerariae (Ge Gen), Radix Aconiti Carmichaeli (Chuan Wu, pre-decoct for one hour so as to reduce the toxicity), powdered Cornu Antelopis (Ling Yang Jiao Fen)[19], Radix Astragali Membranacei (Huang Qi), Radix Ledebouriellae Divaricatae (Fang Feng), Radix Stephaniae Tetrandrae (Han Fang Ji), Radix Et Rhizoma Notopterygii (Qiang Huo), Rhizoma Anemarrhenae Asphodeloidis (Zhi Mu), Gypsum Fibrosum (Shi Gao), Cortex Radicis Moutan (Mu Dan Pi), Radix Rubrus Paeoniae Lactiflorae (Chi Shao), Radix Rubiae Cordifoliae (Qian Cao Gen), Eupolyphagia Seu Opisthoplatia (Tu Bie Chong), Zaocys Dhumnades (Wu Shao She)

It is interesting to point out that modern pharmacological research has shown that Chuan Wu has a relatively strong anti-inflammatory and pain-reducing function.

Jia Wei San Miao Wan (Three Wonders Powder with Added Flavors)[20]

Rhizoma Atractylodis (Cang Zhu), Cortex Phellodendri (Huang Bai), Radix Cyathulae (Chuan Niu Xi), Radix Stephaniae Tetrandrae (Han Fang Ji), Ramulus Mori Albi (Sang Zhi), Radix Angelicae Sinensis (Dang Gui), Radix Rubrus Paeoniae Lactiflorae (Chi Shao), Radix Angelicae Pubescentis (Du Huo), Rhizoma Dioscoreae Hypoglaucae (Bi Xie), Caulis Trachelospermi Jasminoidis (Luo Shi Teng), Flos Lonicerae Japponicae (Jin Yin Hua), Semen Coicis Lachrymae-jobi (Yi Yi Ren).

Modifications:

For a simultaneous exterior disease, remove Bi Xie and Luo Shi Teng and add Radix Et Rhizoma Notopterygii (Qiang Huo) and Radix Ledebouriellae Divaricatae (Fang Feng). For pronounced damp turbidity, remove Dang Gui and Luo Shi Teng and add Rhizoma Atractylodis (Cang Zhu), Sclerotium Poriae Cocos (Fu Ling), and Rhizoma Pinelliae Ternatae (Ban Xia). For pronounced heat, remove Du Huo and Bi Xie, and add Fructus Forsythiae Suspensae (Lian Qiao) and Fructus Gardeniae Jasminoidis (Zhi Zi). For relatively pronounced blood stasis blocking and stagnating, remove Yi Yi Ren and Bi Xie and add Cortex Radicis Moutan (Dan Pi) and Herba Lycopi Lucidi (Ze Lan).

Clinically, this formula was combined with the external remedy San Se Fu Yao (Three Colors [Externally] Applied Medicine, see below).

Shi Gao San Miao Tang (Gypsum Three Wonders Decoction)[21]

Gypsum Fibrosum (Shi Gao), Cortex Phellodendri (Huang Bai), Rhizoma Atractylodis (Cang Zhu), Radix Cyathulae (Chuan Niu Xi), Cortex Radicis Moutan (Mu Dan Pi), Rhizoma Alismatis (Ze Xie), Semen Coicis Lachrymae-jobi (Yi Yi Ren), Semen Plantaginis (Che Qian Zi), Radix Corydalis Yanhusuo (Yan Hu Suo), Radix Glycyrrhizae (Gan Cao)

Modifications:

For pronounced heat, add Caulis Lonicerae Japonicae (Ren Dong Teng) and Rhizoma Paridis Polyphyllae (Zao Xiu). For yin depletion, add Rhizoma Anemarrhenae Asphodeloidis (Zhi Mu) and Radix Trichosanthis Kirlowii (Tian Hua Fen). For pronounced dampness, add Ramulus Cinnamomi Cassiae (Gui Zhi), Radix Stephaniae Tetrandrae (Fang Ji), and Cortex Sclerotii Poriae Cocos (Fu Ling Pi). 

Clinically, this formula was combined with the external remedy Luo Shi Jie Yu Gao (Master Luo’s Dissipate Stasis Paste, see below).

Si Miao Fang (Four Wonders Formula)[22]

Rhizoma Atractylodis (Cang Zhu), Semen Coicis Lachrymae-jobi (Yi Yi Ren), Cortex Phellodendri (Huang Bai), Radix Achyranthis Bidentatae (Huai Niu Xi)

Modifications:

For red, hot, swollen, and painful joints, add Caulis Lonicerae Japonicae (Ren Dong Teng), Cortex Radicis Moutan (Mu Dan Pi), and Caulis Sargentodoxae (Hong Teng). For pronounced dampness, add Rhizoma Dioscoreae Hypoglaucae (Bi Xie), Rhizoma Alismatis (Ze Xie), Sclerotium Polypori Umbellati (Zhu Ling), and Sclerotium Poriae Cocos (Fu Ling). For urinary problems with a tendency to kidney qi vacuity, a

In standard professional Chinese medicine, the basic prescriptive methodology is to base treatment on each patient’s personal Chinese medical pattern discrimination as opposed to their disease diagnosis. This means that different patients with the same disease may get different treatments if their Chinese patterns are different. Likewise, the same patient at different stages of their disease will or at least should be treated differently if their pattern has undergone transmutation. Due to the pervasive influence and great prestige of modern Western medicine, this principle of basing treatment on each individual pattern instead of their disease diagnosis is a very difficult one to stick to for both contemporary Chinese and Western practitioners of Chinese medicine. It is so much easier and, therefore, very seductive to treat all patients with the same disease diagnosis with the same treatment. However, as the following clinical audit and case history of the Chinese medical treatment of post-herpetic neuralgia from "The Treatment of 39 Cases of Herpetic Neuralgia with the Methods of Quickening the Blood & Resolving Toxins" by Zheng Jian-ting^[1] show, this does not always get satisfactory clinical results.

Introduction:

Based on his many years of clinical experience, the author has treated 39 cases of post-herpetic neuralgia with the methods of quickening the blood and resolving toxins with very good results in this difficult to treat disease as summarized below.

Cohort description:

Among these 39 cases, 25 were male and 14 were female. They ranged in age from 45-81 years old. Their course of disease had lasted from 1.5 months to two years with a median duration of six months. All had had herpetic blisters which resolved but had been followed by difficult to bear aching and pain. A number of these patients had been previously treated with various other prescriptions with no marked effect.

Treatment method:

The formula consisted of: Radix Salviae Miltiorrhizae (Dan Shen), Herba Taraxaci Mongolici Cum Radice (Pu Gong Ying), and Radix Isatidis Seu Baphicacanthi (Ban Lan Gen), 30g each, and Radix Angelicae Sinensis (Dang Gui), Flos Carthami Tinctorii (Hong Hua), Radix Rubrus Paeoniae Lactiflorae (Chi Shao), Radix Scutellariae Baicalensis (Huang Qin), Rhizoma Corydalis Yanhusuo (Yuan Hu), Rhizoma Smilacis Glabrae (Tu Yuan), and Radix Glycyrrhizae (Gan Cao), 10g each. These medicinals were decocted in water and administered internally, one packet per day.

If there was old age and/or bodily weakness, 20g of Radix Astragali Membranacei (Huang Qi) and 15g Radix Codonopsitis Pilosulae (Dang Shen) were added. If there was oral dryness and/or bitterness and constipation, 6g of stir-fried Radix Et Rhizoma Rhei (Da Huang) was added. If there were loose stools, 20g of Semen Dolichoris Lablab (Bai Bian Dou) and 10g of Rhizoma Atractylodis Macrocephalae (Bai Zhu) were added. If there was insomnia and/or profuse dreams, 15g of Semen Zizyphi Spinosae (Suan Zao Ren) were added.

Treatment outcomes:

Marked effect meant that all the symptoms completely disappeared. Some effect was defined as marked improvement in the symptoms, and no effect meant that there was no obvious improvement in the symptoms. Based on these criteria, 25 cases or 64.1% got a marked effect, 10 cases or 25.64% got some ffect, and four cases or 10.26% got no effect from this protocol. Thus the total amelioration rate was 89.74%.

Representative case history:

The patient was a 72 year old male. In December 1997, the patient had caught a cold. Afterwards he developed herpes zoster lesions on his right rib-side. These turned into water blisters that were accompanied by severe burning pain. After one month of treatment with Western medicinals, the herpes lesions went away. However, the burning pain did not diminish. This was particularly severe at night and it kept the patient from sleeping. The man tried a number of other treatments for this pain, all to no avail.

When the patient visited the author, there was no redness or swelling of the skin in the affected area. His pulse was bowstring and his tongue was red with thin, yellow fur. In addition, his stools were particularly dry. Therefore, the author discriminated this patient’s pattern as evil toxins internally bound with static blood obstructing the network vessels. Based on this, the treatment principles were to quicken the blood and dispel stasis, clear heat and resolve toxins. The formula thus consisted of: Radix Angelicae Sinensis (Dang Gui), Radix Rubrus Paeoniae Lactiflorae (Chi Shao), Flos Carthami Tinctorii (Hong Hua), Radix Scutellariae Baicalensis (Huang Qin), Rhizoma Smilacis Glabrae (Tu Yuan), and Radix Glycyrrhizae (Gan Cao), 10g each, Radix Salviae Miltiorrhizae (Dan Shen), Herba Taraxaci Mongolici (Pu Gong Ying), and Radix Isatidis Seu Baphicacanthi (Ban Lan Gen), 30g each, and stir-fried Radix Et Rhizoma Rhei (Da Huang), 6g. These were decocted in water and administered.

After six packets, the pain had decreased. After 12 packets, the piercing pain was gone and there was only a feeling of insidious pain. After 18 packets, all the pain had disappeared. Another five packets were given in order to secure the treatment effect. On follow-up, there had been no recurrence of the aching or pain.

Author’s discussion:

Herpes zoster typically heals in 15-20 days. However, in a percentage of patients, after the skin lesions disappear there may be aching and pain or burning pain which does not heal even after enduring treatment. According to the author, this disease is due to external evils entering and assailing and thus damaging the skin. The qi becomes stagnant and the blood becomes static, therefore resulting in this condition. When treated by the common principles of clearing heat and resolving toxins, dispelling wind and disinhibiting dampness, the treatment effects are not so good. This is because the external evils have damaged the skin and caused blood stasis which obstructs the network vessels. Therefore, one should add blood-quickening, stasis-transforming ingredients to heat-clearing, toxin-resolving formulas. When stasis is eliminated, pain is dispersed. Thus the treatment effect is more satisfactory.

Translator’s discussion:

As the Chinese author states, acute attacks of herpes zoster accompanied by water blisters are usually treated by the principles of clearing heat and resolving toxins, dispelling wind and disinhibiting dampness. However, in the case of post-herpetic neuralgia, the water blisters have disappeared and the over-lying skin may no longer be red or swollen. The main clinical manifestation in that case is simply the subjective sensation of burning or piercing aching and pain. Therefore, these symptoms no longer suggest the presence of wind evils or water dampness. Instead, they add up to qi stagnation and blood stasis. However, taking into account the disease history and other such signs as a red tongue with yellow fur, it is the author’s opinion that hidden heat toxins remain. Hence, the treatment principles he advises are to quicken the blood (and transform or dispel stasis) and (clear heat and) resolve toxins. This is based on the fundamental dictum of Chinese medicine, "If there is pain, there is no free flow; if there is free flow, there is no pain."

This is not so much a new way of treating post-herpetic neuralgia but rather a fine adherence to the principle of basing treatment of the patient’s personal pattern discrimination. Although the author is too polite to say so, he is implicitly criticizing other practitioners for treating an idea about the patient’s disease rather than the actual pattern of signs and symptoms they present. This is the single most important principle in all of standard professional Chinese medicine. As Prof. Chen Wei, my formulas and prescriptions teacher at the Shanghai College of Chinese medicine liked to say: "If one discriminates the patient’s pattern correctly, logically derives the treatment principles from that pattern, and then bases their treatment upon those principles, the treatment will be effective."

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The Treatment of Disease in TCM, Vol. 5

---

By Shen Lian-sheng & Li Guo-qing
Translated by Anna Lin & Bob Flaws
Abstracted from The Dao of Increasing Longevity & Conserving One's Life

I. The Causes of Premature Aging And Geriatric Disease

Birth, growth, old age, and death are the natural order which no life can resist. Without birth there can be no death and vice versa. Life and death together form a circle which rolls on forever. Human beings are not outside this natural condition.

All animals have their own life cycle of growth and decline. What is the rule for human beings? The Nei Jing says:

When one is 10 years old, one's five zang begin to grow, one's qi and blood circulate, and all the qi goes downward so one becomes better at walking. When 20 years old, qi and blood become strong, the muscles are firm, and so one becomes good at fast walking. When 30 years old, the five zang are all solidly built and the muscles are strongly formed. One's blood vessels are full so on is good at running. When 40 years old, the five zang and six fu along with the twelve channels are over their peak and are starting to decline. The hair starts to turn grey and one is good at sitting. When one is 50 years old, liver qi starts to decline and gallbladder juice begins to decrease. Therefore the eyesight begins to blur. When 60 years old, heart qi begins to weaken, qi and blood are both becoming slack, and so one tends to sleep more. When 70 years old, spleen qi is weak and the skin is dry. When 80 years old, lung qi declines and the po leaves the body, so one's speech is not clear. When 90 years old, kidney qi is burning out and the four zang and channels and vessels are empty. When 100 years old, the five zang are empty, the shen and qi are gone, and thus one is ready to depart.

Although this description may seem overly mechanical, yet it does reflect the overall life cycle of a human being's birth, growth, and death.

Human beings cannot change the order of birth and death. However, humans can actively improve upon this cycle and delay premature aging. Conversely, peoples' wrong doing can negatively affect this scenario. Our ancestors paid great attention to their lifestyle and this had a major impact on prolonging their lifespan and preventing premature debility and death. They also remind us of the harmful effects of not keeping a good lifestyle. As the Nei Jing says:

Nowadays people are not like this. They use wine as a beverage and they adopt recklessness and unusual behavior. They enter the chamber in an intoxicated condition (i.e., have sex while drunk) and their passions exhaust their vital forces. Their cravings dissipate their true essence and they do not know how to find contentment within themselves. They are not skilled in the control of their spirits and they devote all their attention to the amusement of their minds. Thus they cut themselves off from the joys of long life. Their rising and retiring is without regularity. For these reasons they reach only one half of their 100 years and they degenerate.

The above statements are both correct and practical and are supported by modern medical theory and clinical experience. When a person does not know how to restrict their own action and thus indulges in a lifestyle of overeating, overdrinking, and too much sex, one will never have a healthy longevity. One cannot but have a short life.

Chinese medicine divides the causes of disease into 1) the six evil qi, 2) the seven passions, and 3) diet and stress.

Wind, cold, summer heat, dampness, dryness, and heat are called the six qi (liu qi) when they are normal. The six qi describe the fluctuations and progressions in the weather and climate throughout the year. This is according to natural law. The human body needs these changes and automatically adjusts to and can cope with them during our everyday life. Therefore, the six qi are not harmful to the body. But, if the six qi are excess or deficient, this is not natural. If one of them comes at the wrong time or lingers too long, if it comes too abundantly, if it gets too hot when it is not supposed to or too cold when winter has not yet arrived, all these abnormalities can directly influence our daily physical routine and cause illness to occur. In such cases, the six qi become the six evils (liu xie). In everyday life, it is easier for us to catch a cold when the weather suddenly changes too hot or too cold. When we suddenly move from one climate to another, if we cannot cope with the new environment, we will be affected by the six evil qi and become sick. Sometimes, even when the six qi are normal, we may still catch disease if we do not pay attention to wearing proper clothes or when our immune system is depressed.

As people age, one's jing qi becomes deficient and weak, one's five zang wane, and their zheng or righteous qi becomes insufficient. Thus the six evil qi can easily invade the bodies of the elderly and cause disease. Therefore, it is common to see old people suffering from recurrent asthma or cough as winter approaches or sudden collapse and death during the extreme heat of summer or cold of winter. In short, older people are more easily attacked by the six evil qi.

The emotional factors which cause disease are joy, anger, brooding, sadness, and fear or fright. Under normal circumstances, these emotions are the appropriate reflection internally of stimuli from the outside world. Crying, laughing, and being happy are feelings normal to the human body. When they are not out of control, they do not adversely affect the zang fu and no disease ensues. But, when they are out of control, excessive anger can injure the liver, excessive joy can injure the heart, excessive brooding can injure the spleen, excessive sadness can injure the lungs, and excessive fright can injure the kidneys. Anger arouses the ascent of qi. Joy induces sluggishness of the qi. Excessive sorrow dissipates the qi. Fear causes the descent of the qi. Fright causes disturbance of the qi. And worry causes stagnation of qi.

Although it may at first sound peculiar that emotions may injure or kill a person, in fact, this happens every day. Chinese people are wont to say, "I laughed myself to death," or "I'm so sad I'm dying." These are vivid examples of the reality of this proposition. We have heard of elderly people dying due to sudden joy causing an unstoppable fit of laughter. We have also heard of some elderly persons dying of heart attack caused by a sudden increase in blood pressure in turn due to getting angry. Overthinking can harm the functions of the heart and spleen and liver and spleen which will then manifest such symptoms as anxiety, insomnia, tenderness of the hypochondrium, dizziness, belching, bloating, and decreased appetite. These days, authorities from various countries agree that there is a relationship between cancer and emotional stress or imbalance. When a person suffers from longterm, extreme depression, anger, sadness, or worry, they can develop cancer. Because of their emptiness of jing and qi, the elderly are all the more easily injured by uncontrollable emotions.

Irregular diet includes both overeating and undereating. It also includes eating too much raw, cold food, hot foods, and oily, greasy, or spicy foods. All of these can cause disharmony of the zang fu. Such dietary irregularities first attack the stomach/spleen. This then escalates from mild digestive disturbance to severe disease due to spleen dysfunction failing to perform its functions of transportation and transformation. Poor digestion is a common problem amongst the elderly. Therefore, they need to be more careful than others with their diet. Unfortunately, some people simply ignore their health and lose control during the holiday seasons. They overeat and overdrink at family reunions which cause them immediate woe.

In Chinese medicine, stress means overtaxing the body or overconsuming our body's energy. This includes too much sex. Too much sex causes more harm than most people think. It is a major cause of kidney emptiness. Too much sex exhausts kidney jing and leads to emptiness of both kidney yin and yang. This manifests as loss of teeth, low back weakness and pain, difficulty walking, dizziness, and premature ejaculation or impotence. Too much sex, fang lao in Chinese or literally bedroom taxation, is very harmful to the elderly. Therefore, they should not ignore this.

II. The Dao of Increasing Longevity And Conserving One's Life

To reiterate the above, in conjunction with tonifying their zheng or righteous qi, we know that the elderly need to pay particular attention to the following guidelines in maintaining their health and thus securing longevity.

A. Qi Ju You Chang,
Lao Yi Shi Du

A constant and regular lifestyle,
Suitable amounts of work and rest

What were our ancestors' secrets for attaining longevity? One answer is, "A constant and regular lifestyle (and) suitable amounts of work and rest." This saying implies that there should be a certain regimen to our life which includes reasonable amounts of working time, rest, exercise, and sleep.

According to the Nei Jing, one should go to bed late, rise early, and take a walk in the spring. During the summer, one should go to bed late and rise early being sure to spend a good bit of time out of doors. In the fall, one should go to bed early and get up early, and during the winter one should go to bed early and get up late. Whether or not this theory is scientific requires further investigation. Nonetheless, during the spring and summer when all things are growing and the weather is warm and nice, it is certainly healthy for us to take a walk in the sun and inhale the fresh air outdoors. During the autumn, the sky is high, the air is clear, and the weather is comfortable. Daylight grows less and the night is longer each day. So it is also healthy for the body to take a walk outdoors and inhale the fresh air. Because it is so cold during winter, we should avoid chilly mornings and wait for the warm sunshine in order to prevent attacks of cold evils. According to foreign studies, early risers indeed do enjoy longer life. In Japan, all the elderly of unusually advanced years get up from 4-6 AM. That is the time when all the birds wake. Chinese medicine recommends that everyone get up early during the spring, summer, and fall and wake up late during the winter. This follows the same belief as the long-lived in Japan.

During one's older year, the jing qi is generally weakened and depleted. Zang fu function is not as energetic and strong as in youth. It is, therefore, of utmost importance to avoid hard labor and to pay attention to resting and fostering the needs of the body. To get sufficient sleep is also very important. Good sleep helps our shen reside within the body unperturbed by the outside world. Thus it is a well accepted theory among people that the key to longevity is the ability to eat and sleep well. In everyday life, we often encounter people in poor health due to insomnia and they are invariably fatigued and their memory is poor. When this happens in the elderly, it speeds up the aging process. Thus a good balance between physical labor and mental activity is recommended. It is a proven fact that enjoying pleasant music can increase both one's physical and emotional strength. Taking a walk after meals improves the digestion. Further, gardening, enjoying keeping fish in the house, and playing various Chinese games are all species of active rest which each individual can chose according to their individual preference.

Rest and exercise should complement one another. Rest alone with little if any physical exertion tends to be harmful to the body. Chinese medicine regards longterm sitting as harmful to our muscles and longterm lying down as harmful to our qi. It can, therefore, be concluded that good diet and rest alone without physical exercise, in fact, overburdens the body and thus weakens the entire system. The Nei Jing calls this, "bodily exhaustion not due to fatigue". As Sun Si-miao of the Tang Dynasty said, "In order for the body to feel comfortable and healthy, we need suitable amounts of labor." Modern medicine has proven that decrease in muscle tone due to lack of exercise also results in decreases in the tone and functioning of the nervous, circulatory, and digestive systems and accelerates the aging process. In addition, lack of exercise and too much stress are also causes of heart and cerebral ischemic disease. Therefore, older persons are recommended to choose suitable, individualized exercise to retard aging. This includes qi gong, Tai Ji Quan, walking, etc. Each individual can chose different activities. Whatever the exercise, one should feel well and refreshed after each session. One should also be aware that, "Lifting things which are beyond our strength will cause more harm to the body."

B. Shun Si Shi Zhi Qi,
Fang Liu Yin Zhi Xie

Follow the qi of the four seasons,
Defend against the six wanton evils

According to Traditional Chinese Medicine, in order to conserve one's life, people should live in consonance with the changes of the four seasons and yin and yang qi. Our bodies and our lives should be in harmony with nature and thus remain in a well balanced state. As it is said, "Harmonize with yin and yang and balance with the four seasons." It is also said, "Going against causes harm, while following along results in health; this is the Dao." Dao means rules and laws or the rules of conserving one's life. The Nei Jing mentions again and again the harmful effects the changing of the four seasons can have on the human body. It is said, "One should avoid all emptiness and evils and especially evil wind," and, "The sage avoids emptiness and evils as he would attack by stones." These sayings remind us to avoid the evil qi of the four seasons and to avoid attack by external evils. Dr. Yi Shi of the Ming Dynasty advised weakened persons to be especially aware of the following: to defend against wind in spring; to defend against summer heat in summer; to defend against dampness in late summer; to defend against dryness in fall; to defend against cold in winter; and to also defend against warmness when the season is not supposed to be warm such as in the winter. Following such advice by the ancients is important for maintaining health and should not be neglected by the elderly.

The ability of the elderly to adjust to changeable weather is weak. Therefore, they need to pay special attention to these instructions and also to the way they dress and eat. One should not let external evils attack through the skin and hair, i.e., the surface, nor should one allow them to attack through the mouth and nose. In sum, "One must pay attention to adjust when the seasons are changeable."

C. Yi Le Guan Kai Lang,
Fang Qing Xu Ju Bian

Be happy with a light, open view;
Guard against being seized by sudden
changes in emotion

As mentioned above, when the so-called seven passions or emotions are grossly excessive, they can injure a person. Dr. Sun Xi-miao of the Qing Dynasty said:

To live long, people should take care not to worry too much, not to get too angry, not to get too sad, not to get frightened, not to do too much, talk too much, or laugh too much. One should not have too many desires nor face numerous upsetting conditions. All these are harmful to the health.

He also said:

One who knows how to conserve one's life is one who thinks less, worries less, has less desire, is less active, talks less, is less upset, has less joy, has less anger, and does less wrong. These twelve lesses are the key to conserving one's life.

An individual is but a small part of society and has strong ties to society. Therefore the "twelve lesses" are difficult to follow and not even entirely correct. We do need to worry for our society and our country and to make our contribution to society. Therefore, some of the twelve lesses are not totally right. However, from the point of view of conserving one's life, the emphasis should be on the word less which means avoiding extreme emotional ups and downs. Studies show that talking increases the blood pressure in patients with hypertension. We need to have a broad, open mind with a happy mood and avoid all unnecessary worries and stress. One should not run after fame or money. Therefore, the saying, "A broad mind, a healthy body," proves to be very true. Li Ma-kang, a centenarian from Beijing has said that the secret of his longevity was to 1) never worry and 2) not to overeat.

The emotional well-being of the elderly depends both upon the individual and upon society and one's family. We also recommend the good habit of respecting and loving the aged. And we strongly criticize any maltreatment or disrespect of older people. Rather we should make them feel comfortable no matter where they are, whether at home or in public.

D. Yin Shi You Jie
Ji Bao Yin Bao Shi

Be abstinent in food and drink;
Refrain from eating and drinking till you bulge

Diet is the key to bodily health. There can be no healthy body without a healthy diet. Overeating and inappropriate foods harm the body. As our ancestors said,

Care of the body depends upon diet. Being drunk yet longing to drink more, being full yet craving to eat more are major impediments on the path to yang sheng or lengthening life.

It is important for the elderly to have a well regulated diet. Overeating and overdrinking are harmful. In maintaining a better balanced diet and hence a healthy body, it is wise to eat more vegetables and bean products such as tofu. Vegetables stimulate the secretive functions of various glands within the body. Vegetables are easily digested and assimilated by the body. They can increase intestinal peristalsis and improve bowel movements. They can detoxify. They also prevent obesity, diabetes, heart disease, and other disorders. As one ages, the functioning of the zang and fu becomes debilitated. Therefore, it is important for the elderly not to overeat. Overeating high cholesterol and high calorie food is generally the cause of cancer, arteriosclerosis, coronary heart disease, hypertension, and premature aging. The Nei Jing states that xiao ke or diabetes (literally thirsting & wasting) is caused by "all fat, greasy, oily foods". One should not be prejudiced in favor of a particular food. In Guangxi, one centenarian eats mainly vegetables, the five grains, and little animal products. His main foods are cereal and bean products like tofu and vegetables cooked in sesame oil. This kind of food provides less calories but more of the nutrients the body needs.

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In my experience, the overwhelming majority of Western patients have liver-spleen, liver-stomach disharmonies no matter what other patterns they may also exhibit. To say one has a liver-spleen disharmony in Chinese medicine usually means that the liver is replete and the spleen is vacuous. Liver repletion is most often due to liver depression qi stagnation which is, in turn, most commonly due to emotional stress and frustration. Unfulfilled desires damage the liver's coursing and discharge. Every desire is, in part, a movement of the qi either towards or away from something. When we fulfill our desires, this means that our qi was allowed to move the way it wanted. Conversely, when our desires are thwarted, it means the movement of our qi was inhibited, and the liver likes to spread freely.

Spleen vacuity may be due to liver depression due to liver wood's controlling spleen earth according to the five phase control cycle. In other words, if the liver becomes depressed and, therefore, replete, this may, all by itself, result in a spleen qi vacuity. Spleen qi vacuity may also be the result of faulty diet, excessive thinking and worry, over-taxation, insufficient exercise, and excessive or wrongful use of such spleen-damaging medicines as antibiotics.

Because the spleen is the latter heaven root of the engenderment and transformation of qi and blood, spleen qi vacuity may also cause or aggravate liver depression. The liver and lungs work together to maintain the free and uninhibited flow of qi. The lungs diffuse and downbear the qi, providing the motivating force behind the movement of the qi, while the liver allows the qi to flow freely and easily. The lung qi comes from the spleen qi. Therefore, if there is insufficient spleen qi, there will also be insufficient lung qi, and thus less pushing power behind the movement of the qi. In addition, the liver can only fulfill its function of coursing and discharging if it obtains sufficient blood to nourish it. Thus, if spleen qi vacuity leads to blood vacuity, then a liver blood vacuity may also cause or contribute to liver depression.

As for a liver-stomach disharmony, this refers to liver depression with upward counterflow resulting in upward counterflow of the stomach. The stomach is only harmonious when its qi is downborne. Qi is, by nature yang. Therefore, inherently, it has a tendency to rise or ascend. When qi becomes stagnant and accumulates, it first usually results in distention and fullness. However, this accumulated qi has to go somewhere. If liver depression qi stagnation counterflows onto stomach earth via the control cycle, this results in the stomach also becoming replete. In that case, liver and stomach qi join to counterflow upward. Since qi is yang and, therefore, also inherently warm, qi stagnation affecting the liver and stomach may also easily transform into depressive heat. Thus liver-stomach disharmony resulting in upward counterflow is also often complicated by depressive or transformative heat.

Just as the liver and spleen and liver and stomach may become disharmonious, the spleen and stomach may also become disharmonious. This means that the spleen becomes vacuous and weak, possibly cold and/or damp, while the stomach counterflows upward and/or becomes hot and possibly even dry. In real-life Western patients, it is very common, in fact for a wood/earth disharmony to include both liver/spleen and liver/stomach disharmonies.

Because of the prevalence of stress and frustration in our increasingly complex and speeded up world combined with too much thought and worry, faulty diet, too much fatigue, and too little physical exercise plus iatrogenensis from Western medicinals, liver wood/spleen earth or liver wood/stomach earth disharmonies are extremely common in contemporary clinical practice. In my opinion, they are the rule rather than the exception, and this is especially so in the case of three groups of people: women, the elderly, and the chronically ill.

Women are prone to liver depression and spleen vacuity because of changes in modern society forcing them to shoulder both traditional female and many traditionally male roles. On the one hand, many women feel extremely stressed and frustrated, while, on the other, they are over-worked and exhausted. In addition, women are more prone to spleen vacuity due to their monthly loss of blood via menstruation as well as gestation and lactation. As we have seen above, if there is a spleen qi and liver blood vacuity, then liver depression qi stagnation is far more likely. According to the Nei Jing (Inner Classic), most women tend to become spleen vacuous around 35 years of age with concomitant blood vacuity. This is the Nei Jing's explanation for developing wrinkles on the face at around this age. The blood is no longer nourishing the skin the way it once did and the skin dries out and wrinkles.

Older people, whether male or female, are prone to liver depression qi stagnation as well as spleen vacuity. The maturation process according to Chinese medical theory is the process of first the spleen and stomach becoming mature and later, because of the maturation of the spleen and stomach, the kidneys becoming exuberant and mature. When we age, this process is reversed. First, typically the spleen and stomach become vacuous and weak. Because of this, they no longer engender and transform the same amounts of qi and blood. With less qi to promote its flow and less blood to moisten and nourish the liver, liver depression tends to worsen with age. In addition, unstoppable changes in appearance and deterioration in physical and mental abilities mean that most of us fulfill less of our desires as we get older, at least certain kinds of desires. It's not for nothing that Buddhism considers aging one of the four great rivers of human suffering.

If one is chronically ill, this also means that one will not be able to fulfill all one's desires. Either one will not be able to do and eat what one wants or look the way one would like to, or one cannot get away from certain pain and discomfort. There are two types of desires in this life: 1) the desire to get what we want and 2) the desire to eliminate or get away from what we don't want. Chronic disease usually results in some combination of both of these desires being thwarted. Thus, even if liver depression did not cause a certain disease, if that disease endures, liver depression will inevitably complicate any chronic disease process. In addition, since the body's qi mechanism is a unified, inter-related whole, disease in one part will inevitably affect all the other viscera and bowels and their functions, including the spleen's engenderment and transformation of the qi and blood. Hence most chronic disease is accompanied by fatigue, a main symptom of spleen vacuity.

The above theory helps explain why harmonizing formulas are some of the most commonly used and most important of all Chinese medicinal formulas. Harmonizing formulas do not just harmonize the constructive and defensive, even though that is their first listed textbook indication. They also harmonize the liver and spleen, liver and stomach, spleen and stomach, and stomach and intestines. This is why I find myself prescribing harmonizing formulas to more of my chronically ill patients than any other category of formulas. For instance, Xiao Chai Hu Tang (Minor Bupleurum Decoction), Xiao Yao San (Rambling Powder), and Ban Xia Xie Xin Tang (Pinellia Drain the Heart Decoction) and their cognates and derivatives are all harmonizing formulas.

Ye Tian-shi was one of the greatest Chinese doctors of the Qing dynasty. Ye lived and worked in Suzhou in eastern China and is remembered as one of the leading lights in the wen bing xue or warm disease school. However, Ye was more than just a warm disease doctor, treating the full range of human disease. Ye was one of the leading Chinese doctors of his generation. The Ye Tian Shi Zhen Zhi Da Quan (A Great Collection of Ye Tian-shi's Diagnoses & Treatments) by Chen Ke-zheng, published by Chinese National Chinese Medicine & Medicinals Publishing Co. in Beijing in 1995, is a collection of Ye's theories, case histories, and special treatments. In this book, there is a chapter titled, "Wood/Earth Disharmony Pattern Formulas." This chapter is comprised of a number of Ye Tian-shi's special liver wood/spleen and stomach harmonizing formulas. Since I think harmonizing formulas are especially important in the Western practice of Chinese medicine, I would like to share these formulas with my Western peers.

A. Liver/stomach disharmony mixed with heat

1. Gou Teng Dan Pi Fang (Uncaria & Moutan Formula)

Ramulus Uncariae Cum Uncis (Gou Teng)
Cortex Radicis Moutan (Dan Pi)
blackened Fructus Gardeniae Jasminoidis (Shan Zhi)
Sichuan Rhizoma Coptidis Chinensis (Chuan Lian)
Pericarpium Citri Reticulatae Viride (Qing Pi)
Cortex Magnoliae Officinalis (Hou Po)
Semen Raphani Sativi (Lai Fu Zi)
Pericarpium Citri Reticulatae (Guang Pi)
Caulis Menthae Haplocalycis (Bo He Gen)

(Herba Menthae [Bo He] can be substituted for Caulis Menthae.)

Functions: Clears the liver and harmonizes the stomach

Indications: Treats liver wood insulting earth with enduring depression making heat and symptoms of drum distention, decreased eating, and emission of heat (i.e., what is usually called fever in the West, although one can have emission of heat and have a subnormal temperature as measured by a thermometer)

Formula analysis: In this formula, Uncaria, Moutan, Gardenia, Coptis, and Mentha all clear depressive heat from the liver and stomach. Orange Peel, Immature Orange Peel, and Magnolia rectify the qi and downbear counterflow. Radish Seeds disperse (food) accumulation and abduct stagnation. In addition, the combination of Moutan and Gardenia resolves depression and eliminates vexation due to depressive heat.

2. Dan Pi Sang Ye Fang (Moutan & Morus Leaf Formula)

Cortex Radicis Moutan (Dan Pi)
Rhizoma Pinelliae Ternatae (Ban Xia)
Ramulus Uncariae Cum Uncis (Gou Teng)
Folium Mori Albi (Sang Ye)
Sclerotium Poriae Cocos (Fu Ling)
Exocarpium Citri Erythrocarpae (Ju Hong)

Functions: Clears the gallbladder and harmonizes the stomach

Indications: Shao yang gallbladder channel depressive fire, insomnia, heart vexation, and oral thirst

Formula analysis: Morus Leaves and Uncaria both clear heat from the liver and especially liver heat which has counterflowed into the upper part of the body. Moutan clears heat from the blood division as well as quickens the blood, and the liver stores the blood. Pinellia and Citrus Erythrocarpus both harmonize the stomach and downbear counterflow, transform phlegm and eliminate dampness. Poria fortifies the spleen and percolates dampness.

3. Ren Shen Huang Lian Fang (Ginseng & Coptis Formula)

Radix Panacis Ginseng (Ren Shen)
Rhizoma Coptidis Chinensis (Chuan Lian)
Rhizoma Pinelliae Ternatae (Ban Xia)
Succus Zingiberis (Jiang Zhi)
Fructus Immaturus Citri Aurantii (Zhi Shi)
Sclerotium Poriae Cocos (Fu Ling)

(Uncooked Rhizoma Zingiberis [Sheng Jiang] can be substituted for the Ginger Juice.)

Functions: Acrid opens and bitter downbears, supports the stomach and opens glomus

Indications: Liver channel qi fire assailing the stomach, no thought for eating or drinking, (stomach) duct glomus and vomiting, diaphragmatic occlusion, and nausea

Formula analysis: Ginseng and Poria both fortify the spleen and supplement the qi. Pinellia harmonizes the stomach and downbeares counterflow. It also transforms phlegm and eliminates dampness. When Pinellia and Poria are combined along with uncooked Ginger or Ginger Juice, the transformation and elimination of phlegm dampness is even stronger. In addition, Ginger has the strong specific empirical effect of stopping nausea and vomiting based on its also downbearing upward counterflow. Coptis clears heat from the heart, stomach, and intestines. This can either be depressive or damp heat. Depressive heat in the liver and stomach often ascends to accumulate in the heart. Immature Aurantium strongly rectifies the qi and disinhibits the qi mechanism.

4. Ren Shen Sang Ye Fang (Ginseng & Morus Leaf Formula)

Radix Panacis Ginseng (Ren Shen)
Radix Angelicae Sinensis (Dang Gui)
Succus Fructi Immaturi Citri Aurantii (Zhi Shi Zhi)
stir-fried Rhizoma Pinelliae Ternatae (Ban Xia)
Folium Mori Albi (Sang Ye)
Cortex Radicis Moutan (Dan Pi)

(Fructus Immaturus Citri Aurantii [Zhi Shi] can be substituted for Immature Aurantium Juice.)

Functions: Supplements earth and discharges wood, clears depression and nourishes the blood

Indications: Liver depression assailing the spleen with middle burner glomus and binding and bleeding after defecation

Formula analysis: Ginseng fortifies the spleen and boosts the qi. Pinellia harmonizes the stomach, transforms phlegm, and eliminates dampness. Morus Leaves clear liver heat, while Moutan clears heat from the blood division. Immature Aurantium strongly rectifies the qi, and Dang Gui both nourishes and quickens the blood.

5. Suan Ku Xie Re Fang (Sour & Bitter Discharging Heat Formula)

Radix Panacis Ginseng (Ren Shen)
Concha Ostreae (Mu Li)
Radix Albus Paeoniae Lactiflorae (Bai Shao)
Fructus Pruni Mume (Wu Mei)
Rhizoma Coptidis Chinensis (Chuan Lian)
Rhizoma Pinelliae Ternatae (Ban Xia)
Fructus Meliae Toosendan (Chuan Lian)
Pericarpium Citri Reticulatae (Guang Pi)
Succus Zingiberis (Jiang Zhi)

(Uncooked Rhizoma Zingiberis [Sheng Jiang] can be substituted for the Ginger Juice.)

Functions: Sour and bitter discharge heat, discharges the liver and supplements the stomach

Indications: Qi fire upbearing and soaring, liver wind inversion stroke with tetany inversion, summerheat dampness internally binding interior heat with heat within the heart and glomus, oppression, nausea, and vomiting, lack of eating, and diarrhea

Formula analysis: Ginseng fortifies the spleen and boosts the qi. Pinellia, Orange Peel, and Ginger Juice or uncooked Ginger harmonize the center and transform and eliminate phlegm dampness. Coptis clears both damp and depressive heat. Melia rectifies the qi. It is an especially good qi-rectifying medicinal when there is damp heat, yin vacuity, and/or chong worms or parasites. Oyster Shell heavily subdues yang, quiets the spirit, and astringes yin. Mume is also an astringent. However, in addition, it nourishes the stomach and engenders fluids at the same time as it dispels chong parasites. In Chinese medicine, chong parasites are believed to flourish in a terrain where there is damp heat complicated by spleen vacuity. Parasites in Chinese medicine include tapeworms, roundworms, and pinworms as well as candidiasis, and may include non-specific forms of what Western medicine refers to as intestinal dysbiosis.

6. Tai Yin Jue Yin Fang (Tai Yin & Jue Yin Formula)

Rhizoma Atractylodis Macrocephalae (Bai Zhu)
Cortex Magnoliae Officinalis (Hou Po)
Radix Angelicae Sinensis (Dang Gui)
Cortex Radicis Moutan (Dan Pi)
Radix Scutellariae Baicalensis (Huang Qin)
uncooked Carapax Amydae Sinensis (Bei Jia)

Functions: Supplements earth, discharges wood, and clears heat

Indications: Yin vacuity blood heat, liver/spleen disharmony vacuity taxation

Formula analysis: Atractylodes supplements the spleen and aromatically dries dampness. Magnolia rectifes the qi and downbears counterflow, transforms phlegm and dampness and frees the flow of the stools. Scutellaria clears damp and/or depressive heat from the liver, gallbladder, stomach, and lungs. Dang Gui nourishes and moves the blood, while Moutan cools and quickens the blood. Uncooked Carapax Amydae likewise performs more than a single function in this formula. On the one hand, it nourishes yin anbd heavily subdues yang, while on the other, it quickens the blood and scatters nodulation. In addition, Carapax Amydae is a good choice whenever there is blood stasis and/or yin vacuity/vacuity heat complicated by damp heat. Often times, damp heat, vacuity heat, and blood stasis occur simultaneously in a single patient.

7. Bei Tu Xie Mu Fang (Bank Earth & Discharge Wood Formula)

Radix Panacis Ginseng (Ren Shen)
Rhizoma Atractylodis Macrocephalae (Bai Zhu)
Rhizoma Pinelliae Ternatae (Ban Xia)
Sclerotium Poriae Cocos (Fu Ling)
Radix Glycyrrhizae (Gan Cao)
Pericarpium Citri Reticulatae (Guang Pi)
Cortex Radicis Moutan (Dan Pi)
Folium Mori Albi (Sang Ye)
uncooked Rhizoma Zingiberis (Sheng Jiang)
Fructus Zizyphi Jujubae (Da Zao)

Functions: Banks earth and discharges wood

Indications: Glomus and fullness, inability to digest food, enduring cough bone-steaming

Formula analysis: Ginseng, Atractylodes, Poria, Licorice, and Red Dates all fortify the spleen and supplement the qi. Pinellia, Orange Peel, and uncooked Ginger harmonize the stomach and downbear counterflow, transform phlegm and eliminate dampness. Morus Leaves clear liver heat, while Moutan clears heat from the blood division.

8. Xie Mu An Wei Fang (Discharge Wood & Quiet the Stomach Formula)

Folium Mori Albi (Sang Ye)
Ramulus Uncariae Cum Uncis (Gou Teng)
Radix Polygalae Tenuifoliae (Yuan Zhi)
Rhizoma Acori Graminei (Chang Pu)
Rhizoma Pinelliae Ternatae (Ban Xia)
Pericarpium Citri Reticulatae (Guang Pi)
Herba Dendrobii (Jin Hu)
Sclerotium Poriae Cocos (Fu Ling)

Functions: Discharges wood and quiets the stomach

Indications: Liver yang transforming wind and assailing the stomach, dizziness, vertigo, heart palpitations, reduced intake (of food), and desire to vomit

Formula analysis: Morus Leaves and Uncaria clear liver heat, while Uncaria also levels the liver and extinguishes wind. Polygala rectifies the heart qi and transforms phlegm. Acorus transforms phlegm and opens the orifices. Pinellia and Orange Peel transform phlegm and eliminate dampness. Poria supplements the spleen and percolates or seeps dampness. And Dendrobium clears heat from the stomach and lungs at the same time that it nourishes the stomach and engenders fluids. The stomach is averse to dryness, while the spleen is averse to damp.

9. He Yang Yi Wei Fang (Harmonize Yang & Boost the Stomach Formula)

Radix Panacis Ginseng (Ren Shen)
Sclerotium Poriae Cocos (Fu Ling)
Rhizoma Pinelliae Ternatae (Ban Xia)
Radix Albus Paeoniae Lactiflorae (Bai Shao)
Fructus Pruni Mume (Wu Mei)
Rhizoma Coptidis Chinensis (Chuan Lian)
uncooked Rhizoma Zingiberis (Sheng Jiang)
Pericarpium Citri Reticulatae (Guang Pi)

Functions: Emoliates the liver and frees the flow of the stomach

Indications: Liver yang transforming wind and assailing the stomach with dry vomiting, reduced intake, a bland (taste in the) mouth, slight perspiration, and clouding inversion

Formula analysis: Ginseng fortifies the spleen and supplements the qi. Pinellia, Orange Peel, and uncooked Ginger harmonize the stomach and downbear counterflow, transform phlegm and eliminate dampness. Poria helps Ginseng supplement the spleen at the same time that it aids the three foregoing medicinals to eliminate dampness by percolating or seeping it. White Peony emolliates and harmonizes the liver. Coptis clears both damp and depressive heat from the heart, liver, stomach, and intestines. And Mume astringes and secures at the same time as it nourishes the stomach and engenders fluids. In addition, Mume dispels chong or worms.

10. Shi Jun Zi Hu Lian Fang (Quisqualis & Picrorrhiza Formula)

Fructus Quisqualis Indicae (Shi Jun Zi)
Pericarpium Citri Reticulatae (Guang Pi)
Rhizoma Picrorrhizae (Hu Lian)
Fructus Crataegi (Shan Zha)
Fructus Amomi (Sha Ren)
Rhizoma Atractylodis Macrocephalae (Bai Zhu)
Sclerotium Poriae Cocos (Fu Ling)
Radix Albus Paeoniae Lactiflorae (Bai Shao)
Cortex Magnoliae Offiicnalis (Hou Po)
Endothelium Corneum Gigeriae Galli (Nei Jin)

Functions: Disperses accumulations and rectifies the qi, fortifies the spleen and emolliates the liver

Indications: Gan accumulation taxation and bodily emaciation, vexatious heat and night sweats

Formula analysis: Quisqualis kills worms, but it also fortifies the spleen and disperses (food) accumulation. Gan accumulation is mostly a pediatric condition made up of a combination of spleen vacuity and food stagnation. Crataegus and Chicken Gizzard both transform food and abduct stagnation. However, they are especially good for treating meat-type food stagnation which, in Chinese medicine, includes milk. Atractylodes and Poria supplement the spleen and eliminate dampness. Magnolia also eliminates phlegm and dampness at the same time as downbearing counterflow and freeing the flow of the stools. Orange Peel and Amomum both rectify the qi and harmonize the stomach while aromatically transforming and drying dampness. Picrorrhiza clears heat, especially damp heat, from the heart, liver, and stomach. And White Peony emolliates and harmonizes the liver while it also relaxes cramping, as in abdominal cramping.

11. Mu Li Chuan Lian Fang (Oyster Shell & Coptis Formula)

Concha Ostreae (Mu Li)
Fructus Meliae Toosendan (Chuan Lian)
Rhizoma Corydalis Yanhusuo (Yuan Hu)
Semen Pruni Persicae (Tao Ren)
Rhizoma Pinelliae Ternatae (Ban Xia)
Sclerotium Poriae Cocos (Fu Ling)
Exocarpium Citri Erythrocarpae (Ju Hong)
Semen Sinapis Albae (Bai Jie Zi)
Rhizoma Coptidis Chinensis (Chuan Lian)
Fructus Evodiae Rutacarpae (Wu Zhu)
Rhizoma Cyperi Rotundi (Xiang Fu)
Succus Zingiberis (Jiang Zhi)

(Uncooked Rhizoma Zingiberis [Sheng Jiang] can be substituted for Ginger Juice.)

Functions: Rectifies the qi, clears heat, and transforms dampness

Indications: Damp heat obstruction and stagnation, liver/stomach disharmony, vomiting, and gatherings and conglomerations in women

Formula analysis: Pinellia, Poria, Citru Erythrocarpus, and uncooked Ginger or Ginger Juice fortify the spleen and eliminate dampness. Mustard Seeds warm and transform cold phlegm, scatter nodulation and stop pain. Coptis clears heat from the heart, liver, stomach, and intestines. Evodia is an extremely warming ingredient, but, in this formula, is mostly used to downbear counterflow at the same time as strongly stopping pain. Although classified as a warming medicinal, Evodia is routinely used for damp heat conditions causing nausea and vomiting complicated by spleen vacuity, in which case it is usually combined with Coptis. Corydalis quickens the qi within the blood and also stops pain. Persica quickens the blood and dispels stasis. Melia moves and rectifies the qi, and is especially good when there is damp heat. Cyperus also rectifies the qi and is an excellent choice when qi stagnation manifests as distention. Oyster Shell subdues yang, downbears counterflow, and heavily quiets the spirit. It also is empirically specific for neutralizing stomach acid

B. Liver/stomach disharmony mixed with cold & rheum

1. Pao Fu Ren