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Development of Pi Wei (Spleen-Stomach)
Theory in Early Chinese Medical Classics
Oregon College of Oriental Medicine
DAOM Program 2010
Fang Zhang, LAc, M.Med (China)
December 2011
©
© Fang Zhang, LAc, M.Med (China)
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Acknowledgement
My first deeply appreciation would go to my parents. I have observed and experienced
traditional Chinese medicine since my early childhood from my parents, who both are
Chinese medicine doctor in China. Without their inspiration, I would have not chosen
Chinese medicine as my career. With years of teaching at the Chinese medicine
university and practicing in the hospital as internal medicine doctor, I found that the most
challenging is how to understand Chinese classics and apply them into daily practice and
modern diseases. Later, I had opportunity to study Chinese classics with the guidance of
famous Chinese classics scholar and practitioner, Dr. Xin Song from Chengdu University
of Traditional Chinese Medicine for three years. The study had really let me appreciate
the rich history of Chinese medicine and broadened my knowledge in Spleen and
Stomach theory. I am so grateful and would give my sincere gratitude to him. I would
especially like to thank my mentor, Dr. Guohui Liu, who is wisdom of Chinese classics
and is able to recite most of original texts of Huang Di Nei Jing, Shang Han Za Bing Lun
and Wen Bing Xue. His guidance has helped me tremendously to put the capstone
project together. Lastly, I would also like to acknowledge support of both my family and
the administrators of Oregon College of Oriental Medicine, and the gentle guidance of
OCOM doctoral program teachers, especially Dr. Beth Burch, Dr. Zhaoxue Lu, and Dr.
Tsuey-hwa Lai. Without their support and guidance, I would not be able to finish the
doctoral program.
© Fang Zhang, LAc, M.Med (China)
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Table of Contents
Introduction
Development of Theory
1.
Huang Di Nei Jing—laid the theoretical foundation for Pi Wei (Spleen-Stomach)
theory
•
Anatomy of Spleen and Stomach
•
Physiological function
•
Etiology and pathogenesis of diseases from dysfunction of Spleen and Stomach
•
Prevention of diseases of Spleen and Stomach
•
Therapeutic treatment of diseases of Spleen and Stomach
2.
Shang Han Za Bing Lun—established the basic treatment principles based on
syndrome differentiation
•
Emphasize the importance of treatment principle of strengthening the Function of
Spleen
•
Elaborate the outline of the diseases of Spleen and Stomach
•
Emphasize the importance of harmonizing Stomach to secure the root of the life
•
Stress the cooking methods of herbal decoction
•
Clarify the application of four diagnostic methods in treating diseases caused by
dysfunction of Spleen and Stomach
•
Contribution to health and preventive medicine
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3.
Yi Shui school—formally found and explained the basic Pi Wei (Spleen-Stomach)
Theory and its application
•
Zhang Yuan-su: advocated to set up treatment principles based on the nature of
disease, such as deficiency, excess, heat or cold.
•
Li Dong-yuan: composed the classic book Pi Wei Lun (Pi Wei Treatise)
•
Hao-gu Wang: clarified the Yin pattern of Spleen and Stomach
•
Tian-yi Luo: treated diseases due to dysfunction of Spleen and Stomach with San
Jiao theory
Conclusion
Reference
Index: A Case Study: Treatment of GERD with Classic Chinese Herbal Formula-Under
the Guidance of Pi Wei Theory
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Introduction
Theory of Pi Wei (Spleen-Stomach) has been considered as one of the most important
component of Traditional Chinese Medicine. Since Jin and Yuan dynasty, Pi Wei theory
has become a unique and popular academic school and served as a very practical tool in
the TCM field after being developed and polished by ancient physicians. Overall, Spleen
and Stomach has been considered as the sea of food and body fluid, the source of the
production of both Qi and Blood and the pivot of the Function of Zang and Fu organs.
Therefore, they are called the root of post-heaven Qi and the dysfunction of Spleen and
Stomach is one of the major causes of various diseases. Pi Wei theory acts as an
important guidance in the physiology, pathology, diagnosis and treatment of various
diseases in clinic. The collection and research on successive achievements that related
this theory from ancient physicians shows important practical significance on inheriting
and carrying forward the work of traditional Chinese medicine.
Based on the review various original classic literature and commentaries, this paper will
focus on the establishment and development of the Pi Wei (Spleen-Stomach) theory,
particularly at the important historical periods and medical classics including Huang Di
Nei Jing, Shang Za Bing Lun and Yi Shui School. In the end, a case is presented from my
practice in the regard of application of Spleen-Stomach theory for modern disorders.
Development of History
1
Huang Di Nei Jing—has laid the basic foundation of theory of Spleen and
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Stomach
Huang Di Nei Jing should be considered as the earliest medical classic to set the
foundation of the Pi Wei (Spleen-Stomach) Theory. It has description in detail of the
anatomy, physiological functions of the Spleen and Stomach, and the etiology, pathology,
prevention and treatment of the Pi Wei diseases.
1.1 The anatomy of the Spleen and Stomach
There is no systemic record related to the anatomical structure of the stomach in Huang
Di Nei Jing but the anatomical structure of the stomach was discussed in Lin Shu, one
part of this classic. Only Stomach is mentioned in Ling Shu. In the chapter of Chang Wei
(The Intestine and Stomach), it says: The body of the Stomach is tortuous, bending and
stretching, its length is two Chi and 6 Cun (Chi and Cun are ancient length measurement;
its circumference is one Chi and five Cun; its diameter is five Cun and its capacity is
three and half liters (Wang, 1963). There is not too much other discussion related to this
until the Nan Jing was written. Nan Jing started to have more detailed description about
anatomy of Spleen and Stomach in terms of their shapes, weight and volume. In the
chapter 42 of the Nan Jing where it says: “The Spleen weighs two Jin and one Lian (Jin
and Lian are ancient units for weigh measurement), and it is three Cun wide, five Cun
long and has half Jin of fatty tissues surrounding it”(Qing,1956). Comparing the
description of Spleen and Stomach in both Nei Jing and Nan Jing to the modern
biomedical view, they both share some similarity as well as difference. For example, Nan
Jing mentions that “There is half Jin of fatty tissue surrounding the Spleen” (Qing,1956).
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which is slightly similar to the pancreas form modern anatomy. According to the classic
description mentioned above, it seems that the size and weight related to the Spleen and
Stomach in ancient Chinese texts is based on its actual cut and open inspection.
Otherwise, it is unbelievable how these estimates are close to ones in the modern
anatomical decription. Meanwhile, the TCM tends to pay more attention to the Function
of the internal organs than its pure anatomical structure, “All the function of internal
organs will reflex to the surface of the body”, based on method of observation from the
outside to estimate the inside.
1.2 The physiological function of the Spleen and Stomach
There are a few aspects regarding the physiological functions of the Spleen and Stomach
in Nei Jing, which can be summarized as follows:
1.2.1 The Spleen and Stomach takes charge of transportation and transformation of
water and food.
Spleen and Stomach can digest food, transport the nutrients and are related to water
metabolism. Su Wen Ling Lan Mi Dian Lun (The Confidential Collections in the Royal
Library about the functions of the Twelve Viscera in Su Wen) The Spleen is like an
officer who is in charge of the digesting, absorbing, spreading and storing of the essence
of food; all five tastes are from there. Su Wen Jing Mai Bie Lun (Further Comments on
Channel in Su Wen) states that when the food enters the Stomach, after being digested, its
refined substance is transported to the Liver to moisture the tendons of the whole body.
The channel-Qi circulates in the channels and goes up to the Lung. After the various
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channel-energy being converted in the Lung, it is transported to the skin and hair. When
the water enters the Stomach, it evaporates the refined energy and spreads it to the Spleen
above; and the Spleen spreads the essence into the Lung above; the Lung energy
communicates with the water passway, and transports the essence to the bladder. In this
way, with the production, circulation activity of the vital energy and the promotion of the
water, the refined energy is spread to the skin and hair of the whole body, circulated in
the channels of five Zang-organs and is kept in accordance (Ni, 1995).
From the description, the understanding of physiological function of Spleen and Stomach
is very similar to the function of digestive system in modern western medicine.
1.2.2 The Spleen and Stomach are the sources of Qi and Blood.
Nei Jing believes that the Qi and Blood in human body is generated after the
consumption of food and water. Therefore, the energy of Spleen and Stomach in middlejiao for Qi and Blood generation is of critical importance. In the chapter of Ling Shu Xie
Ke says: “After the five cereals enters into the Stomach, it divides into dross, body fluid
and initial energy (Ying-Qi), which flow to the lower, middle and upper Jiao (burner)
respectively in three routes. The initial energy accumulates in the chest (becomes into
Chest Qi), comes out from the throat, links up the Heart and carries out the respiration.
The Ying-Qi (nutrient Qi) permeates the body fluid and pours into the channels; then it
turns into Blood to nourish the four extremities outside; and pours into the solid and
hollow organs inside of the body in the speed of fifty cycles a day and night or a hundred
graduations of the clepsydra. The Wei-Qi (defensive Qi) has the property of being valiant
and swift, moving along the muscle and the skin unceasingly” (Wang, 1963, Ni, 1995).
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This means that Zong-Qi (Chest Qi), Ying-Qi (nutrient Qi), Wei-Qi (defensive Qi) and
the Blood generated by the Ying-Qi are originally derived from water and grain in the
Stomach. In the chapter of Lin Shu Wu Wei (The Five Tastes) also says: “The Stomach is
like the sea for converting the nutrition of the five solid organs and the six hollow organs,
as well the water and cereals enter into the Stomach, so, all the five solid organs and the
six hollow organs will receive the refined energy formed by the digestion of the
Stomach.” In the chapter of Su Wen Yu Ji Zhen Zang Lun (The Valuable Collection of
the Jade Plate on the Pulse Condition Indicating the Exhaustion of the Visceral-Qi) also
said: “The nourishment of the energies of the five viscera depends on the refined
substance of water and cereals of the Stomach, so, Stomach is the root of the five viscera”
(Wu, 1997) In short, despite the production of Ying, Wei, Qi, Blood, body fluids is a
complex process involving the five Zang, six Fu-organs, congenital, acquired and other
factors, but all depends on the transportation and transformation of water and grain in the
Spleen and Stomach to complete. This is very similar to modern western medicine that
the digestive system is critical for digestion and absorption of food nutrients in order to
maintain normal activities of life activity.
1.2.3 The Spleen and Stomach are related to muscles and four limbs
It was first proposed in Huang Di Nei Jing that the Spleen has the function of controlling
the muscles and the four limbs. The Nei Jing chapter 5 - Su Wen Yin Yang Ying Xiang Da
Lun (The Corresponding Relation between the Yin and Yang of Man and All Things and
That of the Four Seasons) says that the normal function of Spleen can promote the
generation of the muscle.
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The Su Wen in chapter 44 (Su Wen Wei Lun) says:” The Spleen governs the muscles of
the whole body.” The Su Wen in chapter 18 (Shu Wen Pin Ren Qi Xiang Lun) says that
the Spleen is to store the muscular-Qi mainly. As for the relationships between the Foot
Yangming of the Stomach and muscle, it has been mentioned in the Su Wen chapter 31
Su Wen Re Lun (On Febrile Disease). It states that the Yangming Channel governs the
muscle; in its course of running, it clips the nose and surrounds the eyes. In chapter 29 it
says: “The four limbs depend on the Stomach for Qi, but Stomach-Qi can only reach the
channels through the transmission of the Spleen. If the Spleen is diseased it cannot
transport the fluids of the Stomach, with the result that the four limbs cannot receive the
Qi of food” (Wang, 1963, Wu,1997). All these descriptions have explained that both
Spleen and Stomach share the similar function of the nourishing and controlling the
muscle for the whole body.
As far as the particular relationship between the four limbs and Spleen and Stomach, it is
fully reflected in the discussions in the Su Wen chapter 19 Su Wen Yu Ji Zhen Zang Lun
(The Valuable Collection of the Jade Plate on the Pulse Condition Indicating the
Exhaustion of the Visceral-Qi) and chapter 29 Su Wen Tai Yang Yang Ming Lun (On the
Relations Between the Superficies and Interior of Taiyin and Yangming Channel). For
example, it states that the Spleen associates with earth and it is a solitary viscus which
has the function of moistening all around and other viscera, and all the four limbs are
nourished by the Stomach-Qi. All these statements show the normal functions of the
Spleen and Stomach play essential roles on the formation of the strong muscles and
robust limbs. In contrast, the status of the Qi of the Spleen and Stomach such as
abundance or declining can be speculated based on the physical condition of the muscle
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and four limbs. It should be noted that the transformation and transportation of the food
essence and generation of the Qi, Blood and body fluid can only be completed normally
if there is harmonized complement between the Spleen and Stomach. In the Su Wen
chapter 29 Su Wen Taiyin Yangming Lun (On the Relations between the Superficies and
Interior of Taiyin and Yangming Channel), the detailed explanations are given through
three reasons. Firstly, they physiologically connect each other with only a piece of
membrane. Secondly, they connect each other through the channel relationship. The
Spleen channel of foot Taiyin is interiorly-exteriorly coupled with the Stomach channel of
foot Yangming. Just as mentioned in this chapter, “The Foot Taiyin channel is
surrounding the Stomach, connecting the Spleen and clipping the throat, so, the
Yangming energy can be transported by the Taiyin Channel, and makes it enter into the
three Yin channels of Hand and Foot; the Foot Yangming Channel of Stomach is the
superficies of the Foot Taiyin Channel of Spleen and is also the sea of nutrition of the five
Zang and six Fu, so the Stomach Channel can also transport the Qi of Taiyin into the
three Yang channels of Hand and Foot….”(Wang, 1963, Wu,1997). Thirdly, functionally
they complement each other. The four limbs are nourished by the Stomach for Qi, but
Stomach Qi can not reach the four limbs directly except with the help of the transmission
of the Spleen which can convert the food and water into food essences. Overall, the
structural configuration of the Spleen and Stomach is also reflected in the Functional
connections.
1.2.4 The Spleen and Stomach have open orifice of the mouth
In addition to the influence played on the digesting and absorbing of water and food,
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transporting, distributing and transforming of the nutrients and nourishing the muscles
and limbs, Spleen also opens into the mouth as stated in the Ling Shu chapter 17 Mai Du
(The Length of Channels) says: “The Spleen-Qi communicates with the mouth orifice,
and when the Spleen function is balanced, the mouth can distinguish the fragrances of the
five grains.” That is why in the Nei Jing chapter 5 Su Wen Yin Yang Ying Xiang Da Lun
(The Corresponding Relation between the Yin and Yang of Man and All Things and That
of the Four Seasons) says “mouth is the orifice of Spleen” (Wang, 1963, Wu,1997)
Therefore, a complete digestive system is formed including the mouth, Spleen, Stomach,
small intestine, and large intestine, etc.
1.2.5 The Spleen and Stomach are also associated with certain mental and spiritual
activities
The connection between the status of the function of the Spleen and Stomach and mental
activity has been discussed in the Nei Jing because Spleen is related to Ying-Qi (nutritive
Qi) and idea. The Ling Shu chapter 8 Ling Shu Ben Shen (The Diseases Caused by
Spiritual Activities) says: “The Spleen stores the Ying-Qi, and idea adheres to the YingQi. When the Spleen-Qi is deficient, it will cause dullness of the motions of the four
limbs and the disharmony of the five viscera; when the Spleen-Qi is obstructed, it will
cause abdominal distention, menoxenia, dyschesia” (Qing, 1956). The Su Wen chapter 5
Su Wen Yin Yang Ying Xiang Da Lun (The Corresponding Relation between the Yin and
Yang of Man and All Things and That of the Four Seasons) claims Spleen affects the
ability of thinking and excessive thinking would damage the normal function of the
Spleen. It even influences the content and nature of the dream. The Su Wen chapter 80
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says: “If the Spleen is deficient, one dreams of being hungry; if the dream takes place in
late summer, one dreams of building a house.” and the Ling Shu chapter 43 says: “If the
Spleen is in excess, one dreams of singing and being very heavy…if the Spleen is
deficient one dream of abysses in mountains and of marshes” (Wang, 1963, Wu, 1997,
Zhu, 2001). All of these confirm the close connection between Spleen and spiritual
activities.
1.3 Etiology and pathology of the Spleen and Stomach disease
There are so many etiological and pathological factors causing the diseases, including six
kinds of exogenous pathogenic evils, abnormal stimulation of seven abnormal emotions,
injury by irregular diet or over taxation, trauma, insect-bite, etc. Additionally, some
pathological products such as blood stasis and phlegm generated by various dieases are
also can cause the diseases as well.
Like other ogans, the spleen and the stomach are
commonly affected by those pathologic factors, among which irregualar diet plays an
important role in the theory of the spleen and the stomach because of the close relatiohsip
between the diet and these two organs.
1.3.1 Irregular diet
Diet always needs to be balanced from both quantity and quality. Through long term
clinical practice, the ancient Chinese physicians realized that the combination of
appropriate amount of food and balanced variety of food were essential for maintaining
normal physical activities as it provides Qi and Blood to supplement whole body.
Firstly, regulating the amount of food intake is important since overeating or hunger may
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give rise to damage of Spleen and Stomach. The Su Wen chapter 43 Bi Lun (On Bidisease) says that “if the food and drink are taken excessively, the intestine and the
Stomach will be injured.” Another good example can be seen in from Su Wen chapter 3
Sheng Qi Tong Tian Lun (On the Human Vital Energy Connecting with Nature). It
explains the possible damage to the body from over eating or drinking after external wind
invading (Qing,1956). Overeating makes the stomach and the intestines so full that the
tendons will become loose. If the intestine stores up with the undigested food for a long
time, usually the tendons will be kept loose constantly; and this could eventually develop
bloody stool or hemorrhoid. In similar situation, excessive consumption of liquor causes
rebelling of Lung Qi. On the other hand, excessive hunger causes malnourishment of the
body and leads to insufficient supply of Qi and Blood, which causes general body
weakness. Hence, appropriate amount of food intake is considered as one of the key for
health care in Nei Jing.
Secondly, indulging in a particular kind of food or flavor of food can cause imbalance of
internal organs as well. Different flavors are connected with respective internal organs
through the corresponding meridians. Therefore, they have their corresponding important
impact upon the different internal organs. In order to explain the dialectical relationship
between the function of internal Zang organs and consumption of five flavors of food, the
Su Wen chapter 3 Sheng Qi Tong Tian Lun says that the “the nourishments of the five
viscera are stemmed from the five flavors (acrid, sweet, sour, bitter and salty flavors are
considered as tastes of food); but when the five tastes are taken excessively, they will
damage the five viscera.” In the same chapter, it sets out a few detailed examples
regarding excessive consumption of certain flavor of food bringing on pathological
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changes on its coreresponding internal organ. It says: “The sour taste acts on the Liver; if
sour taste is taken excessively, it will make the Liver to have too much body fluid which
causes weakness of Liver-Qi, which will restrict the Spleen-earth and make the Spleen-Qi
vanishing. The salty taste acts on the Kidney. As Kidney determines the condition of the
bone, and salty taste can soften the hardness and damage the Qi and Blood; so when the
salty taste is taken too much, it will damage the bone and muscles; the Heart-Qi will be
restrained in the end. The sweet taste acts on the Spleen, and the property of sweet taste is
sluggish and greasy. If the sweet taste is excessively taken, dyspnea will happen. When
the Spleen is abnormal, it will restrict the Kidney-water. When the Kidney-water is
restricted, the Kidney-Qi will be abnormal to become ill. The bitter taste acts on the Heart;
if the bitter taste is taken excessively, the Heart will be hurt. When the Heart is hurt, the
Spleen-earth will fail to be moistened. When the Spleen is not moistened, it can no more
do the transportation work for the Stomach, thus, the dry-evil of the Stomach will become
abundant and the disease of the distension of the Stomach-Qi will happen. The acrid taste
acts on the Lung; if the acrid taste is taken excessively, the Lung-Qi will become
abundant, and the abundant Lung-metal will restrict the Liver wood. As Liver determines
the condition of the tendons, when the Liver is restricted, the tendons will become loose.
Due to the acrid taste also has the function of dispersing, the excessive taking of acrid
flavor will consume the spirit as well.” It also advocates: “the five tastes should be
adjusted in a harmonious condition without taking them excessively, the whole body will
obtain ample source of nourishment, and the tendons, bones, energies, Blood and striae of
skin will be kept in a strong and normal condition. Thus, the one who is good at adjusting
the five tastes can live a long life” (Wang, 1963, Wu, 1997, Zhu, 2001, Qing, 1956).
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1.3.2 Damage from imbalanced emotions
Imbalanced emotions may affect Spleen and Stomach functions directly or indirectly.
The normal emotions could turn into evils to cause internal impairment whenever there is
sudden strong or persistant emotional stimulation, which surpasses a human being's
physiological endurance and disturbs the function of the relevant internal organs. Because
the Spleen houses thought, the Su Wen chapter 5 Yin Yang Ying Xiang Da Lun (The
Corresponding Relation between the Yin and Yang of Man and That of the Four Seasons)
says: “excessive thinking/anxiety may damage the function of the Spleen.” The Ling Shu
chapter 8 Ben Shen (The Diseases Caused by Spiritual Activities) points out: “When the
excessive melancholy can not be removed, the idea will be injured; when it is injured, the
patient will become depressed, disquieted and reluctant to lift the limbs due to the
weakness of them; when the disease develops further to cause the patient’s hair to
become withered and the complexion to become abnormal, he will die in spring.” (Wang,
1963, Wu,1997)
1.3.3 Damage from external pathogens
Zhi Zhen Yao Da Lun (The Various Changes in the Dominations of the Six Energies and
their Relations with the Disease) says: “Spleen pertains to Yin earth and Zang; it desires
dryness and is of aversion to dampness; it is healthy in ascending; The Stomach pertains
to Yang earth and Fu organ; it is incompatible with dryness but desires moisture; it is
secure (health) in descending. In general, the humidity and dampness predominantly
damage the Spleen.” All the syndrome of edema and fullness caused by the dampness
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evil pertain to the Spleen. When the energy of Taiyin is retaliating, the disease of
dampness energy will occur; the patient will contract heaviness of body, fullness of the
chest, indigestion of food, adverseness of Yin-Qi. When the dampness energy of Taiyin is
partial overabundant and invaded, the fire energy is stagnated inside of the
body…distention
of
Stomach…distention
of
lower
abdomen…watery
diarrhea…heaviness of the head, swelling of the tibia of foot, and edema in the upper part
of the body due to the fluid retention inside(Wang, 1963, Wu,1997).
Yu Ji Zhen Zang Lun says: “The evil-Qi was transmitted from Liver to Spleen to cause
spleen wind-syndrome, jaundice, hot of the abdomen, irritability and yellow urine”. Re
Lun (On Febrile disease) says: “On the second day, the evil is transmitted into the
Ynagming Channel. The Yangming Channel takes charge of the muscle, in its course of
running; it clips the nose and sleepiness” (Wang, 1963, Wu,1997).
Ben Zang (The Various Conditions of Internal Organs Relating Different Disease) says:
“When the Spleen is small, the Spleen-Qi will be stable, and one can hardly be injured by
the exogenous evil; when the Spleen is large, it will often cause pain in the empty and
soft part under the hypochondria and one will not be able to walk fast. When the position
of the Spleen is high, it will have drawing pain under the hypochondria; when the
position of the Spleen is low to attach the large intestine, the Spleen is apt to be injured
by the exogenous evil. When the Spleen is firm, the Spleen-Qi will be harmonious and
the Spleen can hardly be injured by the exogenous evil; when the Spleen is fragile, one
will apt to contract diabetes and he is apt to be injured by exogenous evil. When the
position of the Spleen is upright, the Spleen energy will be harmonious, and one can
hardly be injured by exogenous evil; when the position of the Spleen is slanting, one will
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apt to contract colonic convulsion and abdominal distention” (Wang, 1963, Wu,1997).
1.4 Prevention of Spleen and Stomach disease
Nei Jing Ping Ren Qi Xiang Lun (On the Normal Pulse of a Person) says: “The normal
pulse energy stems from the Stomach, and the Stomach-Qi is the main pulse energy of a
normal person. If the Stomach-Qi is absent in one’s pulse, it is called the adverse
condition, which may cause the death.” Therefore, no matter the self damage of Spleen
and Stomach or the result from damage by other organs, we should pay attention to the
prevention. There are two types of prevention. One is to prevent the occurrence prior to
actual happening and the other one is to prevent the progression and conversion when it
is ill. Su Wen Si Qi Tiao Shen Da Lun(On preserving Health in Accordance with the
Four Seasons) says: “ When a sage treats a patient, precaution is always emphasized…If
the disease is treated after it has already been formed, or try to calm down the disturbance
after it has already taken shape, it will be too late, just like to dig a well until one is thirsty,
or to cast the weapon after the war has already broken out; when one is completely free
from wishes, ambitions and distracting thoughts, indifferent to fame and gain, the vital-Qi
will come in the wake of it. When one concentrates his spirit internally and keeps a sound
mind, how can any illness occur?” Shang Gu Tian Zhen Lun (On Human Preserving
Health Energy in Ancient Times) says: “The right-Qi exists inside; evils cannot make
disturbance”(Wang, 1963, Wu,1997).
The temperature of the food is particularly mentioned when try to avoid Spleen and
Stomach issues in Nei Jing. Shi Chuan (Treating Instructions Imparted by Precedent
Masters) says:“In taking food and drink, avoid taking that of excessive heat and cold, but
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keep them in moderate temperature, in this way, the healthy-Qi can be maintained in the
body so that the invasion of the evil-Qi which causes disease may be avoided.” In Ling
Shu Ben Zang (The various Conditions of Internal Organs Relating Different Disease), it
says: “When one can adapt the changes of the cold and hot weather, the function of
transporting and transforming of the six hollow organs will be normal; the arthralgia due
to wind-evil will not occur; the channels will be unimpeded, and the activities of the four
extremities will be normal.” (Wang, B. 1963, Wu,1997)
1.5 Treatment of Spleen and Stomach disease
1.5.1 Treatment with acupuncture
From the record of Ling Shu Bing Chuan(The Transmission of Disease), breathing
exercises, massage, moxibustion, topical application of heated herbs, acupuncture,
burning therapy and the administration of herbal decoction multiple treatments can be
used to treat all kinds of diseases. But “nine needling” technique is in the first priority.
Regarding the acupuncture treatment for Spleen and Stomach disorder particularly, it is
spread in many different chapters(Wang, B.1963, Wu, 1997, Zhu, 2001, Qing, 1956)..
Re Lun (On Febrile Disease) says: “It should base on the conditions of the solid and
hollow organs of various channels.”
Ci Re (Acupuncture for Treating the Febrile Disease of the Viscera) says: “prick Foot
Taiyin and the Foot Yangming channels.”
Ke Lun (On Cough) says: “When treating the cough of the five solid organs, prick the
Shu-points; when treating the cough of the hollow organs, prick the He-points; to the
patient of edema caused by cough, dredge the channel by pricking the points of the
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related channel.”
Wei Lun (On Flaccidity) says: “When treating the flaccidity, it should treat the Yangming
Channel alone.” etc.
1.5.1 Treatment with herbs
Regarding the treatment with herbs, there are only 13 formulas mentioned in total in Nei
Jing. Besides topical formulas, there are only two herbal formula particularly related to
the treatment of Spleen and Stomach. In Xie Ke (Retention of the Evil), the Ban Xia
Tang(One liter of husked sorghum and half liter of Zhi Ban Xia)，is classically used for
insomnia due to disharmony of the Stomach. In Su Wen Qi Bing Lun (On Extraordinary
Disease), the Lan Cao Tang is use to treat Pi Dan (pre-diabetes condition). Some people
have sweet taste in the mouth, what is the disease, and how does it come about? Qibo
said (In Nei Jing): “it was due to the overflowing of the earth-Qi, and the disease is called
Pi Dan…It should be treated with stem of the orchid which can remove the staleness
heat.” The other name of Lan Cao is Pei Lan, which is aromatic and able to transform
turbidity, promote the Spleen Function to eliminate dampness. Although only a small
number of herbs mentioned in Nei Jing, the ancient physicians had already got great
experience how to treat Spleen and Stomach disease and some methods have been
upgraded to the level of therapeutic principles for the later age. For example, in the
chapter of Su Wen Zang Qi Fa Shi Lun (On the Relation Between Energies of Five
Viscera and the Four Seasons), it says: “The evil-Qi of Spleen should be moderated with
sweet herb; when purgation is needed, herb of bitter taste should be used to purge the
Spleen; when invigoration is needed, herb of sweet taste should be used to replenish the
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Spleen; when there is an abdominal flatulence, therapy of promoting digestion can be
used…; when the disease associates with excess syndrome, it should be treated with
dispersing therapy.” In Su Wen Liu Yuan Zheng Ji Da Lun (On the Changes and Symbols
of the Five Elements, it says “When the earth-Qi is suppressed, it should be attacked
hastly” (Wang, 1963, Wu, 1997). Those treatment principles had been followed by the
later ancient physician, as a basis to establish comprehensive herbal prescription system.
2 Shang Han Za Bing Lun has established the basic treatment principles of Pi Wei
Theory based on syndrome differentiations
In the Eastern Han Dynasty, Zhang Ji (also known as Zhang Zhong-Jing) put theoretical
principles established in the Nei Jing and Nan Jing into clinical practice. Since then,
ancient physicians have considered Shang Han Za Bing Lun as the ancestor of Chinese
medical prescriptions. This monumental work has been recognized as the first classic that
not only combined theories with clinical practice from the prespective of six stages
differentiation….., but also opened up broad prospects for the clinical application of the
Pi Wei (Spleen-Stomach) theory. Zhang’s contribution to the Spleen and Stomach theory
mainly includes in the following areas:
2.1 Emphasis on the importance of the rule of “Maintain the strength of the Spleen”
and apply it in the prevention and treatment of diseases.
In terms of the treatment of complex diseases, Zhang Ji was the first physician to propose
treating diseases through strengthening the function of the Spleen based on the theories
from Nei Jing. In the chapter of Jin Gui Yao Lue, Zang Fu Jing Luo Bing Mai Zheng Di
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Yi, Zhang pointed out that “Liver disease eventually transfers to the Spleen; therefore
first of all the strength of the Spleen needs to be maintained when the liver disease
presents; one should be aware that the liver disease might affect or progress to the spleen.
So the priority of the treatment should be placed on strengthening the spleen” (Zhang,
1963). This is also the so-called “In any season when the Spleen is vigorous, it will not
contract any ailment”. Therefore, a physician who can treat disease before its onset is
called a superior physician. Only when Spleen Qi is sufficient, will the Qi of the Heart,
Liver, Lung and Kidney be abundant because the Spleen is the postal-natal foundation
which supplements the other Zang and Fu organs. Conversely, various diseases occur
whenever the Qi of Spleen and Stomach is damaged. Indeed this point of view has
opened the precedent of Spleen and Stomach theory and drew the ancient physicians’
close attention, which was particularly reflected in Li Dong-yuan’s Pi Wei Treatise
2.2 Elaborate the outline of pattern differentiation and treatment of the diseases of
Spleen and Stomach
Nei Jing has set up the principles of treatment based on identification of patterns
according to the channels and the internal organs which has been fully inherited and
carried forward in the Shang Han Za Bing Lun. Zhang’s major contribution to the
treatment of diseases of Spleen and Stomach is the outstanding achievements in various
areas including the methods of pattern differentiation, treatment principles and the
selection of effective herbs, etc.
2.2.1 The application of Six-Channel Theory on the pattern differentiation and
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treatment of Spleen and Stomach diseases
Six-Channel Theory is the core of Shang Han Lun. It has provided the basic treatment
principles not only for treating externally contracted diseases, but also for treating
miscellaneous diseases. According to the discussion of six channels from “Su Wen
Discourse of Febrile Disease”, Zhang Ji developed and completed the Six-channel theory.
He divided the whole course of externally contracted diseases into six stages which was
associated with six channels including Tai Yang, Yang Ming, Shao Yang, Tai Yin, Shao
Yin, Jue Yin, etc. In the Shang Han Za Bing Lun, Zhang Ji attached great importance to
Yang Ming disease in conjunction with his clinical practice and summarized it as
"Stomach domain is replete". Thus it confirmed that the nature of Yang Ming disease in
Shang Han Lun belonged to interior heat repletion patterns and could be further divided
into 3 types: Taiyang, Yangming (The evil passes from the Tai Yang channel into the
Yangming channel), ZhengYang Yangming (The evil invades directly into the Yangming
channel) and Shaoyang Yangming (The evil passes from the Shao Yang channel into the
Yang Ming channel). The causes of Taiyang Yangming and Shaoyang Yangming are
related to depletion of body fluid due to inappropriate promotion of sweating, urination
and bowel movement. The major symptoms to indicate a channel pattern include
generalized heat effusion, spontaneous sweating, and no aversion to cold; but aversion to
heat accompanied by thirst, large pulse, red facial complexion, etc.; while the typical
symptoms of a bowel pattern include failure to defecate, internal repletion, and difficult
defecation accompanied by tidal heat effusion, dry stool, focal distention, abdominal
fullness, abdominal pain, a tense and firm abdomen, etc. Even unconsciousness like
delirium can be seen in the severe cases. In order to treat excessive heat in Stomach and
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Intestine, the treatment principle is to clear heat and remove pathogens from Yang Ming
by choosing herbs with the nature of acrid cold, bitter cold and even salty cold. Zhang Ji
characterized the main symptoms of Tai Yin disease as abdominal fullness and vomiting,
inability to get food down, severe spontaneous diarrhea, and periodic spontaneous
abdominal pain. The main pathogenesis includes either constitutional Spleen Yang
deficiency which contracts wind-cold, direct internal damage to the internal organs from
external cold, or damage to the Spleen when a condition is not treated or treated
inappropriately. As a result, some herbs and herbal formulas which are good at either
tonifying deficient Qi in middle Jiao or warming Yang Qi in Middle Jiao are widely used
such as Ren Shen, Bai Zhu, Gan Cao, Fu Zi, Gan Jiang in single herb and Li Zhong Tang,
Si Ni Tang in formula. Comparing Yang Ming disease to Tai Yin disease, the nature of
Yang Ming disease tends to be more excessive, hot and Yang, while Tai Yin disease tends
to be more deficienct, cold and Yin. In terms of location of the pathogens, the Yang Ming
disease is more superficial and Tai Yin disease is more interior. This so-called “excess is
in Yang Ming, deficiency is in Tai Yin” (Wang, Qi, 1988)
Among the dysfunction of six channels, diseases of Spleen and Stomach are accounted
for two of six. As for the diseases deriving from dysfunction of other four channels are
concerned, Shang Han Lun has emphasized on treating them through protecting the
Stomach Qi and keeping liquid because the nature of the earth is the center and the pivot
of reference for all the other elements.
2.2.2 The application of eight therapeutic methods in treatment of the Spleen and
Stomach diseases
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Although eight therapeutic methods were first organized by the Qing dynasty physician
Cheng Zhong-ling in his book Yi Xue Xin Wu (Medical Revelations), its clinical
application were found in Zhang Ji’s-work originally. Even the eight therapeutic methods
were not originally designed for the spleen and stomach or Tai Yin and Yang Ming
diseases, they have indeed refected Zhang Ji’s idea in supporting, and protecting Qi of
Spleen and Stomach organs as the key when composing the formulas. Therefore, Zhang
attached great importance to the role of the Spleen and Stomach when treating three Yins
and three Yang diseases. For example:
2.2.2.1 Diaphoresis: Physiologically, Spleen governs transportation and transformation
of nutrients and body fluids and control muscles. The Spleen also has the physiological
characteristic of desiring dryness but aversion to dampness. Therefore, a dysfunction of
the Spleen in transportation and transformation due to the deficiency of the Qi of the
Spleen is susceptive to generating dampness, while excessive dampness will most likely
disturb the Spleen. Moreover, the Spleen is also easily attacked by external dampness.
External dampness manifests various symptoms, such as a feeling of tiredness, heaviness
of limbs or head and abdominal distension, etc. In this case, Zhang Ji treated the
symptoms by adding herbs which can strengthen Spleen to resolve dampness into
formulas to release the exterior syndrome. For example, in Jin Gui Yao Lue (Zhang,
1963), he used Ma Huang Jia Zhu Tang to treat generalized vexation and aching due to
invasion of wind-dampness or damp-cold in the interior in patients with chronic
dampness due to Spleen deficiency. When originally there was Tai Yang disease, but the
physician used purging method incorrectly, and consequently there was abdominal
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fullness with periodic pain, which belongs to Tai Yin disease. Gui Zhi Jia Shao Yao Tang
is based on Gui Zhi Tang with increased dosage of Shao Yao and is a classic formula to
address this condition.
2.2.2.2 Purgation：
：It is appropriate for the Qi of the Spleen to ascend, and for the Qi of
the Stomach to descend. Purgation is one of common methods widely applied in the
diseases of Spleen and Stomach, especially whenever there is abdominal fullness and
pain accompanied by difficult bowel movement and dry stool due to excessive Stomach
and/or Intestinal heat with damage of body fluid. In Shang Han Lun, Zhang Ji has come
up several formulas to target this condition in purging by descending Stomach Qi. Da
Cheng Qi Tang, Xiao Cheng Qi Tang, Tiao Wei Cheng Qi Tang and Ma Zi Ren Wan are
four main formulas to treat this kind of abdominal disharmony.
2.2.2.3 Emesis: According to the chapter 74 in Su Wen, it states that if the location of
disease is at the upper part of the body, it should be treated with a method to lead it up
and out. Emesis is this kind of a special and strong therapeutic strategy expel phlegm,
saliva, undigested food or toxic substances that retain in the throat, thoracic cavity or
Stomach, mainly for the removal of the phlegm and saliva clogging in the throat, or the
stubborn phlegm retaining in the thoracic cavity in the Stomach. Emesis can be induced
either by sticking a feather probe into the patient’s throat or using Chinese herbs. The
selection of herbs is based on the nature of syndromes. For excess syndromes, Gua Di, Li
Lu and Dan Fan are chosen; at the same time, Ren Shen is chosen for patients with
deficiency syndrome. In the Shang Han Lun line 166(Mitchell ect, 1999), Gua Di San is
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used for eliminating phlegm retention in the upper Jiao by causing the patient to vomit.
On the other hand, if there is vacuity vexation and inability to sleep or anguish in the
Heart or vomiting, it can be treated with Zhi Zi Chi Tang and Zhi Zi Sheng Jiang Tang,
etc. The Dan Dou Chi in Zhi Zhi Chi Tang and Sheng Jiang in Zhi Zi Sheng Jiang Tang
are used for protecting Stomach Qi.
2.2.2.4 Harmonizing: Harmonizing is mostly used to treat half-exterior and half-interior
syndrome by harmonizing or regulating the functions of different levels or organs,
including harmonizing the Shao Yang, venting the membrane source, harmonizing the
Liver and Spleen and regulating the Stomach and Intestine. It can be used in treating
disease of Spleen and Stomach through regulating Middle Jiao Qi. Just as Line 30 in the
Shang Han Lun(Mitchell etc 1999): “When in Yangming disease, there is hardness and
fullness under the rib-side, inability to defecate, retching, and white coating on the tongue,
one can give Xiao Chai Hu Tang; the upper burner will unblock, liquid and humor will be
able to descend, stomach-Qi will thereby become harmonious, and then there will be
generalized streaming sweat, bringing about resolution.” In addition, Sheng Jiang Xie
Xin Tang can treat water and heat complexes or Stomach deficiency with food stagnation
and suspended fluids lingering internally by using acrid herbs to disperse clumping, using
bitter herbs to descending Qi downward, and using sweet herbs to benefiting and
harmonizing the Middle Jiao Qi. After pathogens blocked in the Middle Jiao is removed
as well as Zheng Qi is supplemented, the balance in the Middle Jiao is back to normal.
2.2.2.5 Warming: According to the chapter 74 in Su Wen, it states that when treating the
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cold disease, apply the hot herb; when treating the hot disease, apply the cold herb.
Warming method is used to treat both excess cold syndrome and deficiency cold due to
Yang Qi deficiency. Spleen and Stomach is considered as the post-natal foundation and is
responsible for digestion and nutrition. There are different formulas discussed in Shang
Han Lun to work on deficient cold in Middle Jiao. For example, Li Zhong Tang is the one
to treat abdominal fullness and pain accompanied by vomiting, watery diarrhea with
undigested food, and lack of thirst due to Yang Qi deficiency in the Middle Jiao. In
addition, Da Jian Zhong Tang was recorded in the Jin Gui Yao Lue for relieving severe
epigastric and abdominal pain and vomiting due to Middle Jiao Yang Qi deficiency with
Stomach Qi rebelling.
2.2.2.6 Clearing heat: This therapy is used to clear heat of the Stomach with
representative formula Bai Hu Tang. If there is a impairment of body fluid, Ren Shen is
added to Bai Hu Tang to supplement Qi and generate body fluid, therefore it is called Bai
Hu Tang Jia Ren Shen Tang; if there is lingering heat located in the Lung and Stomach
which already damage the Qi and body fluid, Zhu Ye Shi Gao Tang is the one to clear
residual heat, nourish body fluid, tonify Qi and harmonize the Stomach. Furthermore,
when there is jaundice resulting from the combination of heat and dampness in the
middle, Yin Chen Hao Tang was mentioned in Shang Han Lun line 236 and 260 to treat
this condition.
2.2.2.7 Elimination: Zhang Ji applied the strategy of elimination to resolve the
abdominal fullness and distension. For example, he used Hou Po Sheng Jiang Ban Xia
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Gan Cao Ren Sheng Tang to relieve abdominal fullness and distension resulted from
sweating. Originally, it is Gui Zhi Tang syndrome and but mistreated with Ma Huang
Tanng. After excessively sweating promoted, the exterior syndrome is relieved; however,
Yang Qi is impaired due to inappropriate sweating and there is also Qi stagnation because
of the dysfunction of the Spleen. This is a conflicted situation because of the nature of the
disease. If pure tonifying method is used, the Qi stagnation will be worsened; if pure
eliminating method is applied, the Yang Qi deficiency will become more severe. Thus the
function of this formula is to treat both conditions simultaneously. In this formula, Ren
Shen, Gan Cao and Sheng Jiang are used to tonify Yang Qi; Hou Po and Ban Xia are for
moving Qi of Spleen. The elimination method is widely used in the clinic with good
success.
2.2.2.8 Tonification: According to Su Wen chapter 20, whenever there is deficiency
syndrome, tonifying method is appropriate to be utilized. Zhang applied the treatment
strategy of tonification in different ways, but one of his major treatment methods to
compose his formula is to build up and tonify Middle Jiao. The formulas reflecting this
composition include Xiao Jian Zhong Tang, Shu Yu Wan, Fu Mai Tang and Huang Tu
Tang, etc. In addition, when tonifying was not his main treatment focus, however, he still
added small amount of tonic herbs to the formulas which are composed of other treatment
strategies, such as sweating, vomiting, purgation, harmonizing, warming, clearing heat
and elimination. His purpose of using tonification here is to remove pathogens and
rebalance the body through tonifying Zheng Qi and harmonizing the Middle Jiao.
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In short, there are plenty of descriptions either in brief form or detailed form on the
application of the "Eight TherapeuticMethods" on the treatment of diseases of the Spleen
and Stomach in Shang Han Za Bing Lun. Even to date, they are very useful for clinical
practice.
2.3 Emphasize the importance of harmonizing Stomach and tonifying Spleen Qi
In Shang Han Za Bing Lun, Zhang Zhong-Jing often used the herbs of harmonizing the
Spleen and Stomach as assistant herbs in the formulas of attacking pathogenic factors in
order to avoid the damage of Zheng Qi (vital Qi). It reflects two basic characteristics of
the composition of attacking-pathogen formula. The first one is to eliminate pathogenic
factors with a mild tonifying method; and the other one is to emphasize on harmonizing
Stomach to consolidate the root of the body.
For instance: Gan Cao is in the formula of Ma Huang Tang which is the basic exteriorreleasing formula; Sheng Jiang, Da Zao and Gan Cao are seen in the Gui Zhi Tang which
is the major formula to harmonize Yin and Wei; Ren Shen, Gan Cao, Sheng Jiang and Da
Zao are in the formula of Xiao Chai Hu Tang which is the main formula to treat Shao
Yang disease; Geng Mi and Gan Cao are in the Bai Hu Tang which is for Yang Ming
channel syndrome; Gan Cao is in the Tiao Wei Cheng Qi Tang to harmonize Stomach,
etc. Even there is no herb such as Gan Cao etc.to harmonize Middle Jiao in the Da Cheng
Qi Tand and Xiao Chen Qi Tang, special attention was paid in terms of administration
method for both of formulas. Discontinue these two formulas once bowel movement has
been induced, which can prevent damage of Zheng Qi due to over-dosage.
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The emphasis of applying the principle mentioned above was also reflected through the
frequency of use of single herb in the composition of the herbal formulas. In the Shang
Han Lun (Wang Qi, 1988), Gan Cao which is one of the major herbs to harmonize
Spleen and Stomach has the highest using rate. It has been shown in 70 formulas or for
70 times. Then it is followed by Gui Zhi 43 (times), Da Zhao 40 (times), Sheng Jiang 39
(times). There are 20 herbs shown in this book for equal or over 7 times. Among them,
80% of them either have direct channel connecting with the Middle Jiao which means
they go into the Spleen and/or Stomach channel and work on internal organs through
channel and internal organs connection, or functionally they can treat Spleen and
Stomach related diseases. There are another 14 herbs which have been shown in the book
for over 10 times. All of them have close relationship to the Spleen and Stomach function
except 3 of them. The frequency of using such herbs have confirmed that Zhang ZhongJing played close attention on the importance of strengthening the Spleen and Stomach
through applying certain herbs to eliminate pathogens and supplement Zheng Qi.
2.4 Attaching importance to preparation and administration of herbs
Zhang Zhong-Jing not only attached importance to the pattern differentiation, the
composition of the herbal formulas and the dosage of each single herb, but also paid great
attention to the methods of preparation and administration of formulas. Regarding the
preparation, the detailed information including the usage of the different level of heat, the
amount of water to be added and the time of cook can be found in his book. He also
pointed out some special ways to administrate herbal tea and some precautions after
administration. The key he emphasized on is to eliminate pathogens or/and tonify Zheng
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Qi without damage the function of the Spleen and Stomach. The most typical example is
the method of preparing and administrating of Da Huang Huang Lian Xie Xin Tang.
Zhang’s direction states that “For the above two ingredients use two sheng (liter) of
boiled water and steep for a moment; Pour through a cloth and squeeze out the juice and
remove the dregs. Divide into two parts, and take warm twice a day” (Mitchell, etc. 1999).
His preparation method is different than usual because of using steeping herbs instead of
boiling them. In this way, the light Qi gets extracted without getting the heavy and turbid
flavor. It can meet treatment requirement without the possibility of damage of Middle
Jiao Yang Qi because of the bitter and cold nature of the herbs.
2.5 Application of Four Diagnostic Methods in treating the Spleen and Stomach
diseases
In terms of discussions of Four Diagnostic Methods, there is some description in the Nei
Jing and Nan Jing which is too brief and not systematic. Zhang Ji (Zhang Zhong-Jing)
greatly developed it and applied it to clinical practice especially for diagnosis of the
Spleen and Stomach diseases. For example, the observation is not only applied to the
color change of the face, but also used for nose, teeth, tongue coating and color and
nature of the bowel movement. Hereby are described in the following:
2.5.1 Observation
2.5.1.1 Observation of color change of the skin related to the Spleen and Stomach
diseases
In Jing Gui Yao Lue, the key points of the observation of patient's facial color change
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are listed. For instance, “When the tip of the nose looks greenit signifies abdominal
aching. If the patient also feels chilly and aches painfully，he is in critical condition.
When the tip of the nose appears slightly black，it denotes the presence of moisture.
Yellow indicates chills (water stagnancy）in the chest” (Zhang, 1963)
Observation of the nose has shown the importance of the Spleen. Other than that, the
book states if there is Stomach fire, a feverish face as though being drunk/intoxicated can
be observed which would guide the selection of the herbs. For this situation, Da Huang
will be added to purge the fire downward.
2.5.1.2 Observation of the tongue and tongue coating related to Spleen and Stomach
In Shang Han Lun, the tongue diagnosis is very important and the white and slippery
tongue coating has been used as an indicator if downward purging formulas are
appropriate. For example, “When in storehouse bind, Yang signs are absent, and there is
no aversion to cold and heat … the tongue fur is glossy, one cannot attack”; “Storehouse
bind…when the tongue fur is white and glossy, this pattern is difficult to treat” (Wang, Qi,
1988). All these statement marked the beginning of observation for tongue diagnosis.
Furthermore, it was first time mentioned that yellow tongue coating can be observed in
the patients with abdominal fullness and pain due to excessive Evil Qi retention in the
Stomach and was considered as one of the basis pattern differentiations. Just as “A
distended abdomen that does not ache when pressed is due to weakness；if the abdomen
aches，there is firmness and purging is needed. The yellow color on the tongue will
disappear after purgation.”
As described above, Zhang Zhong-jing has accumulated rich experience on the tongue
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diagnosis derived from tongue observation.
2.5.1.3 Observation of the general appearance
Besides the observation of the skin and tongue, extremely close attention has been paid in
the observation of the pathologic change of the local appearance for diagnosing the
Spleen and Stomach diseases. For instance, the symptoms indicated for the usage of the
Da Jian Zhong Tang include severe chills, pain in the chest and epigastrium and bulging
of the abdominal skin due to flushing of chills, vomiting that prevent eating, and painful
skin without desire to be touched. The mutual up-down repulsion is vividly displayed in
front of the reader through the description of the symptoms which reflects the detailed
observation.
2.5.1.4 Observation of the color and quality of the excreta
In terms of pattern differentiation of the Spleen and Stomach diseases, Zhang mainly
focused on the nature of the bowel movement and urine; therefore he came up the
pathogenesis with the combination of other clinical symptoms. Generally speaking, the
pattern of excess heat leads to dry and hard stool and the pattern of deficient cold results
in loose stool. But it is not always the case. For instance, diarrhea with pus and blood in
the stool can be seen in either excess syndrome or deficiency syndrome. In the Shang
Han Lun line 307, it points out Spleen and Kidney Yang Qi deficiency can cause
incessant diarrhea because deficient Yang Qi is unable to contain the blood within the
vessels. However, it is also stated in Shang Han Lun line 258 that diarrhea with pus and
blood in the stool can be resulted from the Blood heat damaging the blood vessel as well
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as steaming and corroding the membrane of the Intestine. Another good example is the
pattern differentiation of watery stool. Based on the observation of the color and nature of
the stool, there are at least 4 possible reasons to cause watery stool. The first one recorded
in line 127 is due to accumulated heat in the Intestine; the second one line 228 is related
to Yang Qi deficiency; the third one can be found in line 253 and it mentions the damage
of Spleen function from impropriate purgative treatment; and the last one recorded in line
321 describes that the blue-green, watery stool with a foul smell is caused by interior
excessive heat binding with the stool (Mitchell, etc. 1999).
2.5.2 Interrogation and auscultation of olfaction
It is very important to record the patient's medical history and subjective symptoms based
on the interrogation and auscultation of olfaction. From inquiry, lots of clinical symptoms
related to Spleen and Stomach diseases should be included, such as course of the disease,
pain, thirsty, appetite, bowel movement, urination and usual lifestyle and habit, etc..
Zhang Zhong-Jing had showed detailed inquiry of patients' medical history and lifestyle
and recorded some contraindications for the usage of certain formulas due to the patients'
history of long-term drinking, panting, excessive sweating, sores, stranger and Blood
collapse. In addition, based on listening, Zhang Zhong-Jing used vivid description such
as thunderous rumbling in the abdomen to show one of the main symptoms for indication
of choosing either Gan Cao Xie Xin Tang or Sheng Jiang Xie Xin Tang. From the smell,
dry belching with foul breath is included in the clinical symptoms for indication of usage
of Sheng Jiang Xie Xin Tang.
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2.5.3 Pulse taking and palpation
In terms of diagnostic methods, pulse taking and body palpation especially chest and
abdomen are another two great contributions of Zhang Zhong-Jing which are widely
applied in his practice. Based on his experience of pulse taking, different pulses are
associated with different pathological change of Spleen and Stomach. For instance,
excess Yang Ming heat could lead big pulse (Shang Han Lun, line 191); if there is
spontaneous diarrhea due to weak Stomach Qi, the pulse is weak (Shang Han Lun, line
280); if there is dryness and heat in the Stomach and intestines accompanied by
deficiency of body fluids, the instep Yang pulse is floating and rough (Shang Han Lun,
line 247). There is pulse descriptions listed in the Jin Gui Yao Lue to show food
stagnation can also be detected through different pulse change. One pulse can be felt is a
rope-like pulse with alternately tense. Another one is there is floating and big pulse at the
Cun Kou pulse (under the first finger). When it is pressed deeply, it becomes hesitant.
However, pulse at the Chi position (under the ring-finger) is also feeble and choppy. In
addition, Da Chen Qi Tang is prescribed to treat rapid and slippery pulse caused by food
stagnation.
Palpating the chest and abdomen is another feature of Zhang Ji’s contribution. Palpation
originates from Nei Jing. In the Su Wen chapter of Ju Tong Lun (Differentiation of Pain),
it already mentions that some pain is aggravated by touch; some is relieved by touch;
some pain does not respond to touch at all, and “All these can be detected by palpation”.
Zhang Zhong-Jing has inherited and further developed the theory and application of body
palpation, especially chest and abdominal palpation is used as a key diagnostic method
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for pattern differentiation and selection of herbal formula. In Jin Gui Yao Lue chapter of
Fu Man Han Shan Shu Shi Bing, it states that if the abdominal pain is worse with the
palpation/pressure, it is excess syndrome; if the pain is relieved with the pressure, it is
deficiency syndrome. Still in this chapter, it describes one of the main clinical symptoms
to choose Da Jian Zhong Tang is due to severe abdominal pain which is nearly
untouchable. Chest and abdominal palpation can also be used for differentiation of excess
syndrome or deficiency syndrome of the Intestinal abscess, presence or absence of pus,
differentiation of glomus and chest binding and application of the Da Xian Xiong Tang or
Xiao Xian Xiong Tang.
Overall, the general approach of applying the Four Diagnostic Methods in diagnosing and
treating Spleen and Stomach diseases has been recorded in details in Zhang's work,
Shang Han Za Bing Lun. Nowadays, it still acts as a guideline and has been widely used
in the clinical practice.
3. The Yishui School formally established and explained Pi Wei Theory and its
application
Yishui School is considred to be first established by Zhang Yuan-su, a famous ancient
physician in Jin and Yuan dynasties (1115 A.D.-1368A.D.). In Yishui School the cold and
heat properties of Zang-Fu organs are utilized to analyze and explain the onset, the
development, and the determination of pattern-differentiation and treatment of diseases.
With the inspiration of Zhang Yuan-su’s theory and the inheritance from Zhang’s
achievements, Li Dong-yuan (also named Li Gao) attached great importance to the Pi
Wei in terms of onset, progressions and treatments for various diseases. It was a
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cornerstone for the development of the Pi Wei theory. The theory has been flourishing
since then. The new theory is rooted in the perception in Su Wen that earth generates
myriads things. He advocated that Spleen and Stomach disorders were mainly caused by
deficiency. In practice he preferred to prescribe herbs which could supplement the middle
Jiao, ascend Yang, tonify Qi, and nourish Stomach. Therefore he is regarded as the
founder of Earth-supplementing School. Wang Hao-gu, the disciple of both Zhang Yuansu and Li Dong-yuan, harbored similar understandings of the pathologic factors with Li’s,
i.e. improper diet and excessive taxation. Luo Tian-yi, another disciple of Li Gao,
supplemented the Pi Wei theory and further elaborated the pattern differentiation and
treatment for San Jiao. The academic ideas of the distinguished doctors mentioned above
seem chronologically well-arranged due to inheriting, but each is unique in their
characteristics respectively as well.
3.1 Zhang Yuan-su formed Pi Wei theory based on pattern differentiation
Zhang Yuan-su, the founder of Yishui School, had engaged in medicine for more than 20
years and earned apparent therapeutic outcomes. The primary contributions to the
formation and the development of Pi Wei Theory are briefly introduced as follows.
3.1.1 The pattern differentiation of Zang-Fu organs is employed to direct the
treatment of Pi Wei diseases
Zhang Yuan-su had developed systematic and comprehensive therapeutic approaches
treating deficient and excessive Pi Wei diseases based on the Zang-Fu theory and five
elements relationship.
For instance, he proposed that, for Spleen disorders, excessive
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earth must be reduced with the methods of draining Son-metal, promoting vomiting and
promoting bowel movement; deficient earth must be supplemented with the methods of
supplementing mother-fire, replenishing Qi, and supplementing Blood; the dampness root
(the cause of Spleen disorders) must be eliminated with the methods of drying Spleencenter, cleaning Jing-Fu i.e. urinary bladder; the dampness branch (the outcome of Spleen
disorders ) must be percolated with the methods of opening Gui-men i.e. pores on the
skin. For Stomach disorders, Stomach excess must be reduced mainly with the methods
of clearing damp-heat and removing foods retention; Stomach deficiency must be
supplemented with the method of strengthening Stomach Qi in order to overcome dampheat and damp-cold; the heat root (the cause of Heart disorders) must be cooled with the
method of clearing fire; heat branch must be resolved with method of releasing muscles.
Thus it can conclude that Zhang Yuan-su formulated the principle of treating Spleen
disorders by guarding, supplementing, and ascending, and treating Stomach disorders by
harmonizing, reducing, and descending. All his principles are based on the natures of
Spleen and Stomach: Spleen prefers to warmth and moving, while Stomach prefers to
moisture nourishment and descending, which presents the secret of treating Pi Wei
disorders.
Zhi Zhu Tang is a formula originally created by Zhang Zhong-Jing (in Jin Gui Yao Lue,
chapter 14). Zhi Zhu Wan, a formula created by Zhang Yuan-su typically shows his
thought of “cultivating Stomach Qi” after changing the dosage of herbs in Zhi Zhu Tang.
Zhi Zhu Wan can eliminate Pi or epigastric, disperse foods accumulation, and promote
digestion. The formula is composed of Bai Zhu 2 liang(60g) and Zhi Shi 1 liang (30g)
with pulp removed stir-fried to yellow with bran,. The two herbs are grinded to fine
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powder, which is then, together with rice, wrapped around by lotus leaf cooked and then
are made to pill in the size of Chinese parasol. Fifty pills should be taken every time, with
rice soup.
He explained that the reason of using twice dosage of Bai Zhu than Zhi Shi was to tonify
and supplement Spleen and Stomach predominantly and to remove the epigatric
distention and the food accumulation secondarily as the adjuvant therapy.
As he
remarked for the formula, Bai Zhu does not remove food stagnation but strengthens
Stomach Qi and prevents further impairment of Pi Wei. The lotus leaf ascends Stomach
Qi with its aromatic taste and ascending nature. The rice helps Bai Zhu to supplement
Stomach Qi so that further internal injury could be avoided. The formula just
demonstrates Zhang’s key understanding on Pi Wei disorders, like the comment from Luo
Qian-fu, “if Zheng or vital Qi is nourished, morbid accumulation is removed
automatically”
3.1.2 Zhang valued regulating the Spleen and Stomach when prescribing herbs.
Zhang Yuan-su researched herbs under the guidance of Huang Di Nei Jing and
combining the theory of Wu Yun Liu Qi (the Movement of Five Celecial Body and the Six
Qi Produced in Universe). Thereby he discussed in-depth the tastes/flavors and natures,
reinforcing and reducing function, and channels entered of herbs. Just as Su Wen, Yin
Yang Ying Xiang Da Lun says that, the thickness of tastes (including five tastes) is Yin
while the thinness of taste is the Yang within Yin; the thickness of Qi natures (including
heat, warm, cool and cold) is Yang while the thinness of Qi is the Yin with Yang.
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The Qi (nature) of herb pertains to Yang and the Taste pertains to Yin. Differentiating
thickness and thinness from Qi and Taste indicates the division of Yin and Yang based on
the theory of Yin and Yang. Not all of thin-Qi herbs go upward and not all of thin-taste
herbs go downward. Therefore, in his book Yi Xue Qi Yuan (Zhang, YS. 1989) he paid
great attention to the thickness-thinness of taste/flavor and Qi, and action direction such
as ascending-descending-floating-sinking properties of herbs and their relationships.
Accordingly, he had originally formulated Fa Xiang (the relationship between the quality,
action of herbs and the human body in the regard of symbolism principle, which includes
five categories. For example, it is recorded in the category of dampness that, the Qi of
earth (the 5th 10 Heavenly Stems) which corresponds to Stomach for human body, is
neutral and combined with warm, cool, cold and heat in nature of Qi; the earth (the 6th 10
Heavenly Stems) which corresponds to Spleen for human body, is bland and combined
with aromatic, sweet, salty, and bitter in Taste/flavor. There are twenty one herbs
including Huang Qi, Ren Shen, Gan Cao, Ban Xia, Bai Zhu, Cang Zhu, Chen Pi and Qing
Pi listed under this category. He elaborated the thickness-thinness of Taste and Qi and
ascending-descending-floating-sinking action tendency of those herbs above mentioned
and their application on the treatment of Pi Wei disorders.
Zhang Yuan-su further developed the reinforcing-reducing function of herbs according to
the Zang-Fu properties in Huang Di Nei Jing. It is recorded in Su Wen, Zang Qi Fa Shi
Lun that if Spleen suffers from dampness and desires bitterness to dry its dampness.
Therefore, when treating Spleen disorders, he preferred using Bai Zhu to dry the
dampness of Spleen. It is also recorded in Su Wen, Zang Qi Fa Shi Lun that Spleen tends
to be moderated and desires sweet to moderate, bitter to reduce and sweet to reinforce.
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Consequently, he preferred to use Gan Cao to moderate Spleen, Huang Lian to reduce
Spleen and Ren Shen to supplement Spleen.
He created the theory of “herbal channel direction” (Zhang, YS. 1989). He believed that
the full use of the advantages of each herb combining with guiding herbs to enter their
own channels could give rise to more concentrated and powerful actions. For instance, in
the treatment of Pi Wei disorders, Huang Qin reduces large intestine fire while Shi Gao
reduces Stomach fire even both can reduce fire. In addition, he believed that, when
selection of guiding herbs, Sheng Ma and Bai Zhi were used to treat Yangming Fu
(Stomach Fu-organ) disease, Shi Gao is used to treat Da Chang Jing (Large Intestine
channel) disease and Bai Shao is used to treat Taiyin (Spleen) disease.
Zhang’s principle of prescribing herbal formula is built upon the coordination of
pathogenesis and the Qi and the taste of herbs and the rule of interactions of five elements.
For instance, he explained the formulating principle of treating Pi Wei diseases: “Spleen
pertains to the earth and sweet property, and it is the hub of transportation and
transformation Therefore, when dampness accumulates inside, bitter and hot herbs are
predominantly used to dry dampness and salty and bland herbs are used to percolate
dampness” (Zhang, YS. 1989). Hereby, according to above principle he explained Dang
Gui Nian Tong Tang as follows.
Dang Gui Nian Tong Tang is mainly used to treat damp-heat which manifests as
arthralgia, heaviness of shoulder and back, chest discomfort, general pain and swollen
legs with unbearable pain.
Huang Di Nei Jing says: “When dampness accumulates inside, it should be treated in
bitterness and warmth.” For this formula, Qiang Huo, a bitter and aromatic herb, can
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move through joints, eliminate and dry dampness. Fang Feng, a sweet and aromatic herb,
can warm and dissipate retained dampness in channels. Therefore the two herbs are
classified as king herbs of the formula. Dampness-water has tendency pouring downward.
Sheng Ma and Ge Gen are bitter, aromatic and moderate in properties, which belong to
the thinness of taste and Yang within Yin. They can ascend other herbs in the formula
because of dissipating the bitter taste. Bai Zhu, a bitter, sweet and warm herb, can
harmonize middle Jiao and eliminate dampness. Cang Zhu with a light and floating
substance harbors strong energy and can eliminate dampness in Cou Li or interstices.
Four herbs of the above are used as minister herbs. If Blood circulation is blocked, pain
happens. Dang Gui Shen with aromatic and warm properties can promote blood
circulation and bring Qi and Blood back to their right path. Ren Shen and Gan Cao,
which are sweet and warm can strengthen Spleen and supplement right Qi so as to
prevent the injury of Stomach from bitter herbs.
Zhang Zhong-jing said that the
combination of dampness and heat leads to painful limbs and joints and could be cleared
with bitter herbs such as Ku Shen, Huang Qin, Zhi Mu, and Ying Chen Hao. It is said that
eliminating dampness without herbs to promote urination can never work. For this reason
Zhu Ling, a sweet, warm and moderate herb, and Ze Xie, a salty and moderate herb, can
eliminate dampness with their bland taste and promote urination. So the two herbs are
assisting herbs. The detailed explanation of Dang Gui Nian Tong Tang not only has set a
good example of how to compose a formula, but also has enlightened later practitioners
how to select herbs to treat Pi Wei disorders caused by damp-heat.
3.2 Li Dong-yuan’s unique monograph, Pi Wei Lun (Spleen-Stomach Treatise)
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contributed to the Pi Wei Theory systematically.
Li Dong-yuan started to learn medicine from Zhang Yuan-su, and inherited and carried
forward Zhang’s medical theories and experiences. Enlightened by Zhang’s perception
which lays stress on Zang-Fu organs to analyze disease, he dived into Huang Di Nei Jing,
Nan Jing and Shang Han Lun and other medical classics and then became a veteran
physician after long practice. Afterwards he put forward a unique opinion on Pi Wei
disorder i.e. the internal impairment of Spleen and Stomach yields a hundreds of diseases,
which made him the initiator founder of Earth-supplementing School. This new school
has made outstanding contributions to enrich and advance TCM. In his monographs, Pi
Wei Lun, Nei Wai Shang Bian Huo Lun, and Lan Shi Mi Zang he made a
comprehensive treory of Spleen and Stomach including its systemic and integrated
theoretical foundation, the physiological functions, the etiolo-pathology and the patternsdifferentiation and treatment-determination of internal injuries, and some effective
formulas. Therefore there is a saying in later ages that: “Phsyicians should follow Zhang
Zhong-jing’s strategy to treat externally contracted diseases and follow Dong-yuan Li’s
idea to treat internal damages.”
3.2.1 Elaboration on the physiological functions of Spleen and Stomach
3.2.1.1 Spleen and Stomach is the source of Yuan Qi (original Qi)
In TCM, Yuan Qi (original Qi), which must be supplemented by Stomach Qi, is regarded
as the root of life support. Original Qi is first recorded in Nan Jing, in which Ming Men
or vital gate is the source of original Qi. However Li Dong-yuan advocated that Spleen
and Stomach are the source of original Qi. He said: “Zheng Qi or right Qi, also named
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original Qi, is the prenatal essence Qi which must be supplemented by Stomach Qi”.
“Original Qi, grain Qi, nutrient Qi, clear Qi, defensive Qi, up-rising Qi which ascends all
kinds of Yang Qi, total six kinds of Qi are derived from Stomach Qi and originated from
foods. Actually they are just different names of Stomach Qi”. (Li, 1963, Yang, 1993). He
believed that original Qi is the foundation of health and the adequacy of original Qi
primarily arises from the security (health) of Qi of Spleen and Stomach and secondly
from the supplementation of Spleen-Stomach Qi. In other words, if Spleen-Stomach Qi is
injured, original Qi can not be supplemented and turns to be deficient. Deficient original
Qi leads to the onset of many diseases. The status of original Qi fully relies on Spleen and
Stomach. Thereby he said that as for regimen nothing was more important than enriching
original Qi and if original Qi was going to be enriched, the priority of regulation of
Spleen and Stomach needed to be given.
3.2.2.2 Spleen and Stomach is the hub of ascending-descending, transportation and
transformation for essence and Qi
Li Dong-yuan says: “Stomach is the sea of grain and water. Foods are digested in
Stomach and transformed into essence. Then, like the clear qi goes up to the sky in spring
and summer, the essence is transported into Spleen and then upward to Lung where the
essence is distributed to enrich the whole body, likewise the clear Qi goes up to the sky in
spring and summer. Afterwards, the ascended essence goes down to bladder where it is
transformed into dross and expelled, likewise turbid Yin goes down to earth in autumn
and winter” (Li, 1963, Yang, 1993)
He believed that the ascending-descending
movement of essence and Qi of the body depends on Spleen and Stomach, the hub of
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transportation, likewise in spring and summer the Qi of earth grows up and goes upward,
while in autumn and winter the Qi of heaven diminishes, going downward and is stored,
but only in late summer, the earth Qi stays in center and acts as the hub of the movements
of ascending and descending. Thus he warned
that only when
one had been in
conformance with the alterations of four seasons, followed healthy way of life, avoided
cold and summer heat, ate regularly, calmed mind, controlled emotions can the one be
healthy without any unevenness and abnormality. Moreover he attached more importance
on the ascending and growing aspect of in ascending-descending movement. For this
reason he focused on ascending Spleen Yang and Spleen-Stomach Qi. He pointed out the
deficiency of Stomach could cause the insufficiency and disorders of all organs,
meridians, and original Qi and the blockages of nine orifices, so he prefers Chai Hu and
Sheng Ma (in Pi Wei Lun, Chai Hu is used more than 20 times, Sheng Ma more than 24
times) to make full use of the ascending functions of the two. In addition to advocate that,
when ascending Spleen Qi, Yin Huo or Yin fire is also required to descend, which was
just not as important as the ascending in his theory.
3.2.2 “Internal Injures of Spleen and Stomach”are the primary etiologies
Li pointed out that, the internal injury of Spleen and Stomach could yield hundreds of
diseases; all diseases are caused by the deficiency of Spleen and Stomach. Why? Because
the internal injury of Spleen and Stomach leads to the deficiency of the two organs and
can not generate enough Qi and Blood, which fails to maintain normal activities of mind
and body nor prevent the invading of pathogenic factors. Thus illness happens.
Li thought the main etiologies of the internal injuries of Spleen and Stomach are:
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3.2.2.1 Irregular diet: Li pointed out that irregular diet impairs Stomach and then Spleen.
He said: “Irregular diet results in Stomach disease; stomach disease will cause lack of Qi
and Spirit, so the heavy heat (deficiency) will be generated, manifesting as flaring up of
fire on the face…. … Stomach disease will cause the inability of storage and
transpormation of the Spleen… …”(Li, 1963)
3.2.2.2 Over-work and taxation: Over-work impairs muscles and four limbs which
correspond to Spleen and it is first damaged. Because the fluid depends on transportation
and transformation of Spleen, the fluid in Stomach must be transported by Spleen as well.
Stomach is involved as the result of the impairment of Spleen.
3.2.2.3. Internal damage from imbalanced emotions: Joy, anger, anxiety, and fear
impair original Qi and indulge Heart fire. Original Qi and fire are not compatible;
therefore the hyperactive Heart fire must overact on earth, which leads to diseases.
Affected mind dissatisfaction or over emotion gives rise to relatively hyperactive Heart
fire which is bound to overact on earth, resulting in impairment of original Qi. Li Dongyuan defined Heart fire as “Yin fire” and vigorous fire, which consumes Qi.
3.2.2.4 External contracted seasonal evils: Intestines and Stomach are like a market
where nothing is refused and everything can enter. Therefore if any of wind, cold,
summer-heat and dryness is relative excessive, Spleen and Stomach are impaired.
Among the four etiological factors mentioned above, Li emphasized that the internal
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damage of emotions played an initial role in the onset of diseases very often. He said that,
first of all, joy, anger, anxiety, sorrow, and fear impair the body and then Stomach Qi was
obstructed; afterwards Over-work and Irregular Diet were followed to injure original Qi
in the end. Once original Qi was injured, the body was susceptible to suffer external evils.
In summary, the formation of internal injuries is due to the comprehensive impact of the
above mixed causes, which damage the Spleen and Stomach in the end.
3.2.3 Elaborating the pathology of “Internal Injuries of Spleen and Stomach”,
particularly the importland role of Spleen and Stomach among the relationship of qi
ascending and descending, yin fire and original qi, internal injuries and externalycontracted diseases
Li believed the internal injuries of Spleen and Stomach were primarily caused by the
disharmony of Qi dynamics and dysfunction of ascending-descending movements.
According to Su Wen, Wu Chang Zheng Da Lun, “the people staying in the place where
the Yin essence (refined energy of Yin) is ascending, their striae will be dense and they
will live long; the people living in the place where the Yang essence (refined energy of
Yang) is descending, their striae will be loose and they will die early”, he further
developed this idea and applied to the Pi Wei theory.
Li thought that “The ascending of Yin-essence means the harmony of Spleen and
Stomach, resulting in ascending of Grain-Qi.” So Spleen and Stomach sitting in middle
Jiao, are the hub of the ascending-descending movement of essence and Qi, which is
conveyed up to Heart and Lung and down to Liver and Kidney. Therefore only when
Spleen and Stomach operate normally, i.e. Spleen ascends Clear Qi and Stomach
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descends Turbid Qi, can the normal organic function--- (clear Yang goes up to upper
orifices, turbid Yin goes down to lower orifices; clear Yang is distributed to interstices,
turbid Yin is distributed to five Zang organs; clear Yang enriches four extremities, turbid
Yin returns to six Fu organs) be maintained. Once Spleen-Stomach Qi is deficient and
fails to ascend and descend, various disorders would be yielded in internal five Zang
organs and six Fu organs and external four extremities and nine orifices. For instance, his
understanding on the pathogenesis of “internal obstructions of the eye (blurring vision
diseases, such as glaucoma-originally defined from Su Wen Zang Qi Fa Shi Lun) is that,
if original Qi is obstructed and Stomach Qi goes downward, they will lead to the fire of
Heart and the triple burners in the chest to overact on the Lung, invade brain and burn
marrow. Because fire is dispersing and overflowing, pupil is dilated. Besides he said that,
as Spleen and Stomach were overacted by Yin fire, grain Qi was blocked and went
downward i.e. clear Qi could not go upward and nine orifices cannot be enriched. All
those disorders are due to the deficiency of Spleen-Stomach Qi, the dysfunction of Qi
dynamics, the disturbance of ascending-descending movement and the insufficiency of
five Zang organs.
In addition, he thought that: “the descending of Yang essence means the disharmony of
Spleen and Stomach resulting in pouring downwards of Gu Qi (food Qi)” (Li,1963). The
deficiency of Spleen-Stomach Qi leads to the deficiency of original Qi, failure of clear
Yang going upward and pouring downward of Gu Qi (food Qi), and up-invading of Yin
fire; on the other hand, if Spleen-Stomach Qi is sufficient and original Qi is rich, Yin fire
moves downward by itself. Li thought that the Yin fire was called as “the thief of original
Qi” (Li,1963); the Yin fire was the actually Heart fire which was relatively hyperactivity
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of Yang derived from the deficiency of original Qi due to the deficiency of Spleen and
Stomach; it was originated from lower Jiao and linked to Heart.
Li thought that if Heart could not issue orders, Xiang Huo (minister fire) would replace
the function. Xiang Huo (minister fire), also named the thief of original Qi, is the fire of
the pericardium and Lower Jiao. Fire and original Qi can not exist together, if one won,
another one would lose. If the Spleen-Stomach Qi is deficient, the original Qi goes out
and Yin fire gets more excessive. The more excessive the Yin fire is, the more exhausted
the original Qi is, the less ascending the Spleen Qi is and the more descending the Grain
Qi is, which gives rise to the insufficiency of Qi and Blood yielding various disorders of
organs and orifices and susceptibility to external contractions.
As mentioned above, Li elaborated the waxing and waning alternation of fire and original
Qi based on the content in Huang Di Nei Jing, particually using the ascendingdescending function of Spleen and Stomach. Hereby, for the sake of harmonizing the
contradiction of ascending Yang and reducing fire, first of all, Li chose sweet and warm
herbs to ascend Yang and supplement center (Middle Jiao) then he selected sweet and
cold herbs to reduce fire, which is very creative.
3.2.4 Li clearly clarified the differentiation of fever from internal injury, external
contractions and Qi deficiency (Middle Jiao Qi deficiency)
In Nei Wai Shang Bian Huo Lun (Li, 1963), identification of Yin pattern and Yang
pattern are the general outline for differentiating internal and external disorders, which
consists of twelve differentiations including the differentiation of pulses, cold and heat,
the palm and the back of hand, mouth and nose, sinew-bone and four extremities, and
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thirsty and no absence of thirsty. Those key points are his experiential summary based on
of his long term clinical practice, which is not only the theoretic development of the
identification of internal injuries and external contractions but also of high clinical value.
Especially, he was the first person who originally explained the etiology, the pathology,
the patterns and manifestation, and the treatment of heat, which is caused by from (Yang)
Qi deficiency in internal injuries. It should be regarded as one of his most excellent
contributions to Chinese medicine.
3.2.5 Li created two important principles-Clearing Heat with Sweet and Warm
herbs, and Dissipating Fire within Ascending Yang, and established their herbal
composition strategies
The major contribution and essence of Li’s Pi Wei Lun comprises of three aspects. Firstly,
it is the analysis of the etiology- that the internal injuries of Spleen and Stomach play a
key role in the onset of the disorders; Secondly, it is analysis of the primary pathologythat the Qi (Yang) deficiency of Spleen-Stomach is the root to cause disharmonized Qi
dynamics of Spleen-Stomach and the dysfunction of ascending-descending movement.
Thirdly, it is the emphsis of the treatment principle-that ascending Spleen Yang must be
primarily focused. Therefore he created two therapeutic methods to eliminate Heat by
ascending Yang and using sweet and warm herbs. Most of his formulae are based on the
principles in Huang Di Nei Jing that over taxation should be warmed and deficiency
should be supplemented. Under such guidance, sweet and warm herbs including Ren
Shen, Huang Qi, Bai Zhu, and Gan Cao are used to supplement center. According to the
principle that the sunk should be lifted, Sheng Ma, Chai Hu, and Ge Gen are used to
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ascend Yang; sweet and cold herbs are assisted to reduce Yin fire in order to resolve the
conflict between dealing with the fire and original Qi. His representative formulae are Bu
Zhong Yi Qi Tang and Sheng Yang San Huo Tang. Bu Zhong Yi Qi Tang employs sweet
and warm herbs to clear great heat (deficiency heat) and to eliminate the source of Yin
fire. Sheng Yang San Huo Tang employs sweet and warm herbs to supplement Qi and
guide the clear Qi of Spleen and Stomach upward to treat the root. Meanwhile dissipating
herbs are added to smooth depression and disperse Yin fire.
In Pi Wei Lun, besides adopting the formulas created by previous physicians, such as Yi
Gong San, Wu Ling San, San Wu Bei Ji Wan, and San Huang Wang, Li had created 59
new formulas (including Bai Zhu San and Zhi Zhu Wan, created by his teacher, Zhang
Yuan-su) by himself. Those formulas demonstrated the therapeutic methods of ascending
Yang and supplementing Qi, ascending Yang and dissipating fire, ascending Yang and
eliminating dampness, and ascending Yang and enriching Stomach. There are total 103
herbs that have been involved with those methods related to the Pi Wei theory. There is
different frequency of using those herbs. For example, among those herbs, 43 herbs are
used only once, 14 herbs twice, 8 herbs three times, 4 herbs four times, 20 herbs five to
nine times, 6 herbs (Cang Zhu, Huang Bai, Qiang Huo, Fu Ling, Ban Xia, Ze Xie) ten to
nineteen times, 7 herbs (Ren Shen, Chen Pi, Sheng Ma, Dang Gui, Bai Zhu, Huang Qi,
Chai Hui) twenty to twenty-nine times, and Gan Cao thirty times. It can be seen from his
book that he had focus on selected herbs and his dominant idea was to enrich Qi, ascend
Yang and reduce Yin fire. The usage of above herbs originated from his several decades
of clinical experience, which is unique in theory and practice and is still effective at
present.
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Furthermore, he composed some other formulae to support right Qi and expel evil
pathogens by supplementing Spleen and Stomach primarily, such as Qing Shu Yi Qi Tang,
Tong Qi Fang Feng Tang, and Sheng Yang Chu Shi Fang Feng Tang. Although he is the
creator of Earth-Supplementing School, it does not mean that he has ignored the
importance of Treatment-Determination based of Pattern-Differentiation, but he stresses
modification according to symptoms rather than insisting on fixed formula.
Bu Zhong Yi Qi Tang is a hallmark formula that demonstrates the application of Li’s
insightful thought in the Pi Wei theory. As far as Bu Zhong Yi Qi Tang is concerned,
there are total 27 modifications of the formula, among which 11 come from Pi Wei Lun, 4
(2 are the same in Pi Wei Lun) come from Nei Wai Shang Han Bian Huo, 21 (5 are the
same in Pi Wei Lun) come from Lan Shi Mi Zang, including Sheng Yang Yi Wei Tang,
Cao Dou Kou Wan, Yuan Ming Nei Zhang Sheng Ma Tang, Qing Zao Tang, and Ding
Xiang Zhu Yu Tang.
They are effective for various internal injuries and extern
contractions. For excessive patterns in the Spleen and Stomach disorders, based on the
principle “excess must be reduced,” he also used strong formulas including San Huang
Wan, Shen Bao Wan, and San Wu Bei Ji Wan which contain Ba Dou and Da Huang. For
Stomach Yin deficiency, he advocated moist nourishing and decending. MoistureDampness can help Stomach deficiency, but the dampness must be reduced when it is
excessive in Stomach. This has greatly inspired Ye Tian-shi in Qing dynasty a lot to
develop Ye’s theory on nourishing Stomach Yin.
When prescribing herbs, he preferred light dosage, differentiated between the primary
and the secondary herbs under strict combination strategy and adhered to the
contraindications in terms of disease, time and herbs, which is very instructive. For
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Spleen and Stomach disorders, he promoted that thin taste or delicious foods should be
utilized to strengthen the efficacy of herbs, to promote the ascending Qi and nourishing
Stomach Qi; he opposed to using over bland foods, because they impair the efficacy of
herbs but help evils to go deep. If there is food retention, he insisted on controlling diet
In conclusion, Pi Wei Lun and Neil Way Shang Han Bian Huo have adequately
represented the academic theory of Li Dong-yuan. His theory originated from the
achievements in Huang Di Nei Jing and Nan Jing and inherited from the understandings
of Zhang Zhong-Jing and Zhang Yuan-su. Moreover, he has raised ingenious perception
of Spleen-Stomach disorders that “hundreds of disorders are due to Spleen injury” and
“only herbs that are benefit for the Spleen are effective”, which is still of instructive
significance in clinic nowadays. But later scholars comment on his shortcoming of of Pi
Wei Lun that he attached too much importance to Spleen than Stomach, more ascending
Spleen than descending Stomach, and more warming and supplementing than cooling and
nourishing. Some scholars think his explanation of the Yin fire was not very solid and
sophisticated in theory. Those pertinent comments represent not only the recognition of
his contribution to TCM, but the assessment of his limitation as well.
Later on, Wang Hao-gu and Luo Tian-yi inherited Spleen-Stomach Theory from Li Dongyuan and developed it a little further. Although Zhu Dan-xi was one of the second
generations of Liu He-jian’s disciples, he also absorbed the quintessence of Li’s
knowledge. After Yuan dynasty and Ming dynasty, more physicians followed his theory,
such as Xue Li-zhai, Zhang Jing-yue, Li Zhong-zi and Ye Tian-shi. They all had reached
great achievements in theoretic research and clinical practice. What a profound influence
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of Li Dong-yuan has exerted on the development of Traditional Chinese Medicine!
3.3 Wang Hao-gu elaborated the Yin pattern of Spleen and Stomach based on the
understanding of Zhang Yuan-su and Li Dong-yuan
Both Wang Hao-gu and Li Dong-yuan were students of Zhang Yuan-su. Wang was much
younger than Li, therefore after the teacher Zhang died, Wang learned from Li. Therefore,
although Wang’s academic theory originated from Huang Di Nei Jing and Shuang Han
Lun, it was deeply influenced by the knowledge of Zhang Yuan-su and Li Dongyuan.
Here are his contributions to Spleen-Stomach Theory.
3.3.1 Advocating Yin Pattern as the supplementation of Li’s “differentiation of Yin
and Yang patterns”
Wang was so deeply influenced by Zhang Yuan-su’s theory, that disease was categorized
according to the deficiency-excess of Zang-Fu organs in which the deficiency of organs is
highly stressed. He was also so deeply influenced by Li Dong-yuan’s Pi Wei theory-Qi
deficiency of Spleen and Stomach was of vital importance on the Yang deficiency of
“three Yin patterns”. This helped him to lay the foundation of Yin-pattern Theory. Even
though Li Dong-yuan had formally established the school of strengthening earth, and
systemically elaborated Spleen-Stomach Theory, much his attention was placed on heat
pattern in the center-Middle Jiao caused by excessive Yin fire due to irregular diet, overwork and internal damage of imbalanced emotions, Yin Pattern due to internal cold injury
had not beed investigated in details and needed to be further assessed.
With the
supplementation of Wang’s Yin pattern theory based on internal damage from cold food,
© Fang Zhang, LAc, M.Med (China)
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the theory of Li Dong-yuan, differentiating Yin pattern and Yang pattern, was completed
finally.
3.3.2 The etiology and pathogenesis of Yin Pattern
Wang believed that both contraction of cold externally and drinking cold internally were
external pathogens but the deficiency or excess of Qi in the body was the internal
pathogenic factor, which was the real determinant factor for the illness; if the Qi of the
body was not deficient, the external cold or drinking cold would not lead to disease; if
the Qi of the body was deficient, Yin Pattern would be caused by light cold contraction or
cold drink, even without any pathogens due to the “internal latent Yin”. The Qi deficiency
includes the intrinsic deficiency of Spleen and Stomach and the (Yang) Qi deficiency of
Spleen and Stomach which is caused or worsened by cold contractions and drinks.
Therefore, Wang’s such understanding is significant for the development of SpleenStomach Theory and guidance of clinical practice.
He thought the injuries of three Yin could be supplemented and listed Zhong-jing Zhang’s
formulae such as Dang Gui Si Ni Tang, Tong Mai Si Ni Tang and Li Zhong Wan to
explain the pathogenesis of the injuries three internal Yin. Li Zhong Wan is used to treat
middle Jiao Spleen-Stomach deficient cold, which manifests as Huo Luan (sudden
vomiting and diarrhea) with cold but no thirst and lots of saliva, and chest cold after the
recovery from serious illness. He elaborated the pathogenesis of Taiyin deficiency that
Spleen and Stomach is deficient, fluids and Qi could not nourish muscle and interstices.
The manifestations of Taiyin injury are yellow and glossy complexion, alternative
floating and deep pulse, moderate and slow pulse, which is very applicable to
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differentiate and treat Spleen-Stomach disorders from Spleen-Stomach deficient cold.
3.3.3 Discussion of the treatment of Yin Pattern inspired by “supplementing Spleen
Yang”
Wang had absorbed Zhang Zhong-jing’s essence of differentiating and treating Shang
Han (cold damage) and had summarized Li Dong-yuan’s principle of treating the cold
damage as well. He also cautiously identified Yin Pattern, especially distinguished the
difference of “exuberant Yin repelling Yang”, “Yin Pattern appearing as Yang” and “real
Yang pattern”(Wang, HG, 1963), which was well beyond Zhang Yuan-su’s and Li Dongyuan’s ability of analyzing and treatment of the cold damage.
According to the formulae Wang used, he advocated to warm and enrich Spleen and
Kidney, such as Fan Yin Dan, Hui Yang Dan, Huo Yan San, Pi Li San, and Zheng Yang
San. Fu Zi is used as the main herb to warm Kidney in those formulae. Sometimes even
Liu Huang or sulfur, a drastic herb is included, such as Fu Zi San, Bai Zhu San, and Rou
Gui San, which can supplement Spleen and Kidney. Besides, he had created special
formulae to relieve the internal injuries from cold drinks or foods with combination with
external contractions, such as Shen Zhu Tang, Bai Zhu Tang, Huang Qi Tang, and Tiao
Zhong Wan, which are recorded in his book Yin Zheng Lue Li. Thus it can be seen that
Wang had already stressed on warming and enriching Spleen and Kidney (more
important than Spleen) as well as dissipating external contraction, comparing to Li Dongyuan.
In summary, Wang Hao-gu, based on the inherence of Zhang Yuan-su’s theory and Li
Dong-yuan’s knowledge, had deeply and further explored the foundation and application
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of Yin Pattern, which has promoted the development of Spleen-Stomach Theory and
enlightened later TCM specialists treating Yin Pattern.
3.4 Luo Tian-yi inherited Li Dong-yuan’s achievement and utilized San Jiao theory
to treat Spleen and Stomach
Luo Tian-yi had studied from Li Dong-yuan for over 10 years, therefore Luo had a
profound understanding of Li’s academic ideas.
3.4.1 Developing Spleen-Stomach theory rather than being a conventionalist
Luo had elaborated the importance of Spleen-Stomach in all the organs and its
relationship with Ying Qi (nutrient Qi), Wei Qi (defensive Qi), and fluids.
When analyzing the pathogenesis of Spleen-Stomach injuries caused by foods, he
distinguished the injury from drinks and injury from the foods, which had more clarity in
differentiation comparing to Li Dong-yuan’s understanding. Li believed that the
pathogenesis of internal injury of Spleen-Stomach was due to the disharmony of
dynamics of Spleen-Stomach Qi, the dysfunction of ascending-descending movement, i.e.
the outcome of the conflict between Fire and original Qi. Therefore Li stressed on “The
Heat attacks center internally due to Spleen and Stomach deficiency” and pointed out that,
because drinks and foods impaired Stomach, over-work impaired Spleen, and SpleenStomach deficiency was overacted by external fire, thus great heat was generated. Luo,
based on his own clinical experience, listed the deficient cold and deficient heat due to
over-work in Wei Sheng Bao Jian in order to emphasize the differentiation between
deficient cold and deficient heat, which was more logical than Li’s theory.
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Meanwhile he valued wholism. At the same time when he analyzed Spleen and Stomach,
he also attached much importance on other organs.
3.4.2 Emphasis on Spleen and Stomach when analyzing disorders and special
emphasis on the triple burner
As a successor of Zhang Yuan-su and Li Dong-yuan, Luo not only attached great
importance on Spleen and Stomach but also elaborated special attention to identification
and treatment of the San Jiao. Having been inspired by Huang Di Nei Jing he believed
that Irregular Diet could lead to the ascending-descending disturbance of the San Jiao
(triple burner), which gives rise to the impairment of Stomach and intestines. Because
Luo valued the Qi dynamics of the triple burner, there were differences among upper,
middle and lower burner when identifying patterns and selecting herbs. In the chapter
Reducing Heat of Wei Sheng Bao Jian (Luo, 1963) he elaborated the differentiation of
the heat of upper burner, middle burner and lower burner and in the chapter Eliminating
Cold he elaborated the differentiation of the cold of the three burners and their relevant
formulae and herbs. Even it was not a self-contained system yet, it had inspired later
development on the pathogenesis of the San Jiao.
3.4.3 Unique opinion on the treatment of Spleen-Stomach disorders
Luo’s developed flexible therapeutic principles with characteristics focusing on warming
and supplementing Spleen and Stomach with the sweet and the aromatic, the cautiousness
of using the cold and the cool, and the opposition to misuse of the purging.
He said that: “It is the sweet that enriches Spleen. According to the record in Huang Di
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Zhen Jing (Ling Shu), the nutrient Qi comes from middle Jiao, the defensive Qi comes
from upper Jiao. The defensive Qi belongs to Yang, whose deficiency must be
supplemented by the spicy and pungency; the nutrient Qi belongs to Yin whose
deficiency must be supplemented by the sweet. The mixture of the sweet and the spicy
can enrich Spleen and Stomach and tonify both nutrient and defensive Qi.
Conclusion
In summary, Nei Jing had already had very extensive description and discussion in the
anatomy, physiology, pathology, or diagnosis, treatment and prevention of Spleen and
Stomach, which was the foundation of later developed theory of Spleen-Stomach. So Nei
Jing is the doctrine which laid the theoretical foundation for Spleen and Stomach.
Shang Han Za Bing Lun had laid solid foundation of the Spleen and Stomach theory in
both theory and its initial clinical application aspects including diagnosis of the diseases,
pattern differentiation, treatment principle and prescription of herbal formulas.
Yishui School represented by Zhang Yuan-su, Li Dong-yuan, Wang Hao-gu and Luo
Tian-Yi. Rooted in the perception in Su Wen that earth generates myriads things, with the
inspiration of the Zhang Zhong-jing’s theory and the inheritance from Zhang Yuan-su’s
achievements, Spleen-Stomach Theory was formally initiated by Li Dong-yuan, and
developed and applied in the practice more systematically by his later students with some
inheriting, but each wasunique as well.
© Fang Zhang, LAc, M.Med (China)
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Reference:
Li, Dong-yuan. (1963), Pi Wei Lun (Treatise on Spleen and Stomach). People’s Medical
Publishing House, Beijing, China
Li, Dong-yuan. (1963), Nei Wai Shang Bian Huo Lun (Discussion and Differentiation
for Endogenous and Exogenous Injuries). People’s Medical Publishing House, Beijing,
China
Luo, Tian-yi. (1963), Wei Sheng Bao Jian (Medical Collection and Wisdoms), People’s
Medical Publishing House, Beijing, China
Mitchell, Craig, Ye Feng, Wiseman, Nigel. (1999) Shang Han Lun: On Cold Damage,
Translation & Commentaries. Paradigm Publications, Brookline
Ni, Maoshing. (1995). The Yellow Emperor’s Classic of Medicine-A New Translation of
The Neijing Su Wen with Commentary. Shambhala, Boston & London.
Qing,Yue-ren. (1994), Nan Jing Jie Zhu (The Commentary of Classic of Questioning).
People’s Medical Publishing House, Beijing, China
Shi, Song-ben. (1963), Ling Shu (The Spiritual Pivot). People’s Medical Publishing
House, Beijing, China
Wang, Bing. (1963), Huang Di Nei Jing Su Wen (The Yellow Emperor’s Classics of
Medicine-Plain Questions).People’s Medical Publishing House, Beijing, China
Wang, Hao-gu. (1963), Ying Zhen Lue Lie (Categories and Examples for Yin Syndrome),
People’s Medical Publishing House, Beijing, China
Wang, Qi. (1988), Shang Han Lun Jiang Jie (Teaching and Explanation of Treatise of
Cold Damage). He Lan Science & Technology Press, Zhengzhou, China.
Wu, Nelson Liansheng(1997). Yellow Empero’s Canon Internal Medicine. China Science
© Fang Zhang, LAc, M.Med (China)
- 61 -
& Technology Press, Beijing China.
Wu, Tang. (1963), Wen Bing Tiao Bian ( Detailed Analysis of Epidemic Warm Febrile
Diseases). People’s Medical Publishing House, Beijing, China
Yang, Shou-Zhong. (1993), Li Dong-yuan’s Treatise on the Spleen & Stomach-A
Translation of The Pi Wei Lun. Blue Poppy Press, Boulder
Zhang, Yuan-su. (1989). Yi Xue Qi Yuan (The Origin of Medicine), Shanghai Science &
Technology Press, Shanghai China.
Zhang, Zhong-jing. (1963), Jing Gui Yao Lue Fang Lun (Synopsis of Prescriptions of the
Golden Chamber). People’s Medical Publishing House, Beijing, China
Zhu, Ming. (2001), The Medical Classic of the Yellow Emperor. Foreign Languages
Press, Beijing, China
© Fang Zhang, LAc, M.Med (China)
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Index: Case Study
Treatment of GERD with Classic Chinese Herbal Formula under Guidance of Pi
Wei Theory
Abstract
Background: Gastro esophageal reflux disease (GERD) is a very common digestive
disorder experienced by many patients. It is often treated with western medications
including antacids, H2 blockers and proton pump inhibitors (PPIs). However, their side
effect and the cost of GERD medications may limit their use.
Objective: To investigate the effectiveness of Chinese herbal medicine in relieving
symptoms for a patient with GERD .
Setting: A 39 year-old female who was diagnosed as GERD was treated at my private
practice.
Results: After 10 treatments, this patient had great improvement regarding to her chief
complaint.
Conclusion: This is just a case to show the possible effectiveness of Chinese classical
herbal medicine treating GERD. However, it cannot be generalized that all patients would
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be benefit from the TCM herbal treatment. A larger scale randomized study would be
necessary in the Future to demonstrate if acupuncture and Chinese herbs are effective for
GERD.
Introduction:
Gastro esophageal reflux disease (GERD) is a common health problem in our
communities. In Biomedicine, GERD affects 25 to 35 percent of the U.S. population.1
Although GERD rarely causes death; it reduces quality of life and has a serious morbidity
rate of 10 to 15% due to its complication.2 While most patients experience mild
symptoms from this disorder, it can potentially lead to serious medical complications.
According to report, up to 50% may develop reflux esophagitis and a small portion of
these may develop serious complications, such as esophageal erosion, peptic strictures,
Barrett’s esophageal metaplasia, and increased chances esophageal adenocarcinoma.3 In
addition, the medical expense involved in the diagnosis, treatment, and management of
the disease is significant. According to a recent study on the burden of chronic
gastrointestinal disorders, GERD was found to be the most expensive, with direct and
indirect costs totaling $10 billion per year.4
Background:
Biomedical Perspective
Prevalence
According to the guidelines developed by the American College of gastroenterology,
GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of
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gastric contents into the esophagus.5
Studies suggest that approximately one-third of the population has GERD, according to
the American Gastroenterological Association.4 About 5-7% of the world population,
including men, women, and children, are affected by GERD, defined as Heartburn at least
one time per day (other information say this can be as high as 10%).6,7 Furthermore,
19.8% of the population experience Heartburn and/or acid regurgitation one time
weekly.8 One out of five people experience Heartburn or acid regurgitation on a weekly
basis and two out of five people experience Heartburn or acid regurgitation at least once a
month.9
Etiology
The cause of GERD is complex. Production of abnormally large amounts of acid is a
contributing factor in some patients with GERD, however the more common causes for
majority of patients include the incompetent lower esophageal sphincter (LES), hiatal
hernias, abnormal esophageal clearance, and delayed emptying of the Stomach. Transient
LES relaxations are considered as a major mechanism of gastroesophageal reflux
disease.10 The LES acts like a one-way valve that opens to allow food and liquids to pass
into the Stomach, and closes to prevent food and Stomach acid from flowing back into
the esophagus. Normally, the LES closes immediately after a person swallows food,
keeping irritating Stomach acid and digestive enzymes out of the esophagus. The
inappropriately relaxation of the LES causes food and Stomach acid flowing back into the
esophagus. The refluxed Stomach contents, including Stomach acid, bile salts, and
pancreatic digestive juices, can cause severe irritation when they come into contact with
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the lining of the esophagus wall which may lead to inflammation, erosion, ulcers, scar,
and stricture. The pathological changes of the esophageal wall may give rise to Heartburn
and other symptoms of GERD. GERD is common among people with a hiatal hernia and
a hiatal hernia may also contribute to GERD. In patients with GERD, however, they
could be associated with higher amount of acid reflux and delayed esophageal acid
clearance leading to more severe esophagitis, especially Barrett’s esophagus.11 When a
hiatal hernia is present, it is easier for the acid to come up from the hiatal hernia sac into
the esophagus and cause reflux. The abnormal esophageal clearance is also responsible
for causing GERD. Acid refluxate normally is cleared and neutralized by esophageal
peristalsis and salivary bicarbonate. Patients with GERD often have delayed acid
clearance from the esophageal body 12,13 and are often more sensitive to acid reflux than
healthy subjects. In some patients, this esophageal hypersensitivity also extends to
mechanical stimuli, which becomes the main pathophysiological problem. When acid
was infused into the esophagus of control subjects and GERD patients, only 15% of the
controls reported Heartburn during acid infusion, while 88% of GERD patients had
Heartburn during acid inFusion.14 In terms of delayed gastric emptying, it can be caused
by gastroparesis or partial gastric outlet obstruction and it Further leads to GERD. Some
other causes may include obesity, dietary habits and smoking. Being overweight or obese
appears to be one of the leading GERD risk factors. There may be a relationship between
an increase in a person’s body mass index (BMI) and GERD symptoms. [4] Consuming
certain kinds of food and drink is a potential GERD risk factor. Some of these foods and
drinks include alcohol, carbonated drinks, fatty foods, spicy foods, chocolate, citrus fruits
and juices, and mint. Surveys have shown that smokers have higher rates of reflux
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symptoms than nonsmokers.15
Symptoms of GERD
The typical symptom is Heartburn which is the feeling of the burning, warmth, heat or
pain just behind the breastbone. It often happens 30-60 minutes after meals and in a
reclining position during daytime or at night. It may start high in the abdomen or may
extend up into the neck. Sometimes the pain may be sharp or pressure-like, rather than
burning. In other patients, the pain may extend to the back. It is well accepted that the
frequency of GERD symptoms is related to the degree of esophageal acid exposure. 16,17
Acid reflux time is significantly correlated with the severity of endoscopic esophagitis 18,
even though the severity is not correlated with the degree of tissue damage. In fact, some
patients with severe esophagitis are only mildly symptomatic. Patients may complain of
regurgitation-the spontaneous reflux of sour or bitter gastric contents into the mouth. 19
Other less common symptoms of GERD include hoarseness, sore throat, laryngitis,
nausea, chronic dry cough, feeling as if there is a lump in your throat, a sour taste in the
back of the throat, noncardiac chest pain and breathing difficulties similar to asthma. A
recent study of reflux and voice disorders suggests that up to 55% of patients with
hoarseness (dysphonia) have laryngopharyngeal reflux. 20 GERD may also irritate the
muscles in the esophagus, causing discoordinated activity during swallowing. Severe
injury to the esophagus may lead to bleeding or ulcer formation. Patients who experience
regurgitation could aspirate Stomach contents into their Lungs resulting in pneumonia.
Other complications of GERD include Barrett’s esophagus which refers to the growth of
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abnormal lining cells due to Chronic irritation of the esophagus, peptic stricture and
esophageal cancer at the site where the esophagus and Stomach join.
Diagnosis of GERD
In most cases, the diagnosis is made from the typical symptoms. If a patient suffers from
chronic Heartburn, chances are good the patient also has GERD. (Occasional Heartburn
does not necessarily indicate the presence of GERD.) However, in some cases, the
symptoms are not so typical. The diagnosis of GERD can be confirmed if the patient
finds relief from persistent Heartburn and acid regurgitation after taking antacids for short
periods or a proton-pump inhibitor medication, such as omeprazole (Prilosec) which
blocks Stomach acid secretion to relieve symptoms. Patients with typical symptoms of
Heartburn and regurgitation and with uncomplicated disease may be treated empirically
for 4 weeks for gastroesophageal reflux disease without the need for diagnostic studies.
Further investigation is required in patients with complicated disease and those
unresponsive to empirical therapy.
19
The additional examinations include upper
endoscopy, esophageal pH test and esophageal manometry.
Biomedicine Treatment for GERD
GERD is a lifelong disease and the aim of treatment is the relief of symptoms such as
Heartburn. There are several components to the treatment of GERD. The first component
of treatment consists of various lifestyle modifications. Eating small meals, avoiding a
heavy evening meal and lying down within 3 hours after meals are very helpful to keep
Stomach empty and reduce reflux. Elevating the head of the bed 6" to 8" above the foot
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of the bed is recommended to allow the gravity to help prevent reflux episodes.
Regarding the food selection, patients with GERD need refrain from acidic foods such as
tomato products, citrus fruits, spicy foods and coffee. Other than that, fatty foods,
peppermint, chocolate, alcohol and smoking should be limited because they can relax the
lower esophageal sphincter or delay gastric emptying and trigger the symptoms of GERD.
Some people benefit substantially from weight loss too. The second component of
treatment is medical treatment of GERD with three categories of pharmaceutical agents
namely antacids, H2 blockers and proton pump inhibitors.21 Most drug treatments are not
designed to stop reflux but instead focus on reducing Stomach acid so that irritation of
the esophagus is minimized. The antacids neutralize the acid and are used for mild cases
as patient-directed therapy, while the other two inhibit the acid production in the Stomach
and are used for chronic and severe cases. All of these medications are effective in
symptom control to certain degree. However, not only the symptoms usually recur when
these medications are stopped but also their side effect and the cost of GERD medications
may limit their use.22 The effect of the acid reduction causes a imbalance of Stomach
acidity and lead to a disturbing problem. For example, a study is showed when Stomach
acidity is reduced by these medications; the risk of pneumonia increases especially in the
elderly and the patients with chronic Lung diseases who are more vulnerable.23 Research
also shows 42% of patients on PPIs are likely to continue the medication for rest of their
life. In the United States, cost of GERD medication rings up $12.5 billion in U.S. sales in
2006.
24
The last option is the surgical approaches such as Stomach wrap to create a
stronger sphincter or endoscopic procedures to tighten the LES. It is a good additional
therapy for patients with severe symptoms and for patients who have a hiatal hernia when
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all treatments fail. It has been tried with some success but risk of surgery should not be
overlooked.
Traditional Chinese Medicine Perspective
Point of view of Chinese Medicine
For diagnosis of disease from point of view of TCM, GERD is in the categories of Tun
Suan (swallowing acid), Ou Dan (vomiting bile), Fu Pi (abdominal glomus), Ou Ku
(vomiting bitterness), and Wei Wan Tong (Stomach venter pain). If patient suffers from
dyspagia and/or esophageal hemorrhage, Ye Ge and/or Ou Xue could be diagnosed
respectively.
The major causes of this disorder include the invasion of external coldness, abnormal
emotional stress, impropriate diet such as unregulated eating or drinking, and weak body
constitutions due to poor life-style or aging. Four different patterns are suggested by Bob
Flaw for this disorder 25: wood and earth disharmony combined with cold and dampness,
wood and earth disharmony combined with depressive heat, wood and earth disharmony
combined with Qi deficiency and wood and earth disharmony combined with food
stagnation. Among these patterns, Liver Qi stagnation overacting on Middle Jiao
(including Spleen and Stomach) is the main pathological change in the clinic. The main
causes for the Liver becoming stagnated are unfulfilled desires and/or anger, both of
which may affect the flow of Liver Qi and cause Liver Qi stagnation. The stagnant Liver
Qi invades the Spleen and/or Stomach which leads to disharmony between Liver-wood
and Spleen/Stomach-earth. As a result, there is dysfunction of Spleen which is unable to
transform the clear upward and Stomach Qi becomes rebelling upward too.
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So the key of treatment principle is to sooth Liver Qi, harmonize Liver and Middle Jiao
and descend rebellious Stomach Qi. The common used formulas are Chai Hu Shu Gan
Tang, Zuo Jin Wan, Xiang Sha Liu Jun Zi Tang and Wu Zhu Yu Tang. Because TCM
works as a holistic medicine, the goal of TCM treatment is to treat both the symptoms
and the underlying causes. The excessive emotional stress is considered as one of the
most common underlying causes for GERD and TCM treatment including Chinese herbal
medicine and acupuncture is very helpful for stress management.
Acupuncture has been used to treat gastrointestinal symptoms including GERD in China
for thousands of years even though it has been addressed according to main clinical
symptoms instead of biomedical diagnosis, such as Tun Suan (swallowing acid), Ou Dan
(vomiting bile), Fu Pi (abdominal glomus), Ou Ku (vomiting bitterness), and Wei Wan
Tong (Stomach venter pain). The common used acupuncture points include SP4, PC6,
CV12, CV17, CV10, CV11, ST36, LI4, LV3, and ST44. The point’s selection need be
based on pattern differentiation.
Research
Biomedical treatment for GERD is widely accepted and used in the western country. The
studies on the effectiveness and possible side effects of the drug are very important due to
the chronic course of GERD. Incompetent LES is a major mechanism of GERD, so
inhibition of transient lower esophageal sphincter relaxations might be a potentially
important therapeutic target. Therefore, a randomized controlled trial conducted by
Omari et al suggested that new GABA type B receptor agonists without the adverse
effects of baclofen, such as dizziness, sleepiness, tiredness, and vertigo, are expected to
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be a mainstay of GERD therapy because of their inhibitory effects on transient LES
relaxations.26
Acid suppressors and prokinetic agents have been used in the medical treatment of
GERD because they can prevent the esophagus from being exposed to refluxed gastric
acid. Prokinetic agents have been used to improve the contractility of the esophageal
body and to prompt gastric emptying and reduce the exposure of the esophagus to acid.
However, Cucchiara et al reported that the efficacy of prokinetic agents for GERD has
been shown only for cisapride
27
, and Dubin et al pointed out that cisapride is not
currently in wide use because of concerns about adverse cardiac effects.28
Though to date, more and more people are interested in alternative medicine and start to
seek care from TCM approach, not many articles or research studies related to the subject
of GERD in English literature. There are two articles written respectively by Tatsuta and
Yagi et al discussing treating dyspeptic patients with Chinese herbal formula with good
results. The abbreviation of herbal formula Liu-Jun-Zi-Tang is TJ-43 in Tatsuta’s article.
Data on the effectiveness of TJ-43 on human gastrointestinal motor disorder in the
English literature are limited. Tatsuta et al.29 demonstrated that TJ-43 significantly
accelerated gastric emptying and reduced gastrointestinal symptoms in adult patients with
chronic idiopathic dyspepsia. Yagi et al. 30 reported that postoperative dyspeptic pediatric
patients exhibited symptomatic relief and a significant reduction in the mean symptom
score after treatment with TJ-43 over a 1-month period. The safety of TJ-43 in terms of
its administration to infants and children has not been established because of infrequent
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use in this age group, although a previous report found no adverse effects.30 In Yagi’s
article, formula called Rikkunshito, a herbal medicine consisting of eight herbs, has been
used to treat chronic dyspepsia. Studies have shown that rikkunshito is effective for upper
gastrointestinal symptoms and has a significant influence on gastric motor function in
adult and pediatric patients.29,30
In addition to that, I couldn’t find any other articles or research studies specifically
related to treatment of GERD with TCM.
Case History:
Patient Identification and Chief Complaint
The patient was a 39-year-old female with severe chronic Heartburn and sore throat.
History of Chief Complaint
A 39 year old female came to the clinic on March 12, 2009. Her chief complaints were
Heartburn and sore throat for the last 4 years which were getting worse gradually. She
started to experience Stomach problem when she was pregnant 6 years ago. She had had
nausea and vomiting through her whole pregnancy. After giving birth to a healthy baby,
her digestive issue went away until she switched her job to work in a high stressful
working environment 2 years ago. At first, she noticed mild and infrequent Heartburn 2-4
times a week. She felt burning sensation with some pain behind the breastbone which
could radiate either up to throat and neck or down to the upper abdomen. It occurred 3060 minutes after meals and was aggravated with meals, bending, recumbence and high
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emotional stress. Her symptoms could be relieved temporally by taking baking soda or
antacids. She got formal diagnosis as gastro-esophageal reflux disease (GERD) one and
half years ago. Recently her Heartburn started to bother her more frequently with
increased severity. Occasionally it would wake her up at midnight. She also had a sore
throat for 4 months and had lost 20 lbs over the last 7 months. The burning sensation in
her throat affected her swallowing as if there was something stuck in her throat and
caused her hoarse. Singing song was a good way for her to relieve her emotional stresses
and she could not sing in the last 4 months due to sore throat. Her appetite decreased
greatly and she preferred soft food intake. Though she had burning sensation behind her
chest bone, she didn’t prefer cold food. Accompanied with her Heartburn and sore throat,
she suffered from difficulty breathing, shortness of breath, indigestion, gas, belching,
abdominal Fullness and distension too. She visited an emergency room because of severe
Heartburn, chest pain and shortness of breath in 2008. Full cardiac work up was done
with negative finding.
Medication at the Visit
Nexium 40mg QD
Multi vitamin
Fish oil
Flaxseed oil
Probiotics
Papaya enzyme
She was allergic to vicodin and Sudafed because of side effect of itching.
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Family History and Lifestyle
She had tubal ligation in 2007, cholecystectomy in 2008 to remove gallbladder due to
chronic inflammation; MRI and Heart work up in 2008 due to chest pain, and
hysterectomy in 2008 due to heavy bleeding and severe cramping caused by uterine cyst
and endometriosis.
Her mother and both of her younger sisters are alive with good health. Her father died of
esophageal cancer when he was 56 years old. She did not smoke or drink alcohol. She did
not use any drugs. She did drink coffee 1 cup a day. Since she had GERD, she was very
careful with what she was eating. She considered her diet was healthy and balanced. She
ate 3 meals a day. Generally she had toast, eggs and coffee for her breakfast; tuna
sandwiches for lunch; and salad greens, brown rice, meat and vegetable soups for dinner.
She did exercised 3 times a week. She was a special education teacher and she felt her job
was very stressful.
Symptoms and Signs at the Visit
During her first visit, she reported all the symptoms related to GERD mentioned above.
In general, she experienced Heartburn 4-6 times a day and the severity of sore throat
varied from 6/10 to 8/10 from time to time (On a scale from 1 to 10, 1 being no pain at all
and 10 being unbearable pain). Both of her chief complaints became worse at night. She
could not lie in a recumbent position which would aggravate her symptoms. Recently she
noticed more severe distension and Fullness on her upper abdomen, some nausea and
vomiting. She had her upper endoscopy done in January 2009 because of her dysphagia.
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According to her EGD report, her esophagus was normal; congestion and erythema of the
mucosa were noted in the whole Stomach. Cold forceps biopsies were performed for
histology which turned out negative finding. Gastric acid secretion test showed elevated
levels of gastrin and suggested increased secretion of acid.
Her body temperature was warm to hot and she experienced hot flashes and night sweats
daily. Her hands and feet were cold. She had headache on both temple sides and ear ring
in the right ear. Her mouth was dry and there was bitter taste in her mouth. Sometimes
she had sores on her tongue or in her mouth. She experienced dizziness often. She had
chronic sinusitis and hay fever for years. She was allergic to pollen and soy products.
There was some post nasal drainage down to her throat. She had chronic mild pain
located on her chest, upper abdomen, upper and middle back. She had her bowl
movement 2-3 times a day which was loose with some undigested food. She had no
menstruation due to hysterectomy. But prior to that, her menstrual flow was always super
heavy with lots of clots. Even she slept 7-8 hours a night, she still didn’t feel rested when
she woke up in the morning. Her energy level was very low and she felt tired most of the
time. Emotionally, she was anxious and stressed. She had history of sexual abuse which
caused her anxiety.
Her tongue body was pale red and tongue coating was thin and yellow. Her pulses on
both sides were similar with rapid, thin and weak quality in general.
With abdominal palpation, the temperature of her abdomen was cold to touch.
Her height was 5’2 and her body weight was 121lbs. But her past maximum weight was
up to 170lbs in 2008. She lost weight dramatically due to exercise and the symptoms
related to GERD. Her Blood pressure was 125/86mmHg and her pulse was 88ppm. Her
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oxygen saturation was 100%.
During interview, she stated that because she was afraid of needle due to the history of
sexual abuse, she didn’t want to get any acupuncture treatment or massage.
Chinese Medical Diagnosis and Treatment
The diagnosis of her condition was Heartburn due to Liver Qi stagnation and disharmony
between Liver and Middle Jiao which leading to Spleen Qi deficiency and Stomach Qi
rebelling. There was also combination of coldness and heat in the Middle Jiao. Kidney
Yin deficiency was present too.
The Liver Qi stagnation was characterized by the history of sexual abuse, anxiety, longterm emotional stress which aggravating her Heartburn, cold hands and feet, temple
headache, history of menstrual cramping. Her middle Jiao had become affected over time
with assault from the Liver, giving her Spleen Qi deficiency and Stomach Qi rebelling.
The symptoms to back up Spleen Qi deficiency included shortness of breathing,
indigestion, gas, abdominal Fullness and distention, fatigue, pale red tongue body and
weak pulse. Stomach Qi rebelling was characterized by Heartburn, sore throat and
belching. The mixture of coldness and heat in the middle Jiao was characterized by dry
mouth, bitter taste in the mouth, sores in the mouth, burning sensation behind the chest
bone, dislike of cold food, loose stool with undigested food, yellow tongue coating,
nausea, abdominal Fullness and distension. According to the relationship among the five
elements, long-term Liver Qi stagnation would affect its mother-Kidney. In addition to
that, the physical surgery to remove uterus aggravated the Kidney deficiency, especially
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Kidney Yin deficiency. The symptoms to support Kidney Yin Xu included the history of
hysterectomy, hot flashes, night sweats, dry mouth, sore throat, dry stool, dizziness, ear
ring and weak pulse.
The treatment plan was aimed at soothing Liver Qi, harmonizing wood and earth,
tonifying Spleen Qi, descending rebellious Stomach Qi, nourishing Kidney Yin, clear
stagnant heat and disperse coldness from Middle Jiao and. Because she experienced more
severe digestive symptoms recently, treating the combination of coldness and heat in the
Middle Jiao and rebalancing the rebellious Stomach Qi would be the treatment focus.
Because of her concern about her treatment, just herbal formula was prescribed.
The basic formula was based on Bai Xia Xie Xin Tang with modification.
Ban Xia 10g, Huang Lian10g, Huang Qin 10g, Dang Shen 10g, Da Zao 6g, Zhi Gan Cao
6g, Wu Zhu Yu 5g, Fu Ling 10g, Zhi Ke 6g, Dai Zhe Shi 25g, Hai Piao Xiao 10g, Chai
Hu 9g, Bai Shao Yao 12g.
She was instructed to take it 4.5g each time, 3 times a day.
Ban Xia Xie Xin Tang—This classic formula was from Shang Han Lun and used for
combination of heat and coldness located in the Middle Jiao. Ban Xia is acrid and warm
to disperse cold and descend rebellious Stomach Qi, both of Huang Lian and Huang Qin
are bitter and cold to clear heat. Dang Shen, Da Zao and Zhi Gan Cao are used for
tonifying Middle Jiao Qi to restore its function. Gan Jiang was removed because it was
too warm for this patient.
Wu Zhu Yu—work with Huang Lian as a formula ‘Zuo Jin Wan’ to clear stagnant heat
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from Liver, direct rebellious Qi downward, relieve nausea and vomiting
Fu Ling—combined with Dang Shen and Zhi Gan Cao to tonify Spleen Qi
Zhi Ke, Dai Zhe Shi—descend rebellious Stomach Qi
Hai Piao Xiao—astringe body fluid to lower acid secretion and relieve Heartburn
Chai Hu, Bai Shao Yao—sooth Liver Qi to treat Liver overacting middle Jiao
She came back for her 2nd visit one week later. She reported that her digestive symptoms
were less severe, including dry mouth, bitter taste in her mouth, distension and Fullness
on her upper abdomen, nausea, vomiting, and loose stool. Her bowel movement was 1-2
times a day which was much former than before. The abdominal pain also decreased
especially at night. However, her Heartburn and sore throat didn’t get better. There was
no change of her tongue and pulse either. She commented the taste of the formula was
bitter, so she added a little juice to the herbal tea when she drank it. Because she noticed
some improvement with the previous formula, the same formula was prescribed for her
second visit. 2 weeks later, she finished her herbal formula and came back for her 3rd visit.
She was under huge emotional stress and even cried during intake. She stated that all her
symptoms including Heartburn and sore throat got much better until she had an
unpleasant conversation with her boss 3 days ago. Since then, her abdominal pain and
distension came back accompanied by right hypochondriac pain. Based on the change of
her symptoms, stagnant Liver Qi overacting on Middle Jiao was predominant. Chai Hu
Shu Gan San was chosen to be the basic formula to sooth Liver and harmonize Middle
Jiao. The formula included the following herbs: Chai Hu 15g, Yu Jin 20g, Zhi Ke 15g,
Bai Shao Yao 15g, Huang Qin 12g, Da Huang 6g, Zhi Zi 12g, Bing Lang 12g, Ban Xia
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12g, Xiao Hui Xiang 6g, Wu Zhu Yu 5g, Dai Zhe Shi 25g, Hai Piao Xiao 10g, Sheng
Jiang 9g, Gan Cao 9g. Chai Hu, Zhi Ke, Yu Jin were used for soothing Liver Qi to relieve
emotional stress; Chen Pi, Dai Zhe Shi and Bing Lang were for regulating, and moving
Qi downward from Middle Jiao; Huang Qin and Da Huang were for clearing heat from
Shao Yang and Middle Jiao; Hai Piao Xiao was to astringe body fluid to lower acid
secretion and relieve Heartburn; Sheng Jiang and Ban Xia were for descending rebellious
Qi to relieve nausea and vomiting; Bai Shao Yao and Gan Cao were for soothing Liver,
harmonizing Liver and Spleen to relieving pain. She was advised to take granule powder
4.5g each time, 3 times a day. When she came back for her 4th visit, she had a big smile
on her face. She reported that her Heartburn and digestive symptoms were 65% better
and her sore throat was 40% better in terms of severity. Her emotional stress was better
too because she would relocate to California for a new job in 2 months. Before her
moving, I treated her totally 10 times with the similar formula, either Chai Hu Shu Gan
San or Ban Xia Xie Xie Tang. Some modifications were made according to her symptoms
changes. When she came back for her last visit, she felt the formula was very helpFul in
terms of relieving her symptoms dramatically including Heartburn, sore throat, and other
digestive symptoms. She just experienced Heartburn 1-2 times a week which was very
mild and lasted for few minutes. Her sore throat was 80% -85% better and she could sing
again which was a blast for her. I prescribed some more herbal formula for her and
recommended her to continue her herbal treatment if she could find an herbalist she
trusted over there. Since then, I did not hear from her.
Discussion:
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Even acupuncture has been widely used in the clinic to treat GERD with effectiveness;
this unique patient can not handle acupuncture treatment because the painFul history of
sexual abuse she had before. Fortunately, she was a very complYing patient and she took
her herbal formula everyday. Extremely emotional stress was coming from her past
history, her job and her daily life. It acted as part of the causes of her symptoms of GERD
as well as one of the trigger factors of GERD to aggravate her symptoms. Comparatively
Chinese herbal formula helped relieve her clinical symptoms greatly, however, it should
be pointed out that part of the effectiveness came from her stress reduction because of her
job changing. Furthermore, if she could stay with me for more treatments, I would like to
explore more treatment opportunities for her by introducing acupressure, gentle
acupuncture and breathing meditation gradually to her and she would get more benefits
from our treatments. This is just a case to show the possible effectiveness of Chinese
herbal medicine treating GERD. However, it cannot be generalized that all patients would
be benefit from the TCM herbal treatment. A larger scale randomized study would be
necessary in the Future to demonstrate if acupuncture and Chinese herbs are effective for
GERD.
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