Central to the treatment of knotty diseases with Chinese Herbal Medicine is an understanding of what has been called the qi mechanism. It has become clear to me from practice and the long study of translated classics and commentaries by modern experts that this basic concept underpins a wide range of treatment options for chronic illness and thus warrants a detailed introduction. I find this concept particularly appealing because I believe it goes a long way towards restoring a dynamic quality to the practice of TCM. Because it is also my thesis that the discontent many American practitioners espouse towards TCM is due to this lack of dynamism in the basic textbooks. It also forms a linkage with the daoist alchemical tradition which has influenced TCM since day one.
In TCM terms, the qi mechanism refers to the four movements of ascent, descent, exit and entry. For clinical purposes, it is basically the up-down flow of qi in all living creatures. The ascent of qi is basically the assimilation and distribution of pure essence and the descent is the removal of turbid matter for excretion. Even the simplest plants and microorganisms must still ingest part of their environment, transform it into pure and turbid components, incorporate the pure and excrete the turbid. This simple process which is describe both in the nei jing and also any college physiology textbook, is the most basic attribute of life. Thus, the emphasis on proper diet and cleansing has been part of many healing traditions, including shamanic, ayurvedic, essene, native American, Egyptian, Greek, Arabic and modern naturopathic, as well. Of course, all of TCM may essentially be broken down into these two categories, with therapies focused either on removing excess (cleansing) or building up deficiencies (nutrition). The real attraction of TCM, in fact, may be the sophistication with which it has developed these two basic approaches. The long written and scholarly tradition of China allowed a refinement of a method used worldwide in ancient times. This refinement was not possible in other parts of the planet for various historical reasons, but the basic method remains the same.
At the core of this refinement is the notion of the qi mechanism. Because TCM is based on a dynamic concept called qi, it is not enough to say that waste is excreted and nutrients are assimilated, the direction of this dynamic force is considered vitally important, as well. The turbid is discharged downwards, which is quite intuitively sensible, as the major wastes of our bodies move in that direction. That the pure should ascend is perhaps less apparent, but is actually physiologically sensible as well. The essences of food must be ascended to mix with air in the lung to form the pure blood that is pumped through the body by the heart. This is remarkably similar to modern physiology's description of blood formation. Also the pure clear essences must rise to brighten the spirit, as well. This was sometimes actually described as nourishing the brain by physicians such as Li shi zhen. Likewise, modern physiologists talk about glucose and oxygen, but both are just part of the blood, which nourishes the spirit, in TCM.
However conceptually correct these terms may be is not near as relevant as their clinical utility. According to Flaws, the most important reason to think about excretion and assimilation in terms of qi direction allows one to utilize herbs chosen with this idea in mind.1 The diagnosis of knotty diseases and the selection of herbs to treat them can be greatly refined by using the directional qualities of herbs in addition to their other more well known attributes. Throughout the centuries, many great physicians have come to the same conclusion. We are lucky to have all their collected insights at our modern disposal.
The key organ networks in maintaining the patency of the qi mechanism are the stomach and spleen. As we recall, the spleen moves qi up and the stomach moves qi down. Thus, the spleen governs the assimilation of the pure and the stomach the excretion of the turbid. Spleen diseases involve failure and weakness of organs, while stomach disease is the beginning place for toxic internal heat to brew. The liver conveys the actual upward force via its smooth distribution of kidney yang qi and the lungs aid descent with their continuous bellows like action drawing air qi down into the body. But the spleen and stomach remain central to this process. The kidneys and the yang organs continue the process of separation of pure and turbid, finally discharging the turbid. The upper burner is like a mist and the lungs must continuously distribute this pure mist throughout the body. If the mist does not circulate, dampness and phlegm cloud the upper body and dampheat may accumulate in the lower burner. Recall that the lung is functionally connected to the bladder as the taiyang bladder channel is where the wei qi from the lungs circulates to maintain external defenses. However you slice it, the net result is that impairment of the qi mechanism leads to dampheat, qi, phlegm and blood stagnation and then spleen/kidney yang xu and/or liver/kidney yin xu.
Li dong yuan was one of the four great masters of the jin yuan dynasty. Bob Flaws, Charles Chace and Heiner Fruehauf have all written or taught about Li's great classic, the Pi Wei Lun, in recent years. While I have read the Blue Poppy translation of this book many times, my understanding owes much to the commentary of these men. According to Bob Flaws, the concept of yin fire espoused by Li Dong Yuan in the Pi Wei Lun is a critical concept in the understanding the TCM pathogenesis of numerous complex modern illnesses, especially chronic viral diseases, autoimmune diseases, AIDS, chronic allergies and food sensitivities.15,16 If true, this mechanism would account for a lot of suffering, morbidity and sometimes mortality.
According to Flaws, Li proposes that when the spleen and stomach fail to properly raise the pure and downbear the turbid, a number of things can happen in the body. Dampness descends into the lower warmer, where it brews and forms dampheat. The ministerial fire of the kidneys is disturbed by either this dampheat and/or by depressed fire due to qi vacuity and/or heat in any other organ system or emotions transforming to fire. The ministerial fire can then become erratic, heat in any other organ system or emotions transforming to fire. This is called a yin fire, because it arises from vacuity and often involves dampness. However, this yin fire may also include yin vacuity, causing the more familiar vacuity heat to complicate matters even more. Yin vacuity may be the result of lower burner heat from other causes burning up the yin or it may arise as a consequence of the spleen's failure to replenish yin from foodstuffs.
Flaws summarizes the process, thusly, "Li describes various disease causes and mechanisms of yin fire, we can identify five basic causes of this condition.These are:
The symptoms associated with such yin fire scenarios can be diverse and include complicated forms of atony and impediment pattern (bi and wei syndrome). Stasis of blood often complicates the basic scenario, either due to qi depression or vacuity. Thus, it is easy to see how diseases as different as multiple sclerosis, rheumatoid arthritis and chronic fatigue syndrome can all share the same pathomechanism. To review briefly, the stomach is responsible for rotting and ripening. The qi of the harmonious stomach descends and propels the turbid waste through the bowels. The spleen transforms and transports, which is to say it breaks down foodstuffs and upbears the finest essences of the food. This pure grain qi mixes with air qi inthe lung, where it moves to the heart as blood to be propelled around the body. If the upbearing fails, then the pure is discharged through the bowels and one is not properly nourished, i.e. assimilation fails. If the foodstuffs are not properly transformed by the spleen, then the turbid may pollute the newly formed blood, i.e. excretion fails.
A number of TCM practitioners over the years have noted the similarity between the naturopathic diagnosis of leaky gut syndrome and the Chinese understanding of spleen dysfunction. While not accepting the premise that spleen deficiency lies at the heart of all chronic illness, impairment of the qi mechanism does and the proper functioning of the qi mechanism is, of course, centered in the spleen and stomach. Continuing along our historical arc, we come to the modern era. TCM has a long history of considering new ideas based on new information or changing times, so it is not surprising that the modern Chinese have considered the role of intestinal dysbiosis in spleen/stomach pathology in TCM. Bob Flaws has pointed this out in his most recent contribution on this topic.73 I think is interesting and useful to understand these latest developments in naturopathy in their historical context. In some states, including Oregon, dietary advice and nutritional supplementation are part of Acupuncture scope of practice, so it makes sense for those so inclined to pursue studies in this area.
While some scientific approaches to TCM attempt to reduce TCM to already understood concepts of physiology, we will pursue a different path. One of Heiner Fruehauf's favorite 20th century authors on TCM was Zhang xi chun. Zhang is remembered as an early proponent of the school of chinese-western medicine integration.74 However, Zhang Xi chun used TCM concepts to expand his understanding of physiology and restore a holistic, dynamic quality to this modern science. He was the first to attempt to describe western drugs in TCM terms, something that has been attempted more recently by others, such as Zíev Rosenberg75, chairman of the department of Chinese Herbal Medicine at the Pacific College of Oriental Medicine. In the same vein, we will consider some of the naturopathic and scientific approaches to illness in such TCM terms. After completing this modern aspect of our understanding, we will return once more briefly to the most ancient times, hopefully bringing both science and TCM full circle to their common roots in the dao.
Modern Naturopathic medicine began at the end of 19th century, largely as a medicalized amalgamation of several popular health trends of the era. These included nature cure, fasting, hydrotherapy, colonics, exercise, diet emphasizing raw foods and vegetarianism. Many religious zealots were involved with these lay movements, but the profession of Naturopathy has been a serious one for a hundred years. Over this century, Naturopathy survived and absorbed the dying professions of homeopathy and eclectic herbalism, as well. Now, naturopaths always used herbs and homeopathics, but they tended to use these methods within their core philosophy, which was distinctly different from the eclectics and the classical homeopaths. Naturopathy has always been focused on removing toxins from the body, the idea being that when the system was purged of filth, it would function properly. As you might surmise, they got it only half right from our perspective.
While naturopaths certainly were early advocates of the need for proper nutrition to build healthy tissues, early proponents like Kloss, Ehret and Lindlahr felt that the vital essences of raw vegetarian foods would be fully absorbed in a system that was totally clean. Thus, the foods they chose for therapy tended to strongly emphasize removal of excess. Raw vegetables stimulate bowel movements and urination. At the turn of the century, when many nature cure patients were farmers, vigorous cleansing may have produced some miracle cures. Zhang zi he, a medieval Chinese proponent of the idea that all disease is evil toxin, which must be purged, would agree with this approach. However, in TCM history, zhang's methods proved too harsh to be used in more sedentary types (like modern office workers). So zhu dan xi modified zhang's method to be more balanced. Thus, purgation is still used in TCM when appropriate. As naturopathy moved into the modern age, it evolved a more sophisticated approach for several reasons.
The absorption of eclecticism and homeopathy before WWII certainly shaped modern naturopathy. Eclecticism and homeopathy both relied on precise methods of regulating what they called the vital force. Naturopathy also embraced this concept, but had largely focused on removing the obstacles to the vital force, largely through vigorous cleansing methods. So naturopaths now began to incorporate subtler methods of regulating the vital force into their practices. At the same time, there was an explosion of research on nutrition occurring in Europe and America. While nutrition has recently become of interest to medical doctors, this not because there was no information available earlier. Naturopaths made early use of this information in their practices. So they have been refining their approach for about sixty years now and have arrived at a theory that meshes very nicely with the Chinese concept of the qi mechanism.
The jumping off point for the most sophisticated naturopathic theories about disease causation are rooted in two important naturopathic concerns, namely bowel toxemia and enzymes. The concept of bowel toxemia was largely promoted by a doctor named John Tilden in the thirties. Tilden postulated that improper diet led to stagnation of food in the colon, which then putrefied and formed toxins. He associated heavy rich food like meat with this toxemia, however he was not a raw foods advocate. He recommended lightly cooked vegetables and broths as his regimen. We now know that low fiber, high fat diets alter the environment of the colon in a way that promotes the formation of carcinogens and other ėtoxinsî.76 If these wastes are not removed from the body, they can indeed wreak havoc on the cardiovascular, immune and neuroendocrine systems, so they very likely play a role in the pathogenesis of diverse illnesses.
Naturopaths have long defended their raw food advocacy, based on what I call the enzyme theory. Knowing that raw foods contain large amounts of enzymes, like all living tissues, and knowing that such enzymes were largely destroyed by cooking, they postulated that eating large amounts of raw food would keep enzyme levels high in the body. These enzymes would then spare the body of the need to produce its own enzymes, thus conserving the vital force for other activities, like immunity and free radical scavenging. There are several problems with this hypothesis. First, while raw foods are higher in enzymes, these enzymes are largely destroyed by stomach acid if the food is well chewed or they are not absorbed at all in poorly chewed food. There is no actual evidence that the enzymes in most common foodstuffs actually enter the bloodstream and impact one's health in any dramatic fashion. However, certain enzymes are pH resistant, like bromelain, the pineapple extract used very effectively to treat inflammation.
The current naturopathic approach still relies on the concept of bowel toxemia and enzyme therapy, but the discussion has been recast in light of recent scientific findings. Bowel toxemia has been replaced with the terms leaky gut syndrome and intestinal dysbiosis. Dr. Jeremy Appleton, ND, says, "the intestinal mucosa is a selective barrier that admits nutrients, but excludes unwanted ... materials".77 This is clearly a modern description of the separation of the pure from the turbid. The term "leaky gut syndrome" specifically refers to an impairment in the integrity of this barrier. So leaky gut syndrome is, by extension of our logic, an impairment in the separation of pure and turbid, thus a failure of the qi mechanism in TCM terms.
Intestinal dysbiosis refers to the alteration in the normal flora and fauna of the colon. this may lead to overgrowth of pathogenic organisms, such as candida. Intestinal dysbiosis is caused by turbid matter stagnating in the colon and overuse of antibiotics. This is interesting for several reasons. First, in modern terms, external dampheat is often caused by bacteria or other pathogenic microorganisms. Examples include dysentery, urinary infections, food poisoning, etc. However, the internal generation of dampheat may also be related to pathogenic microorganisms that live inside of us. Some people find it disconcerting when they learn that we have more bacterial cells inside and on our bodies than human cells. Thus, internally generated dampheat may include intestinal dysbiosis. Overgrowth of bacteria, candida and parasites also indicates gu. So intestinal dysbiosis also may also indicate gu in TCM terms.
Another important component of leaky gut syndrome treatment is the use of bitters and carminatives. Bitters are herbs like goldenseal. Goldenseal may be used in small dosages to stimulate digestion or in larger dosages as an antimicrobial. In larger dosages, goldenseal inhibits pathogenic organisms in the colon, thus treating dampheat directly. Carminatives like ginger and caraway are used to relieve digestive symptoms, however such herbs are thought to uplift or spread the qi in TCM terms. So their effects help get at the root of the problem, rather just relieve suffering.
So we can already see that leaky gut syndrome can be understood in terms of two concepts we have discussed frequently this past month. One is the stagnation of the turbid waste and the other is dampheat. We now turn to the ascent of the pure and the role of enzymes. In recent years, a new form of enzyme has become prominent in the practices of sophisticated naturopaths. These enzymes are produced from friendly bacteria and have the amazing property of being stable in the entire pH range of the human digestive tract. They are not destroyed by stomach acid and remain active in the colon. Similar stable enzymes are produced in the fermentation that produces the Chinese herb, shen qu (a.k.a., massa medicata, fermented leaven), coincidentally a favorite of both Li dong yuan and zhu dan xi. These enzymes serve a variety of therapeutic purposes. Large doses are antiinflammatory. Some evidence suggests anticancer activity, as well. But what they do in normal doses is promote the transformation of food into its finest essences. Thus, nutrients are absorbed and turbidity is not produced from food.
Because the enzymes are active down to the rectum, they continue to promote transformation along the way, thus breaking down old stagnant food and clearing dampheat, as well. This emphasis on transformation reminds one of Stephen Clavey's identical emphasis in the treatment of chronic dampheat. However, the whole story also involves direct repair of the intestinal mucosa. The enzymes prevent further damage, but they do not restore the integrity of the intestinal villi. The restoration of the villi is what we would call in TCM a tonic effect. In all longterm chronic cases, there is some aspect of deficiency or sinking qi present. So this aspect of treatment is more geared towards what we might associate with promoting ascent of spleen qi. The term seems particularly appropriate because we are actually preventing something from leaking or sinking downwards. Naturopaths indicate antioxidants as playing a key role in this aspect of treating leaky gut syndrome. According to Dr. Appleton, ėreducing oxidative stress [in the gut] can help break the vicious cycle that makes other conditions worse.î
Dr. Appleton goes on to recommend antioxidants like gingko, quercitin and N-acetyl-csyteine.78 However, herbs such as bupleurum, ginseng and astragalus all have significant antioxidant activity and all three are used to lift the spleen qi. So, by using our TCM approach to qi mechanism imbalance, we seem to cover another aspect of leaky gut syndrome. Again, we have not reduced treating the qi mechanism to enzymes and antioxidants, but hopefully demonstrated that the TCM approach includes aspects supported by recent scientific enquiry. My goal, like Zhang xi chun, is to illuminate physiology with reference to TCM.
It is not real meaningful to me that bupleurum is an antioxidant and antioxidants improve leaky gut syndrome. that doesnít change my use of bupleurum. However, it might cause me to include quercitin in my treatment of a spleen qi xu patient with food allergies, for example. What is more important to me is to take the concept of ascending spleen qi and use it to expand modern physiology. For example, if bupleurum raises spleen qi and raising spleen qi helps with leaky gut syndrome, then it follows we should use the concept of spleen qi sinking to guide us in our explorations of the western physiological literature. While it is the antioxidant quality of bupleurum that seems to play a role in this, what else is going on? Bupleurum cannot be reduced to an antioxidant. What else is it about bupleurum that contributes to this TCM action and can this lead us to other approaches that may enhance our TCM with nutritional supplementation?
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