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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) -1- 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) -2- 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 © Fang Zhang, LAc, M.Med (China) -3- 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 © Fang Zhang, LAc, M.Med (China) -4- 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 © Fang Zhang, LAc, M.Med (China) -5- 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). © Fang Zhang, LAc, M.Med (China) -6- 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 © Fang Zhang, LAc, M.Med (China) -7- 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). © Fang Zhang, LAc, M.Med (China) -8- 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. © Fang Zhang, LAc, M.Med (China) -9- 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 © Fang Zhang, LAc, M.Med (China) - 10 - 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, © Fang Zhang, LAc, M.Med (China) - 11 - 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 © Fang Zhang, LAc, M.Med (China) - 12 - 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 © Fang Zhang, LAc, M.Med (China) - 13 - 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 © Fang Zhang, LAc, M.Med (China) - 14 - 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). © Fang Zhang, LAc, M.Med (China) - 15 - 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 © Fang Zhang, LAc, M.Med (China) - 16 - 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 © Fang Zhang, LAc, M.Med (China) - 17 - 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 © Fang Zhang, LAc, M.Med (China) - 18 - 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 © Fang Zhang, LAc, M.Med (China) - 19 - 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 © Fang Zhang, LAc, M.Med (China) - 20 - 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 © Fang Zhang, LAc, M.Med (China) - 21 - 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 © Fang Zhang, LAc, M.Med (China) - 22 - 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 © Fang Zhang, LAc, M.Med (China) - 23 - 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 © Fang Zhang, LAc, M.Med (China) - 24 - 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 © Fang Zhang, LAc, M.Med (China) - 25 - 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 © Fang Zhang, LAc, M.Med (China) - 26 - 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 © Fang Zhang, LAc, M.Med (China) - 27 - 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 © Fang Zhang, LAc, M.Med (China) - 28 - 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. © Fang Zhang, LAc, M.Med (China) - 29 - 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. © Fang Zhang, LAc, M.Med (China) - 30 - 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 © Fang Zhang, LAc, M.Med (China) - 31 - 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 © Fang Zhang, LAc, M.Med (China) - 32 - 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 © Fang Zhang, LAc, M.Med (China) - 33 - 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 © Fang Zhang, LAc, M.Med (China) - 34 - 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. © Fang Zhang, LAc, M.Med (China) - 35 - 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 © Fang Zhang, LAc, M.Med (China) - 36 - 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 © Fang Zhang, LAc, M.Med (China) - 37 - 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 © Fang Zhang, LAc, M.Med (China) - 38 - 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 © Fang Zhang, LAc, M.Med (China) - 39 - 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. © Fang Zhang, LAc, M.Med (China) - 40 - 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. © Fang Zhang, LAc, M.Med (China) - 41 - 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 © Fang Zhang, LAc, M.Med (China) - 42 - 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) © Fang Zhang, LAc, M.Med (China) - 43 - 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 © Fang Zhang, LAc, M.Med (China) - 44 - 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 © Fang Zhang, LAc, M.Med (China) - 45 - 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: © Fang Zhang, LAc, M.Med (China) - 46 - 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 © Fang Zhang, LAc, M.Med (China) - 47 - 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 © Fang Zhang, LAc, M.Med (China) - 48 - 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 © Fang Zhang, LAc, M.Med (China) - 49 - 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 © Fang Zhang, LAc, M.Med (China) - 50 - 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 © Fang Zhang, LAc, M.Med (China) - 51 - 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. © Fang Zhang, LAc, M.Med (China) - 52 - 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 © Fang Zhang, LAc, M.Med (China) - 53 - 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 © Fang Zhang, LAc, M.Med (China) - 54 - 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) - 55 - 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 © Fang Zhang, LAc, M.Med (China) - 56 - 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 © Fang Zhang, LAc, M.Med (China) - 57 - 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. © Fang Zhang, LAc, M.Med (China) - 58 - 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 © Fang Zhang, LAc, M.Med (China) - 59 - 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) - 60 - 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) - 62 - 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 © Fang Zhang, LAc, M.Med (China) - 63 - 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 © Fang Zhang, LAc, M.Med (China) - 64 - 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 © Fang Zhang, LAc, M.Med (China) - 65 - 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 © Fang Zhang, LAc, M.Med (China) - 66 - 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 © Fang Zhang, LAc, M.Med (China) - 67 - 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 © Fang Zhang, LAc, M.Med (China) - 68 - 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 © Fang Zhang, LAc, M.Med (China) - 69 - 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. © Fang Zhang, LAc, M.Med (China) - 70 - 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 © Fang Zhang, LAc, M.Med (China) - 71 - 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 © Fang Zhang, LAc, M.Med (China) - 72 - 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 © Fang Zhang, LAc, M.Med (China) - 73 - 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. © Fang Zhang, LAc, M.Med (China) - 74 - 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. © Fang Zhang, LAc, M.Med (China) - 75 - 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 © Fang Zhang, LAc, M.Med (China) - 76 - 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 © Fang Zhang, LAc, M.Med (China) - 77 - 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 © Fang Zhang, LAc, M.Med (China) - 78 - 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 © Fang Zhang, LAc, M.Med (China) - 79 - 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: © Fang Zhang, LAc, M.Med (China) - 80 - 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. References: 1. Scott M, Gelhot A. Gastroesophageal Reflux Disease: Diagnosis and Management, American Family Physician, March 1, 1999, Vol. 59 No. 5 2. Goldman & Ausiello, Cecil Textbook of Medicine, 22nd Edition, Saunders, 2004 3 Tierney LM, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis & Treatment © Fang Zhang, LAc, M.Med (China) - 81 - 2005. New York: Lange Medical Books/McGraw-Hill, 2005. 4. American Gastroenterological Association. The Burden of Chronic Gastrointestinal Diseases Study. 2001. 5. De Vault, Kenneth et al, Updated Guidelines for the diafnosisi and treatment of Gastroesophageal reflux disease, American journal of Gastroenterology, 2005 available on http://gi.org/physicians/guidelines/GERDTreatment.pdf 6. International Foundation for Functional Gastrointestinal Disorders, Inc. (IFFGD). About GERD. Available at: http://www.aboutgerd.org. Accessed April 7, 2006. 7. Locke GR 3rd, Talley NJ, Fett SL, Zinsmeister AR, Melton LJ 3rd. Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology. 1997 May;112(5):1448-56. Accessed April 7, 2006. 8. Tierney LM, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis & Treatment 2005. New York: Lange Medical Books/McGraw-Hill, 2005. 9. 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Evaluation of esophageal tests in the diagnosis of reflux esophagitis. Gastroenterology 1976;71:9–15. 15. Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med. 2006;166:965-971. 16. Joelsson B, Johnsson F. Heartburn–the acid test. Gut 1989;30: 1523–5. 17. Kinoshita Y, Adachi K, Fujishiro H. Therapeutic approaches to reflux disease, focusing on acid secretion. J Gastroenterol 2003;38 Suppl 15:13–9. 18. Masclee AA, de Best AC, de Graaf R, Cluysenaer OJ, Jansen JB. Ambulatory 24-hour pH-metry in the diagnosis of gastroesophageal reflux disease. Determination of criteria and relation to endoscopy. Scand J Gastroenterol 1990;25:225–30. 19. Tierney, Jr., L.M.M., McPhee, S.J.& Papadakis, M.A. (2005). Current medical diagnosis and treatment (44th ed.), (pp.548). USA: The McGraw-Hill Companies, Inc. 20. Hopkins C, Yousaf U, Pedersen M. 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