These are the course materials I created for an NCCAOM approved continuing education course in 2000. These course materials are based on an article that was published in the journal of Chinese medicine in 1999. I’m going to separate this into individual posts for each lesson, but this will suffice for now. This material is protected by copyright. It is for your personal use and may not be reproduced or distributed in any form. Thank-you.

Preface

What I have done is chosen a central organizing premise, the qi mechanism, and roughly traced a portion of the historical route this concept has taken. I have relied both on translations of classics, such as the Treatise on the Stomach and the Spleen by Li dong Yuan, and commentaries by a number of modern authors. I have relied exclusively on the commentaries of authors who can themselves read Chinese. A complete set of references and bibliography is included at the end of the “lecture” packet. Such a work as this necessarily relies on the prior works of others. I have made every effort to footnote where appropriate and give informal attribution in other cases. My role should thus be seen as a guide, not as an expert. The experts are my sources and you are encouraged to read their material to supplement my essays.

Most of the web articles were written by Bob Flaws, whose work is an important influence on this course. In addition to Bob Flaws, whose influence dominates my discussion of yin fire, I must acknowledge Heiner Fruehauf’s communications with me for many years on all aspects of TCM, especially six stage theory. The work of these two men forms the essential structure of this course. Subhuti Dharmananda was the first person to suggest to me the connection between spleen conditions, liver depression and dampheat with what Naturopaths call leaky gut syndrome and intestinal dysbiosis. This is a theme also pursued by Flaws for many years. Others, including Fruehauf, have also made this connection. My main teacher, Li Wei, treated most such patients in this fashion, her father having imparted a deep respect for the methods of zhu dan xi. Steven Clavey’s excellent work on fluid pathology has been a source of much inspiration for this course, as well. Jim Cleaver laid a solid foundation for me in basic concepts, while Tim Timmons did the same in clinical practice, TCM pathology and Materia medica. The works of Andy Ellis, Nigel Wiseman and Dan Bensky remain continual sources of renewal for me. While I am sure there are others who have pursued similar lines of inquiry, these are the central influences and sources for my work.

TABLE OF CONTENTS

Lesson1: ADVANCED REVIEW OF QI MECHANISM
Lesson 2: ADVANCED REVIEW OF DAMPHEAT, PHLEGM AND BLOOD STASIS Lesson 3: ZHANG ZHONG JING AND LIU JING (SIX STAGES)
Lesson 4: LI DONG YUAN AND YIN FIRE
Lesson 5: ZHU DAN XI AND YIN DAMAGE
Lesson 6: TRIPLE BURNER DAMPHEAT
Lesson 7: GU SYNDROME
Lesson 8: YAN DE XIN, WANG QING REN AND BLOOD STASIS
AFTERWORD: CORRELATIONS FROM LEAKY GUT SYNDROME TO TAOIST ALCHEMY

LESSON 1

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. In this course, we will focus mainly on the on the up-down flow of central qi. The ascent of spleen qi is basically the assimilation and distribution of pure essence and the descent of stomach qi is the impetus for 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 described 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 Bob Flaws, the most important reason to think about excretion and assimilation in terms of qi direction is that it allows one to utilize herbs chosen with this idea in mind.1 As we shall see, 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 some of their collected insights at our modern disposal.

The key organ networks in maintaining 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.

Now many herbs have obvious relationships with the spleen, such as ginseng, astragalus and atractylodes and others are well known to clear stomach, bladder and intestinal heat, like coptis, phellodendron, dandelion, etc. However, many other herbs are used, as well. For instance, bupleurum may be used to clear lower warmer dampheat through its action of lifting spleen qi. Or Acorus may be used to restore heart and kidney not communicating due to middle warmer obstruction. In some cases, the use of diuretic herbs in the former case and moistening yin tonics in the latter may be contraindicated. The reasons for such clinical presentations will become clearer as we progress. For now, it is important to understand that a sophisticated evaluation of the patient’s qi mechanism can have a big impact on your herb selection.

Luckily, the qi mechanism is assessed using the same four examinations used for zang fu diagnosis. Remember, this is just a dynamic approach to TCM, not a new style altogether. And that dynamism is found in the actual texts and commentaries that were used to create TCM in the first place. You can kind of liken this process to an advanced student going to the horse’s mouth, so to speak, and no longer just relying on the interpretations of others. Hopefully, this course will provide some tools and guidance in what will be a lifelong journey through the classical archive of Chinese herbology.

If one does a thorough interview with your patient already, you probably have already gathered the information needed to properly assess the qi mechanism. Details on digestion must be precise, such as the quality of stool, undigested food, number of BM’s, gas, belching, provocation and palliation. It is important not to gloss over these things due to embarrassment. If you can’t get this info the first time, you should try over a few visits. Urination is also critical, especially inhibition versus incontinence. Sweat and fever yield important information as well, as the does the state of memory, concentration, etc. As we shall see, all these factors can lead one to put varying degrees of emphasis in treatment on draining the turbid versus ascending the pure. Finally, tongue and pulse are paramount in determining the degree of excess versus deficiency, the tongue being especially revealing of the degree and nature of the turbid. Specific diagnostics will be discussed in the appropriate lessons.

Case Study:

30 year old female presents with low energy, losing hair, hay fever with constant rhinitis, clear nasal discharge, never recovered from pregnancy, chronic toe fungus, history of bladder infections, facial acne (isolated lesions that don’t heal), always chilly, poor appetite, fine, weak pulse, pale dry scalloped tongue with thin dry white coat. I think this patient clearly has symptoms of qi and blood xu, but also dampheat and phlegm. A typical approach might be to attempt to clear the dampheat and phlegm vigorously, then apply supplementation afterwards. This would be the method used by most of my Chinese teachers. Alternately, one might address the deficiency as this is more apparent, perhaps. A common choice would be ba zhen tang. Many of my American teachers who were not thoroughly trained in TCH would have taken this latter path, perhaps using acupuncture to relieve symptoms, external ointments for toe fungus and probably bi yan pian or pe min kan wan for allergies as needed. While both of these approaches might be theoretically reasonable, I have not found either one to be clinically effective when evaluated in a fair and impartial manner.

However, by using the concept of the qi mechanism, a dynamic quality can be added to this diagnosis. While I will not go into the specific therapy at this time (since we have not learned them, yet!), it is still instructive to see how this patient would be understood via this model. So rather than seeing disparate patterns, it is important to understand how they interlink with each other. In this case, the central qi vacuity, perhaps due to pregnancy and poor diet for a long time, lead to blood xu, which is obvious due to falling hair. It also lead to dampness and heat stagnating in the lower warmer. Phlegm also accumulates in the lung channel, because the lungs do not have sufficient descending and clearing ability due to the qi xu. Repeated wind invasion in the form of allergies are also due to lung qi xu not spreading the wei qi.

From the perspective of the qi mechanism, dampheat and phlegm are both due to improper excretion of the turbid, while the xu symptoms are reflective of failure to assimilate the pure essences from food. When one attempts to clear the turbid without addressing the failure of the qi mechanism, one is doomed to failure. The key, as we shall see in the lessons to come, is the selection of herbs that restore the normal up down mechanism of the central warmer. There are about a half dozen common patterns of qi mechanism impairment and this course will explore all of them. In those lesson, we will learn how to precisely restore this mechanism without either overly purging toxicity or stagnating the system with rich tonics prematurely. But first, we must have a review of dampheat, phlegm and blood stasis so that we may understand these pathogens in relation to qi mechanism impairment.

LESSON 2

Dampheat and phlegm are discussed together because their etiology and presentation can be quite similar and because the patterns often overlap. They are both fluid pathologies in TCM and this discussion owes much to Stephen Clavey’s Fluid Physiology and Pathology in TCM. But let’s begin with a review of more basic definitions. Chen’s Comprehensive Guide to Chinese Herbal Medicine is a text that is representative of basic internal medicine texts (for others, see bibliography). According to Chen, “heat clearing and dampness drying herbs are usually used for skin diseases, hepatitis and bacillary dysentary”.2 Chen is referring to acute diseases here and this is typical when learning about the dampheat pathogen. While texts like Chen and Ellis’ Fundamentals of Chinese Medicine both mention the cause of dampheat possibly being due to eating spicy greasy foods excessively,3 a look at the symptom complexes in FCM and the biomedical diseases associated with dampheat formulae in Bensky’s Formulas and Strategies reveals a litany of acute illnesses.4,5,6 It would seem to appear that when these symptom complexes occur in a chronic patient, something else is going on.

For examples, chronic diarrhea is typically classified as spleen qi xu or liver invading spleen or nightsweats are treated as yin xu, when dampheat is a common cause of both in chronic patients. In Chen’s chapter on diarrhea, for instance, dampheat is mentioned in the acute section, but not mentioned at all in the chronic section, even under modifications (and again, this is typical of such basic texts).7 Nightsweats are almost exclusively relegated to yin xu in basic texts, though Bensky includes a brief reference to dampheat as causative in the modifications for hao qin qing dan tang.8 Flaws has noted that Zhu dan xi pointed out that enduring dampheat can lead to yin xu.9 However,intheearlytomidstages,yintonicswouldonlyfurtherobstructtheqi mechanism with their stickiness. Zhu dan xi is known as the founder of the yin tonification school, but he was a follower of Li dong yuan’s school of earth, as well. Both of these physicians found dampheat to be a predominant factor in their patients’ illnesses. As Bob Flaws likes to point out, this is clear from actually reading their works, but it is not often what is remembered.10 We will talk more in detail about Li and Zhu’s theories in future lessons, but first there is much to be said about dampheat in general.

Damp is a yin pathogen and heat is a yang pathogen. Dampness usually arises from the overconsumption of damp inducing foods and/or weakness of the spleen and stomach. Heat may be induced by spicy foods, but it is usually induced by longterm stagnations, such as damp, phlegm, food and qi. This stagnation often leads to some degree of heat, even in people with inherently cold constitutions. Emotional distress or imbalance also can easily cause heat to arise, especially in the liver and heart. The diet and stress of modern life thus almost inevitably leads to some degree of dampheat formation. While the root imbalance may vary from case to case, it is critical to identify the type, degree and location of dampheat in order to successfully treat most chronic illness.
When damp and heat become entangled together, a sticky clinical situation has been created. The parching herbs that dry damp are often warming, thus aggravating heat and possibly damaging yin and blood. The herbs that cool chronic heat may be moistening or weaken the spleen with their bitterness, thus excaerbating damp formation. Yet it is essential that both damp and heat be treated concurrently in order to have success. It is important to identify the prevalence of heat or dampness and treat accordingly. It is also important to remember that dampness and heat, like all pathogens, cannot be transformed into vital essences like yin and yang. The pathogens must be expelled from the body and the vital essences must be restored through convalescent diet and supplemental herbs, if necessary.

In order to determine the prevalence of damp versus heat, we are again on familiar ground, using our four examinations. Obviously, these pathogens have very different symptom complexes associated with them. So if a patient has mainly symptoms of dampness, but only a little bit of heat, then dampness is predominant. And vice-versa. Sometimes, the pathogens are fairly equal in virulence. This makes things more difficult, but not impossible. Tongue and pulse are important indicators here. A tongue coat that is chronically sticky and dirty or slightly yellow certainly indicates turbidity with heat. We see this tongue all the time in patients who are also liver qi stagnant, yin xu and spleen qi xu and yang xu. The tongue body may be large and scalloped (most common here in Portland) or normal or red. In older or seriously ill, dryness, fissures and unrooted coat is common. The pulse may be slippery, wiry, fast or fine, weak and soggy. But the the thick, greasy coat is always evidence of damp, whatever else may be going on. These reveal the excess versus deficiency, as well as the prevalence of heat or damp. As always, only the results of therapy prove one’s diagnosis.

A continuing theme we shall see throughout this course is the need to approach chronic illness by treating what are called the “mutually engendering” pathomechanisms. According to Bob Flaws, this term appears frequently in the Chinese Medical literature in relation to the treatment of complex illnesses.11 It is very rare to see pure yin xu or pure phlegm stagnation. Because we are often presented with these complex mixed patterns in chronic cases, it is vital to determine the true nature of the disease in order to administer proper herbal therapy. As an aside, I should mention that all of you are aware of the impressive clinical results from China, based on studies that do not usually individualize the formulae for each patient. However, only about 20% of the patients in these studies have dramatic results. Another 20% have no effects and the rest get varied effects. I am convinced that much greater than 20% can expect dramatic results with properly chosen formulae, perhaps on the order of 75%.

Phlegm is very similar to damp, but not to be mistaken, because different strategies are used to address these patterns. However, a disruption in the qi mechanism is invariably involved in all chronic phlegm conditions. While phlegm arises from the same causes as damp, such as poor diet and exercise, impaired digestion and chronic emotional distress, it manifests as different types of pathology. Aside from the obvious phlegm that may obstruct the lung, there are the very serious pathologies, such as uterine fibroids or ovarian cysts when phlegm congeals into lumps and things like alzheimer’s disease when phlegm mists the mind. Of course, dampness and phlegm often coexist and they are mutually causative. In fact, those with chronic dampness often go to develop phlegm problems and those with chronic phlegm often experience dampheat. This is relevant because phlegm is one of the two possibilities for the cause of unusual and stubborn chronic illnesses; the other is blood stasis, which will be reviewed in a moment.

Many of the herbs that treat phlegm and damp overlap, such as chen pi and ban xia, however, specific strategies differ. For instance, the use of herbs to disinhibit the lower warmer and promote urination are generally restricted to cases where there is some type of inhibited urination. They are certainly avoided in those with incontinence, even if damp is present. On the other hand, most of the herbs in the cool and transform phlegm category, such as the fritillarias, tricosanthes, seaweeds and bamboos have distinct uses and are not used for dampness without phlegm being also present. Here is a review of treatment stategies for damp and phlegm and their interrelationships. These will be discussed in more depth as they come up in future lessons.

Transform dampness – some of these herbs treat phlegm, as well, such as the cardamons and magnolia bark
Disinhibit urination – diuretics restricted to urinary inhibition, stones, infections; the overuse of these herbs is thought to severely impair the qi mechanism by overstimulating descent. This problem is well known to students with regard to purgatives, but lesser so with diuretics Strengthen spleen – herbs like fu ling and bai zhu can be used in almost almost all cases of phlegm and damp, except some yin xu
Transform hot phlegm – some tumors, dementia, as well as bronchitis; these herbs are not used for damp alone
Transform cold phlegm – some of these herbs also transform dampness; only ban xia is commonly used. Some texts put jie geng in this category, but it is mostly used in heat conditions, as in yin qiao san.
Descend lung qi – for cough and sputum obviously, but also for dampheat, which will be discussed in the lesson 6
Supplement lung yin – for sticky dry phlegm conditions, herbs like mai men dong are common Clear heat – must be treated directly with either bitter drying herbs like huang qin or moistening herbs like xuan shen, as indicated
Regulate qi – a number of important phlegm herbs are in this category, most notably chen pi Relieve the surface – many herbs that relieve the surface help clear phlegm from the head, such as bai zhi, chuan xiong, ge gen, xin yi hua. However, others of these herbs can play an important role in regulating the qi mechanism, as we shall see in the lesson on Li dong yuan and the pi wei lun
Soothe liver – while not directly addressing phlegm, the liver’s role in maintaining the smooth flow of qi, when impaired, disrupts the central qi mechanism, leading to damp accumulation and the stagnation that promotes congelation of phlegm

To summarize an important distinction when diagnosing phlegm versus damp, its all about signs and symptoms. Since the tongue, pulse and underlying root patterns can be identical for these two patterns, all that is left is to distinguish them by their actual signs and symptoms. Thus, dampness is a primary component of most urinary tract infections, while phlegm usually is not (however if the patient has a thick stringy discharge, think again). Phlegm is the cause of severe mental disturbances, while damp usually is not (however dampheat with a significant heat component can surely disturb the spirit). But these exceptions in parentheses are just that. I suppose this also underscores the importance of symptoms and reinforces the notion that all of the four exams are equally important, in some cases one or the other being more crucial to proper diagnosis. But as this example shows, it would certainly be incorrect to elevate any one of these methods as absolutely superior, such as pulse. The greatest pulse master in the world could not distinguish the slippery pulse of phlegm and the slippery pulse of damp.

As mentioned, Blood stasis is another possible cause of stubborn chronic illness. This is only hinted at in basic texts, which usually relegate blood stasis to cardiovascular and pain conditions. However it is a common factor in many cases of depression and lupus, to name two amongst many. In theory, blood stasis could obviously lead to a wide range of problems involving the TCM function of the xue. The blood is where the body gets its nourishment. It is also where the spirit rests. It is strongly affected by the liver, which in turn responds to emotional distress with depression of qi. So it is no leap to see what role the blood can play in chronic illness. As we shall see in the lesson 8, much has been said in modern times about this concept. Blood stasis is mentioned here because it is often the end result of longterm stagnation of qi, phlegm and dampheat. It is thought that the entanglement of these pathogens is a central component of most serious pathologies, like tumors, cirrhosis and atherosclerosis. So blood stasis must be kept in mind whenever treating chronic illness.

LESSON 3

We all learned about the shanghanlun in acupuncture school. In most cases, you probably learned that it was a book about the treatment of cold invasion according to the six stages (the term is actually liu jing, which means six channels; hereafter, the term liujing theory may be used instead). You may have also learned that it was originally attached to a companion volume called the jin gui yao lue. While the shang han talked about an acute illness, its sequelae, the jin gui yao lue, is a book about miscellaneous diseases. Translations of moderate quality have long been available in English. The latest editions have substantial commentary by modern physicians. What has never been available are translations of commentary on these books. Like most Chinese medical classics, these books have spawned an ocean full of commentary. Several important sources have been available to me over the years.

First, Subhuti Dharmananda, who was one of my teachers, originally learned TCM from a Taiwanese man named Hong Yen Hsu, who himself studied japanese kanpo. Japanese kanpo relies heavily on shanghanlun formulae, so Subhuti has always devoted some time to this matter in his work. Particularly, the wide use of formulae based on chai hu gui zhi tang to treat diverse chronic illness comes from this kanpo tradition. Many of my TCM teachers from China rarely selected this formula, but there were notable exceptions.

Dan Bensky’s teacher, Ma Shou Chun, is a shanghanlun scholar from Chengdu college of TCM in Sichuan province. He has lived in Seattle for many years. Dr. Ma frequently lectured at OCOM, my alma mater. His influence can be seen in Bensky’s formulary, which makes broader use of shanghanlun formulae than most basic internal medicine texts do. The Chengdu college of TCM turns out to be the place in China to learn about liujing theory. Both Dr. Heiner Fruehauf and Dr. Guohui Liu, here in Portland, attended that school, as well. Several other Chengdu physicians also teach and practice in Portland and we were graced with the presence of a living liujing master for over a year, 75 year old Dr. Zeng Rou Xiu. So by chance perhaps, Portland has become somewhat of a mecca for this style of practice.

According to Fruehauf, since the rediscovery of the shanghanlun a thousand years ago, Chinese scholars have argued whether the framework known as the six stages applied only to the analysis of acute illnesses or whether it also included chronic disease, as well.12 The prevailing opinion of mainstream TCM sources is that the six stages are only a framework for understanding acute illness. However, the opinion in Chengdu, which is based on a thousand years of commentary, is that Zhang zhong jing meant the six stages to apply to chronic disease as well as acute. And further that the Jin gui yao lue should be read with this in mind. This position is based on the fact that classical texts were often written very tersely. So the exposition of theory may occur only once in certain clinical works, rather than being repeated almost ad nauseum as they are in modern texts.

How many diseases did you have to study in school before you realized that the liver patterns always had the same underlying symptoms, as did the spleen and kidney and so on. This type of spoonfeeding is not an element of the chinese classics for many reasons, not the least of which was the difficulty of copying lengthy works prior to the printing press. In fact, it is only after the perfection of paper and the printing press that you actually see an explosion in TCM. The medicine just really simmered for thousands of years, then took off in the tang and song dynasties. Up until this time, according to Unschuld, herbal medicine had been the province of daoists, folk healers, magicians, alchemists, qi gong masters, apothecaries and had not been formally integrated into mainstream professional medicine.13

Most of the remainder of this lesson is based on coursenotes, personal discussions and correspondences with Heiner Fruehauf. Additional references will be cited in the body of the essay We will assume in this course that the liujing theory is applicable to diverse chronic illness. According to Heiner Fruehauf, the most eloquent expositor of this method, the first element in understanding liujing theory does not hinge on the number six but rather on the number two. There are three yang channels and three yin channels. Yin and yang are the first two elements to understand. We sometimes forget the importance of these basic concepts.

Though I call this two, it is really always interlocked as two-as-one. Consider the tai ji symbol, still the best representation of this concept. Just like computer scientists can model the world with just 0’s and 1’s and and electrical engineers can manipulate it with just positive and negative charges, so the TCM herbologist can understand the processes of nature with yin and yang alone. In fact, the math and physics that allows scientists to predict the forces and changes of the material world was put in its modern form by Leibniz, an 18th century European student of the I Ching. Yin and Yang lying secretly at the root of our modern society, forever.

Disease usually begins in the yang stages, which are taiyang, yangming and shaoyang. In those who are weak or infirm, disease may strike directly at the yin stages, which are taiyin, shaoyin and jueyin. Constitutional differences partially determine which yang stage may be struck first in a given individual. For instance wood or liver types generally experience shaoyang disorders; spleen or earth types get stuck in taiyin and kidney xu is similar to shaoyin. But certain disease types also tend to cluster in different channels. For instance, taiyang is mostly about circulation of the wei qi and the yang surface of the body. So wind cold and bi syndrome are both often associated with taiyang. A jin gui yao lue formula gui zhi, zhi mu, bai shao tang, is now commonly used by liujing practitioners to treat all kinds of severe chronic musculoskeletal conditions, including autoimmune joint disorders. This formula is derived from gui zhi tang, the flagship formula of the shanghanlun for taiyang illness. Heiner Fruehauf actually calls the shanghanlun ” the book of cinnamon” and he has documented and demonstrated a wide range of uses for this seemingly unimportant formula.

Yangming is a robust type, the most excess of the three yang. Patients experience fever, mania, constipation. While taiyang and shaoyang can linger, yangming disease can progress rapidly in many cases. But it is not just an acute phase of illness It may be associated with invasive cancer of the colon or type 2 diabetes in those who are obese from indulgence in fatty, greasy, spicy and sweet foods. Yangming formulae like da chai hu tang and bai hu ren shen tang are used for diabetes. Chai hu jia long mu tang is used for chronic mental disorders and hypertension, both associated with yangming in some cases. This is an excess pattern and that applies to making correct diagnosis. Look for big pulse, sweating, feverishness, typical yangming stuff.

Shaoyang types experiences problems of excess phlegm and damp-heat due to disturbances of the related organ networks of triple burner and gallbladder, which are both associated with these pathologies. While the liver and spleen are yin organs, liujing theory equates what TCM calls liver qi depression mainly with this shaoyang stage. Formulae based on xiao chai hu tang and si ni san treat the shaoyang stage. The shaoyang stage is called the pivot or hinge stage by Fruehauf. It is considered the point at which yang illness can enter the yin phases. Since the shaoyang phase is often associated with liver spleen disharmony, we can see in TCM terms how a problem that began as excess (i.e. liver qi depression) can ultimately result in a vacuity (in this case, of the spleen qi). Many complaints of those under 40 occur just at this hinge and this is why we so often see liver/spleen disharmony in our patients of this age.
Once the yin phases are entered, dampness and phlegm become greatly compounded, blood and yin and yang xu occur and blood stasis mounts. At the pivot point in shaoyang, a person will begin to experience some aspects of taiyin beginning to encroach. As the liver affects the spleen more profoundly, some dampness accumulates and some blood xu occurs. For this reason, Heiner Fruehauf has found xiao yao san to be the most important formula for american patients. Are you surprised? The combination of shaoyang regulation with chai hu and dampness removal of bai zhu and fu ling with the gentle nourishment of dang gui and bai shao is obviously just what the doctor ordered in many cases. Now xiao yao san is not a shanghanlun formula, however it is based on two that are. Si ni san, which has chai hu, bai shao, zhi shi and gan cao is obviously a shaoyang formula. Combined with this are elements of dang gui shao yao san. Dang gui shao yao san includes dang gui, bai shao, bai zhu and fu ling to harmonize blood and remove dampness, all aspects of taiyin.

Now, a discussion of si ni san and its relatives (like xiao chai hu tang and chai hu gui zhi tang) and its derivatives (like xiao yao san) is essential to our discussion of the qi mechanism. As we shall see, these formulae have inspired several other important threads in the development of this clinical concept. According to a report from ITM, Zeng Rou Xiu, the modern liujing master mentioned above, described his use of si ni san to treat AIDS thusly, “bupleurum raises the qi and zhi shi makes it descend, so that the vital up down dynamics in the body can be restored; at the same time peony and licorice harmonize the liver and the spleen.”14 Zeng goes on to point out that by restoring the qi dynamic of the liver and spleen, accumulations are dispersed and deficiencies are tonified via the improved action of the postnatal root of jing, the spleen. Chai hu gui zhi tang uses ban xia to descend the turbid qi and xiao yao san uses fu ling, but all three regulate the up and down dynamic. This is considered crucial to success at the hinge phase, to keep the pathology from progressing deeply into the yin phases. Yin disease is much harder to treat. Thus, much chronic disease in america, which centers around spleen and liver pathology demands a treatment that consciously addresses the qi mechanism. Liujing theory is a dynamic framework that can be used to understand the progression and connections in such chronically ill patients.

Now this emphasis on the qi mechanism is clearly an emphasis on yang. It is about regulating a dynamic, rather than replacing a substance. It is the opinion of Dr. Fruehauf that the nei jing and the shanghanlun were all about this dynamic view of health and illness and cosmology. This is evident in that pulse diagnosis is the main method used, which has a more dynamic quality than tongue diagnosis. Fruehauf points out that as time went on, TCM became less yang action and more yin substance oriented. Tonification with rich herbs took prominence and tongue diagnosis eclipsed pulse in importance. Modern TCM is strongly influenced by an, albeit one sided, homage to zhu dan xi, the founder of the kidney water reinforcing method. Fruehauf has actually coined the term the school of yang qi to distinguish zhang zhong jing’s emphasis from that of the other great masters. Zhang was very focused on warming and moving (though he did not ignore cooling and moistening, when necessary). Fruehauf says that zhang, like all great masters, encompassed the whole gamut of yin and yang in his theory, he just chose cold as his frame of reference. As we shall see, those who followed him in chinese history paid continual tribute to this man in their selection of herbs and their emphasis on dynamic medicine, but often from a seemingly different frame of reference.

My main teacher, Li Wei, always emphasized the view that formulae were to be adjusted to suit contemporary clinical needs. Thus, an unmodified classical formula was rarely used by Li Wei, though a close observer could usually see her influences. So part of my goal in discussing various formulae in relation to the concept of the qi mechanism and dampheat formation is to illustrate Dr. Li’s approach to formulation, as well. Some schools of thought do not like to tinker with classical formulae too much. This has been an ongoing debate in China and Japan for centuries. I side with the tinkerers. Thus, when I talk about si ni san or xiao yao san, my goal is enliven the understanding of these formulae so that elements of them may be used in your clinical practice. I am definitely not suggesting that there is a disease called qi mechanism imbalance and that what I am presenting is a differential for that disease. We are all familiar with the use of several of the formuale I will present (though I suspect a few are a bit obscure). However, I hope to create a dynamic context in which to utilize this information rather than merely saying that such and such a list of symptoms and signs indicates si ni san or bu zhong yi qi tang or whatever.

So the important point of this lesson is not what symptom complex you treat with xiao yao san, for example. But it is how elements of xiao yao san affect a critical dynamic of the body and can thus be used to unravel a wide range of diverse chronic illness. So we all know that xiao yao san is the formula for PMS. Perhaps some of you have heard that it is a good formula for hayfever, too. You may have wondered why this might be so and even heard an explanation about the liver affecting the eyes, thus itchy eyes can be caused by liver qi depression. However, it is much more satisfying to consider that hay fever is a natural result of the ascent of the turbid and that if the patient presents as a xiao yao san type, that this formula could be right on the money for hayfever. You could spend months addressing phlegm and wind and heat without ever finding a standard textbook reference to xiao yao san for hay fever. Yet from the qi mechanism perspective, this shaoyang stepchild makes a lot of sense.

LESSON 4

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:

1. Spleen qi vacuity
2. Damp heat
3. Liver depression, depressive heat 4. Yin & blood vacuity
5. Stirring of ministerial fire” 17

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.

The central formula for the treatment of yin fire is Bu zhong yi qi tang or an elegant variation called huang qi ren shen tang. According to Flaws, the key to the magic in these formulae is the use of so-called wind medicinals to uplift the qi.18 The basic formula uses chai hu and sheng ma for this purpose. The two herbs serve also to clear depressed fire, so sensations of fever are relieved without necessarily using bitter cooling herbs. This is important as the latter sort of medicinals may damage the spleen. A trio of warm supplementing herbs is typical for Li. He frequently uses ren shen, bai zhu and haung qi, however these herbs are frequently referred to as having the ability to clear heat as well. How can this be? It is because the root of the heat in this condition is spleen vacuity, so when the root is simultaneously addressed with the branch in complex illness using such formulae effectively clears yin fire. Dang gui is included to harmonize the blood and chen pi to downbear the turbid and the basic prescription is complete. Huang qi ren shen tang, a typical variation, adds mai men dong to nourish the yin, shen qu to downbear the turbid by dispersing food accumulation and huang bai. Li used huang bai to clear dampheat, but also to nourish the kidney essence. The combination of zhi mu and huang bai was often indicated for atonic weakness of the lower body, common in multiple sclerosis, for example. Li dong yuan believed that the typical method of addressing chronic dampness by disinhibiting urine with bland percolating herbs like ze xie and zhu ling was contraindicated if urination was not inhibited. He felt the use of such herbs would further exacerbate the pathological descent of spleen qi. He was thus the first to clearly elucidate the use of herbs to restore the normal mechanism of spleen upbearing simultaneously with stomach downbearing. However, he was clearly inspired in his theory by that earliest of herbal classics, the shanghanlun.

Consider Li’s flagship, bu zhong yi qi tang. While perhaps not apparent at first glance, this formula is derived from xiao chai hu tang with ren shen, chai hu and licorice being drawn directly. This has been noted by others, of course, but I had noticed the odd similarity between these formulae as a student and their relationship was confirmed at that time by one of my teachers, Li Wei. In Li Dong Yuan’s variation, the nontoxic chen pi, replaces ban xia, thus making the formula more appropriate for longterm use, while function of descending turbidity is maintained. Now the regulation of the up down dynamic is inherent in the use of shaoyang formula, as described in the previous lesson. Chen pi is one of the many citruses in common use in TCM. Another one, zhi shi is the downbearing component of si ni san. It’s milder relative zhi ke is often substituted. These latter two citruses are cooling, while chen pi is warming. Chen pi is also damp transforming, while zhi shi actually promotes bowel movements. So zhi shi is for a more excess, hot condition, like early stage shaoyang or yangming, while chen pi is better for a cold xu condition, such as shaoyang pivoting into taiyin.

Li dong yuan replaced ban xia, also a warm damp transforming herb, with chen pi, however he might include ban xia for short term use with phlegm or greasy tongue coat. I observed Li wei to do the same thing. In hindsight, I can see that my teacher Li wei often used Li dong yuans modifications right out of the Pi wei Lun. Now because Li dong yuan was focused on weakness of the spleen and stomach, he further modified xiao chai hu tang to emphasize central qi weakness with huang qi and damp turbidity with atracylodes. The addition of dang gui is on one hand a yin component in an otherwise yang formula that dries, supplements, warms and uplifts. However, dang gui also moves stagnant blood, which is critical in longterm health, as was indicated in lesson 2. So while indicated for a distinct symptom complex, one way of looking at bu zhong yi qi tang is as a taiyin pivot formula. While shaoyang is the yang side of the hinge, what happens when the door swings to the yin side?

Well, according to Fruehauf, zhang zhong jing’s flagship for taiyin was li zhong tang.19 In line with his emphasis on yang qi, zhang chose strong warming as his strategy in this phase. He liked gan jiang for chronic spleen disease and fu zi for the kidney. However, what about those strange cases where vacuity is pronounced, thus indicating the use of warm supplementation, but shaoyang is not yet resolved. This is not a situation described precisely by zhang zhong jing and so many liujing practitioners apply bu zhong yi qi tang for this role. Of equal importance to xiao yao san in modern practice, both of these formula can now be seen to be rooted in the shanghanlun. So while xiao yao san could be said to be a refinement of securing the yang barrier at the hinge, so bu zhong yi qi tang could be said to do the same, but from the yin side. In both cases, the normalization of the qi mechanism remains at the heart of the therapy.
The goal of this course will be to lay out a range of choices for addressing abnormalities in the qi mechanism. We have thus far introduced si ni san and her relatives and bu zhong yi qi tang. We will continue to pursue this inquiry by exploring the works and formulae of several other masters and their schools in the remaining lessons. However, this is an good point to stop and talk about fever. Feverishness occurs in all six channels. Tai yang colds, yangming delirium, shaoyang malarial. Jueyin may experience false heat, while shaoyin gets deficient heat. According to liujing theory, all of these patterns can be chronic, so chronic fever with sweating disorders can be attributable to a wide range of patterns. Li dong yuan indicated bu zhong yi qi tang for fever, as well. So chronic fever, often a component of chronic illness can be treated with very diverse formulae.

Yet chronic fever and nightsweats, particularly, are generally pidgeonholed as yin xu conditions. However, they could be shaoyang or spleen qi sinking, too. There are other possibilities, as we shall see, so we shall return frequently to this example. Perhap Li dong yuan’s greatest contribution to TCM was his elucidation of how this pathological heat arises. Li showed that while yin xu was one manifestation of yin fire, it was not the only or the even the most common one. Li’s follower, zhu dan xi, is quite misunderstood in this regard. In the next lesson, we will follow zhu in his use of the qi mechanism. According to Bob Flaws, dampheat or depressed yang disturbing the ministerial fire are two of the primary manifestations of yin fire.20 It is the prolonged presence of heat that typically consumes the kidney yin. So in young people, yin xu is indeed rare, but yin fire is not, so treat accordingly. Formulae like chai hu gui zhi tang, dan zhi xiao yao san and huang qi ren shen tang can thus all be used for yin fire, despite their differing emphases and may be more appropriate for your baby boomer patients.

Fever is a sign that has often been treated incorrectly historically and physicians have often admonished each other about this. Prior to the song dynasty, most fever was treated as an invasion of cold. There was a general overemphasis in the first millenium on hot herbs due to a misunderstanding of zhang zhong jing’s school of yang qi, discussed above. Physicians such as liu wan su with his cooling therapies and zhang zi he with his purging ideas attempted to shift the focus back to dampheat and the ministerial fire. Li dong yuan and zhu dan xi carried on this focus, but added their own twists. Li, as we have just seen, put most focus on the weakness of the central qi as the source of the disturbance. That weakness led to impairment of the qi mechanism and subsequent dampheat, etc. Li actually came full circle by integrating the concept of the qi mechanism, dampheat formation and ministerial fire disturbance back into a framework that emphasized yang qi as the root. He thus embraced both zhang zhong jing’s warming and the cooling methods of his more recent forebearers.

Thus, Li might use a combination of chai hu, anemarhena, huang bai, huang qi, ren shen and wu wei zi to clear heat in some spleen qi xu patients.21 Now this approach is not correct in patients that are robust, excess, etc. It is always necessary to do proper bian zheng diagnosis. However, this again exemplifies how one might expand the use of formulae like bu zhong yi qi tang to treat a wide range of different ailments. For example, here in Portland, when treating AIDS with TCM was still prevalent, we discovered that most of our fever patients did not have yin xu. Most had yin fire, which sometimes included yin xu, but pure yin xu accounted for about less than 10% of 200 patients seen over five years. Formulae for spleen yang xu, liver depression and phlegm stagnation became the norm, so that formulae looked like a cross between bu zhong yi qi tang, xiao yao san and er chen tang. The results were much more satisfactory than the yin supplementing method that had been used up until that point. Now the herbs used to treat spleen qi sinking, the pungent wind medicinals, can severely aggravate yin xu and the rich yin tonics can worsen spleen qi sinking, so this is no small error.

While Li developed a sophisticated approach to dampheat and spleen xu that was taken even further by zhu dan xi, many of those who followed him distorted his ideas, much in the same fashion that zhang zhong jing’s school of yang qi was warped. It is perhaps too easy to say weak digestion is the cause of all disease and treat everyone that way. So an abuse of warm tonification began to occur in some medical circles. The ginseng salesman justified his sale of ginseng to everybody by quoting passages from the pi wei lun to the illiterate masses. By the late 1700’s, neoclassicists like hsu ta-chun were descrying physicians like Li dong yuan because their influence had such detrimental side-effects.22 We must keep in mind this constant tendency to oversimplify the medicine and keep ever vigilant that our selections are always based on the totality of the signs and symptoms. However, unlike the great hsu ta chun, we wil continue to move forward and not throw out the baby with the bathwater. See Unschuld’s Forgotten Traditions of Ancient Chinese Medicine to read hsu’s essays.

LESSON 5

While li dong yuan is remembered for his work on the treatment of spleen and stomach disorders, his follower zhu dan xi is remembered as the founder of the yin tonification school. By the time this lesson is over, we will hopefully remember each for their contribution to the understanding of chronic illness pathology. While these physicians are remembered for their differences, they both shared the opinion that dampheat and disturbance of the ministerial fire were the chief cause of disease. Zhu actually wrote that depression, often translated as stagnation, is the chief cause of disease. In the zhi fa xin yao, zhu says that “the ten thousand diseases are all generated by depression”.23 He goes on to say that “depression always takes place in the middle burner” and that upraising the depressed qi allows turbid food to descend. Sound familiar?

According to zhu, the two most important herbs for upraising the depressed qi were chuan xiong and cang zhu.24 The former is known for treating head diseases and the latter for restoring spleen function in cases of loose stool. Both are spicy, warm herbs that can easily injur the yin. Zhu’s flagship formula for generalized depression is called yue ju wan. To chuan xiong and cang zhu are added xiang fu, shen qu and zhi zi to address qi, food and heat stagnation, respectively. Technically, we could say that chuan xiong addresses blood and cang zhu dampness. Thus, five of the six stagnations are addressed in this formula. The sixth is phlegm, for which nan xing, sheng jiang and gua lou are added, if necessary. This was one of zhu’s most important formulae and it is clearly not a yin tonic.

In modern times, this formula is indicated for a wide range of digestive, pain and emotional complaints, which could include such diagnoses as candida, food allergy, chronic fatigue, etc. More serious ailments related to widespread depression would be mental illness, cancer, heart disease and autoimmunity. So again the main point here is that a complex disease may be rooted in a derangement of the qi mechanism. As an example, according to this model, it would be a mistake to treat a cancer patient longterm with just herbs to tonify qi and move blood. Being a complex multisystemic disorder, cancer treatment requires a sophisticated methodology. The central burner is almost always damaged in cancer patients. Cancer is the extreme example of failure to assimilate vital essences and the accumulation of toxic turbidity. The only way to correct the systemic imbalance must consider how to restore the qi mechanism. This is not to say that yue ju wan is a cancer formula, but that the concepts embodied in this formula may be useful in rectifying the qi mechanism in a particular cancer patient (or other chronic illness).

So far, we have introduced three ways of restoring the qi mechanism. Zhang zhong jing laid the foundation for this approach in his treatment of shaoyang disorders, as related in lesson 3. In lesson 4, we saw that li dong yuan developed his spleen school around a modification of xiao chai hu tang that emphasized vacuity, bu zhong yi qi tang. Both of these formula treat liver depression, spleen qi xu and dampheat, but with differing emphases. The ideas embodied in each may be useful in a given patient. Zhu dan xi seemed to take a different approach, but we have already heard his words on depression above. Here is what he says in his preface to ge zhi yu lun, ” dampheat and ministerial fire are common causes of disease”.25 Both zhu and Li dong yuan devoted much of their written works discussing how to modify formulae for the patient’s presentation. Both of these physicians, notjust Zhu, frequently used herbs to clear heat and nourish fluids, especially in their modfications of formula directed at the qi mechanism.

Here is what Li says about the treatment of heat in the center due to the damage by food and drink, “the only choice is use acrid, warm sweet ingredients to supplement the center and sweet cold ingredients to drain fire”.26 Thus, in huang qi ren shen tang, Li uses huang bai and mai men dong to clear dampheat and nourish yin. One page later, he discusses various additional modifications for heat, including huang lian and sheng di for upper heat, huo ma ren, tao ren and da huang for heat and blood bind in the large intestine and bai shao and huang qin for abdominal pain due to heat.27 Zhu, of course put most of his emphasis on chronic heat and is famous for his statement that “yin is always insufficient”.28 Zhu drew his heat clearing method from the pioneering work of his predecessor, liu wan su, who believed all disease was due to toxic heat. Yet he also used the supplementing formulae of Li dong yuan and it is surprising how often he turns to the cathartic methods of zhang zi he. Zhu’s chapter on phlegm in the zhi fa xin yao has large sections devoted to vomiting, for instance.29 In his chapter on wasting and thirsting, he describes the use of purging to treat an early stage excess condition of the stomach.30,31 Yet he always returned to the role of the qi mechanism in the formation of dampheat.

Zhu’s other favorite formula for the qi mechanism was er chen tang. While yue ju wan focused on uplifiting and outthrusting depression, er chen tang was all about transforming and descending turbidity. Ban xia, chen pi and fu ling are all known to descend turbidity, albeit by different mechanisms. They are indicated for such things as clouded consciousness, dizziness, nausea, phlegm, etc. If such an excess is pronounced, then both Li dong yuan and Zhu dan xi recommended use of such herbs. Both also forbade the use of such herbs if the excess was not present. Zhang zhong jing’s xiao chai hu tang includes ban xia, but its gentler relative, xiao yao san does not. Herbs that descend turbidity can cause two problems. One is that they overstimulate the descending aspect of the qi mechanism at the expense of the ascending aspect. This was Li’s fear. The other is that the warm pungency of herbs like ban xia can aggravate the ministerial fire and damage the yin essences. This was zhu’s fear. Nevertheless, according to Yang Shou Zhong, Zhu used variations of these two formulae to treat the bulk of his patients with depression and phlegm disorders.32 Er chen tang could be modified to treat heat that was contained within yin, such as dampheat. However, if heat was very prominent or yin was already damaged, this formula was prohibited. For yin vacuity, Zhu actually leaned on si wu tang, modified for heat or kidney xu, as necessary. His fourth favorite, according to Yang, was si jun zi tang, thus his four most important formulae all centered around qi and blood disharmony, not kidney vacuity. This should not be surprising given our discussion of zhu’s emphasis on the qi mechanism.

Zhu’s focus on the qi mechanism can also be seen in his frequent discussion of abstemious and bland diet. He blames rich and spicy food on clogging the central burner and disturbing the ministerial fire respectively. These two factors of diet along with taxation from overwork and unrestrained sexual activity were the chief causes of dampheat in zhu’s scheme of things. I agree with this position, as do most modern writers on the subject. He mentions that ideally, meat should be reserved for the elderly. People below fifty should not eat meat. They do not need it to replenish their essences and it thus just clogs their qi mechanism. However, if one eats meat their whole life and then develops a disease after age fifty, this is a disease of accumulation. First, the physician must clear the accumulation. This can best be accomplished by abstemious diet, which both strengthens the spleen and prevents the introduction of further turbidity intothe system. To give meat or tonics to a person in this state of accumulation would be a mistake.33 Of course, the average american has a lifetime of gorging on meat and dairy behind him, so it would seem that zhu’s admonitions on the qi mechanism would be of as much significance to modern clinical practice as his emphasis on yin xu.

LESSON 6

In Fluid Physiology and Pathology in TCM, Steven Clavey discusses a wide range of topics under this rubric. We will focus on his discussion of dampheat. Clavey emphasizes the function of the tripleburner in his understanding of dampheat etiology. He draws on both ancient classics like the nei jing, as well as more modern physicians from the warm disease school, such as ye tian shi and wu ju tong. He presents the best practical discussion of triple burner dampheat available in English. His approach overtly and elegantly addresses the qi mechanism and his formulae are selected from the more modern warm disease school. Thus, Clavey adds insight into the next layer of the historical development of these concepts.

Clavey begins with a discussion of yinyang and the five elements. However, right from the outset he relies on the model that places earth at the center of four points on a circle, with fire above and water below. Heiner Fruehauf also relies on this model in his teaching. The reason for using this model is that it provides a particular understanding of physiology. First, it looks like the body with a top (Heart/Fire/heaven), middle (Spleen/Earth/human) and lower (Kidney/Water/earth). It thus contains a vertical axis running through the three burners, if you will. Wood on the left runs through Earth at the center to form a horizontal axis with Metal on the right. You can imagine this circle with earth at the center and the four other elements forming two axes. It is helpful to draw this diagram or you may be able to view it below. Now overlay the tai ji symbol on this circle (remember the correct tai ji symbol has white, representing the clear, rising on the left and black, representing the turbid, descending on the right).46

This is a symbol that contains much information about the qi mechanism. First, earth is the basis upon which all permutations of yin and yang occur. This cosmological concept is applied to the body by Huang Yuan Wu in Secret Sources of the Four Masters (si sheng xin yuan). Clavey translates, “the central qi is the axis of yinyang ascent and descent, … [through] the movement along this axis, the clear qi spirals upward on the left and transforms into fire (i.e. spirit, consciousness) and murky qi twists downward on the right and transforms into water (for excretion by the bladder)”.47 Master Huang goes on to emphasize the practical importance of this qi mechanism when he says, “if the central qi is vigorous, the stomach can descend and receive, while the spleen rises and promotes ripening of grain to produce essential qi; essential qi nourishes life and there is no disease.”48 So Clavey, just like the other authors we have explored so far, begins his discussion with his take on the central importance of the qi mechanism in the etiology of fluid disorders.

Going on to talk about the triple burner, Clavey states that the “triple burner is … the [actual] route for the ascent and descent of qi movement.” 49 As such , it clearly occupies an important place in our discussion. The triple burner is also responsible for draining the turbidity from qi transformations happening all over the body. This is an interesting point. While we are mainly concerned with regulating the macroscopic qi mechanism of the entire body, it is worth remembering that every cell of the body is constantly assimilating the pure and excreting the turbid. Only when qi flows to every crevice of the organism can these transformations proceed unimpeded. Yet the turbid waste discharged from these microscopic transformations all over the body must be drained by the triple burner. If not, the channels and collaterals will become clogged with dampheat and phlegm, leading to blood stasis.

Clavey goes on to point out that the triple burner must be free and clear in order for the Heart and Kidney to properly communicate. Thus, dampheat in the triple burner can be the cause of a wide range of psychological and sexual problems that may often may be erroneously attributed to yin xu. The treatment for this condition may use fragrant damp transforming and warming phlegm transforming herbs like yuan zhi and shi chang pu to open the middle burner.50 If one thought the heart and kidney not communicating was due to yin xu, then one would not choose fragrant herbs as they dry up yin. However, yin tonics may adversely affect central burner damp stagnation, so careful diagnosis is required. Tongue and pulse are usually key to sorting out this situation. Thick greasy tongue coats demand herbs like shi chang pu, but abhor ones like shu di huang.

As alluded to above, Heiner Fruehauf also discusses the vertical axis of heart, stomach/spleen, kidney in his presentation of dampheat. Relying on shang han lun formula like usual, Fruehauf’s choice is Ban Xia xie Xin Tang (aka Pinellia combination). Fruehauf points out that the literal translation of the formula name refers to draining the heart. So it is Pinellia drain the heart tea. Pinellia, of course, transforms turbid dampness in the middle burner and descends the qi, so it is similar to shi chang pu and yuan zhi, in this respect. However, it is not thought to have a shen calming effect. However, by opening the vertical axis, heart and kidney communication is restored. The effect is indirect, but Fruehauf, a classical scholar, insists the ancients knew this use of ban xia xie xin tang and so named the formula accordingly. It is striking to look in Bensky and see the standard TCM indication for this formula limited to a few acute gastrointestinal diseases. When one goes to Fruehauf’s classnotes, the list includes chronic mental illness and skin diseases, among others.51

Fruehauf’s analysis of the formula should make this no surprise. Like so many of the qi mechanism formulae we have studied so far, this one owes its ancestry to xiao chai hu tang. One may notice that by substituting bupleurum in xiao chai hu tang with coptis, one arrives at ban xia xie xin tang. According to Fruehauf, one might think of xiao chai hu tang as regulating the horizontal axis of the body, because it has herbs that address the liver, spleen and lung. By substituting coptis, we basically cause a pole shift. Coptis addresses heart/stomach fire and lower burner dampheat, as opposed to buplerum, which frees the diaphragm and chest (i.e. liver and lung), as well as uplifting the spleen qi. Not only does pinellia open the heart/kidney connection, but heart fire is cleared by the coptis, directly calming shen. In addition, ginseng, jujube and licorice all have heart nourishing properties. So, with simple modification, this formula can easily be adapted to many chronic dampheat conditions. As we shall see, it also meets Clavey’s criteria for successful dampheat treatment.
Damp easily combines with other pathogens. Internally, long term, the most likely other component would be heat. Damp tends to block the flow of yang qi, so it inhibits the qi mechanism by its very nature. According to Clavey, because of the obstructive effect of dampness upon the qi, dampness must be “changed” or “transformed” before it can be expelled.52 I will reiterate a point that Clavey makes often. The damp pathogen (or any pathogen) cannot substitute for a vital substance of the body. In a private communication to communication to me on this matter, he goes on to say, ” I do not remember reading anywhere in the Chinese literature about pathological substances being transformed back into physiologically useful substances; most of the time where the sequela of ‘transformation’ is discussed it is in regard to expulsion from the body. Probably for this reason, I do not myself think this way in clinic; that is to say I do not try to change pathological substances back into physiological ones.” Damp is a pathological entity which must be removed.53 This is an important distinction. I recently heard it commented that yin deficiency was not a concern for American patients as our rich diet supplied plenty of yin. Now, while I believe pure yin xu is rare, yin vacuity absolutely occurs in a large percentage of chronic patients along with and due to qi xu and damp heat brewing in the lower warmer. So our diet is not protecting us from yin xu. I would actually argue that our rich thick diet impairs the qi mechanism at a young age. The impaired qi mechanism prevents the proper assimilation of food and replenishment of jing, actually leading to yin xu rather than preventing it.

As mentioned in lesson 2, there are a wide range of herbs that may be used to address damp and dampheat pathology. Of central importance are the fragrant damp transforming herbs which by their nature are the opposite of damp. While damp is heavy and fixed, they are light and mobile. Some, like huo xiang, are said to have an ascending qi, yet successfully control nausea. This follows zhu dan xi’s maxim that when the pure is raised, the turbid will descend of its own accord.54 Of equal importance are the diuretics which provide a route out of the body after the transformers do their trick. Dampness often involves urinary inhibition. Damp-cold is treated with bland diuretics and dampheat with bitter cooling ones. However, as mentioned in lesson 4 on yin fire, diuretics should be avoided if the cause of the dampness is a vacuous spleen. Clavey reinforces this point, concurring with Li dong yuan that dampness in such cases should be cleared by ascending the spleen qi.55

Dampheat diseases have a relatively long course, according to Clavey.56 This position stands in sharp contradistinction to statements taken from basic internal medicine books as quoted in lesson 2. Dampheat is relegated to the province of acute illnesses in those books and rarely mentioned in the context of chronic illness. However, chronic forms of painful obstruction and atrophy syndrome, backache, liver or prostate enlargement can all be due to dampheat. According to Clavey, it was the general consensus of the warm disease specialists that dampheat often formed toxin.57 This is very relevant to our discussion, because toxin is considered an important factor in the etiology of several important disease groups, including cancer and autoimmunity. Thus, the identification of dampheat becomes more of a concern than how to treat the occasional UTI.

According to Clavey, a dampheat patient may feel feverish, but feel cool to the touch. They will often also complain of feeling cold but with considerable discomfort in sticky hot weather, as well. Fever may occur without rapid pulse or red face or restlessness. The patient can be either constipated or have diarrhea. Thirst without desire to drink and intermittent sweating are typical.58 This conflicting set of signs and symptoms appears because the damp obstructs the yang qi. So even if heat causes fever, the circulation of that heat is impaired. Thus, the patient may feel subjectively hot, but objectively cold. However, this is not a false cold pattern, which would require an aconite formula. In that case, the patient feels feverish, but has pronounced yang xu signs. False cold is an unlikely clinical situation unless you are dealing with trauma or hospice care.

The dampheat patient can have a wide range of pulses, but will usually have that sticky tongue coat, which my teacher Li Wei usually interpreted as dampheat in the middle burner, even in the absence of acute heat signs. Clavey refers to xue sheng bai from his Systematic Differentiation of Damp-heat (shi re tiao pian), “most dampheat illnesses belong to yangming and taiyin”.59 I find it very common for dampheat patients to not feel they have digestive symptoms, but on closer questioning, it is often revealed that they have significant GI distress that they dismiss as normal or “no worse than anyone else”.

Dampheat symptoms may also include low grade or afternoon fever, not to be confused with yin xu. Other typical symptoms are chest obstruction, lack of appetite, heaviness of head and body, inhibited urination, loose, but difficult passage of stool, nausea, vomiting, abdominal distension.

In order to treat dampheat correctly, first determine which treatment principle is primary, cooling or drying. However, only by simultaneously clearing damp and cooling heat will one be successful. In previous lessons, we have addressed dampness that has accumulated due to spleen xu or qi depression. We will now briefly examine the treatment of dampheat directed at triple burner function.

Formulae for triple burner dampheat could be likened to those treating the shaoyang stage of a pathogen as described in lesson 3. The triple burner is part of the shaoyang network and triple burner pathology does represent a level of illness that is chronic, has impaired the qi mechanism and, if left untreated, will progress into more serious pathology involving vacuity, blood stasis and toxin. So there is an analogy between these methods. They are both for relatively strong patients still mainly in the yang phase of their chronic illness. According to Fundamentals of Chinese Medicine, triple burner dampheat is a type of qi level pathology in the warm disease theory (wei, qi, ying, xue). The pathogen is said to have not yet fully penetrated the interior, conceptually similar to shaoyang. However, the patterns and methodology for treating triple burner dampheat are decidedly different from that for shaoyang disorders and they should not be confused.

According to Clavey, the first step in removing triple burner dampheat is to diffuse the lung qi. The lungs control the waterways, but this is an overlooked step in most dampheat treatment. Xing ren and huo xiang are most commonly used for this purpose. As mentioned in lesson 1, the lung and bladder are related because both are associated with taiyang. Thus, the lungs proper descent helps maintain the downward flow of bladder qi. The second step is to transform the middle burner with fragrant herbs. Finally, diuresis to remove the transformed pathogen. A representative formula is san ren tang, which addresses all three of these principles. Very strong dampheat driers like coptis and scute may be indicated if heat is really prominent. Another example is wu ju tong’s cao guo yin chen tang.60 If you have a chronic patient whose pattern is one of triple burner dampheat, then elements of this approach may prove very useful. Inhibited urination is a key symptom here with which to distinguish this pattern from other shaoyang/yangming level diseases.

LESSON 7

Heiner Fruehauf has written and lectured at length for the past few years about his take on Gu syndrome. Gu syndrome is the result of some sort of evil infestation. This may include worms, protozoa, bacteria and viruses from the modern perspective. In ancient times. gu syndrome was associated with demonic possession, because of the bizarre mental symptoms patients often exhibit. Because of this textual emphasis on demons, the modern communists were pretty quick to jettison this pattern when they standardized TCM. However, the frequent mention of GU in classical texts and the claims of cure for stubborn chronic ailments caught the eye of Fruehauf. Fruehauf practices in Portland, Oregon and has seen a lot of knotty cases over the years. We mentioned Dr. Fruehauf earlier in the lesson on the six stage theory. Fruehauf was trained inthe classical method of zhang zhong jing and relies heavily on these ancient formulae in his practice. Fruehauf also likes Li dong yuan’s dynamic method of regulating the stomach and spleen, so he has always focused on the qi mechanism in his teaching and practice. However, certain patients with chronic digestive and mental complaints were not getting well using standard methods.

Noting that many of these patients had presently or previously tested positive for various parasites led Dr. Fruehauf on a peculiar journey through the archive of Chinese medicine. In the process, he unearthed another piece of the puzzle of how to treat chronic illness through regulation of the qi mechanism.
It is important to begin with the understanding that gu syndrome is not an acute parasite invasion. It often begins that way, but according to Fruehauf, gu is the “state of extreme stagnation and mental and physical decay … [caused] by parasites that combine their toxic potential to gradually putrefy the patient’s body and mind.”34 Other characteristics of Gu reinforce its association with mysterious chronic illnesses. Gu causes noticeable problems long after an initial infection was apparently resolved. Patients often experience diverse unusual groups of symptoms. Digestive symptoms can be severe and painful, with aberration of appetites and cravings. Symptoms of hot, cold, photophobia and fibromyalgia/arthralgia are common. Depression, anger, anxiety, insomnia are a few of many mental aberrations. Patients may feel possesed or even have seizures. So food allergy, candida, multiple chemical sensitivity, fibromyalgia and other common diagnoses may all be related to gu syndrome in some cases. According to Fruehauf, Gu only occurs in a weakened individual, so the therapeutic approach relies on strategies that supplement deficiency as well as expel gu toxins. Longterm gu patients cannot handle the very hot or very cold herbs often used to treat parasites. They are thus prescribed rather unusual formulae that kill parasites directly in some cases, but focus more on calming the mind, as well as supplementing and moving both the qi and the blood. The herbs selected in these various categories are specific for their anti-gu nature. Not just any herbs will do. The key to anti-gu therapy is the use of large dosages of surface relieving herbs. According to Fruehauf, large dosages of surface relieving herbs like bo he and zi su ye have a penetrating effect on the system. They illuminate the dark places where gu toxins lodge and allow the other herbs in the formula to reach to every crevice of the body.35

Bob Flaws has noticed that the formulae suggested for gu syndrome bear a striking resemblance to Li dong yuan’s methodology for yin fire discussed above.36 Remember, Li was famous for his explicit use of surface relieving herbs to ascend the spleen qi. While zhang zhong jing was the first to actually do this, Li was the first to write about this methodology at length. So both approaches use surface relieving herbs, tonics and heat clearing agents simultaneously to treat a problem rooted in the digestive system. However, there are distinct differences, as well. According to Fruehauf, Gu specialists used much larger doses of surface relievers than spleen/stomach specialists because their intent was penetration of the darkest recesses where gu may have lodged, rather than merely uplifting the qi. Fruehauf has also stated that certain tonics are also prohibited in Gu, particularly ginseng, one of Li’s favorites. Ginseng is said to worsen gu and is often used as a diagnostic indicator thereof (i.e. if a very depleted patient becomes violently ill upon taking ginseng, you should consider gu syndrome).37

In any event, there are distinct relationships between certain aspects of gu treatment and regulation of the qi mechanism. First, the very nature of gu is to disrupt the qi mechanism. The traditional description of gu is that of oil mixing with flour.39 Basically, the toxin has seeped into and bound up with the tissues of the body. This can only happen when the body becomes incapable of separating pure and turbid. In the weakened patient, food-borne parasites that are not fully expelled remain in the central and lower burners brewing and putrefying. Thus, the pure is now unable to ascend , the most profound sign of this being the mental aberrations. The turbid fails to be descended and excreted properly. The accumulation of turbidity and toxicity further aggravate the GI and mental symptoms. Meanwhile, the body is unable to replenish its postnatal jing from food and the kidneys are thus drained of their essences.

We often see our old friend dampheat associated with gu, especially if no strong cooling treatments have yet been applied. It is common to treat chronic parasites with strong cooling antimicrobials like berberine, flagyl, nystatin, capryllic acid, etc.40 While these substances may have some role in gu therapy, according to Fruehauf, they do not address the deep penetration of the toxin outside the GI tract nor do they restore the qi mechanism in any way. Treating dampheat makes sense at this stage, but standard dampheat treatments will not work on gu patients. So while herbs like lonicera, forsythia, sophora and artemisia qing hao are used to clear dampheat toxin, they must be combined with the penetrating herbs like zi su ye. So like most of our other approaches, dampheat and the qi mechanism are at the core of this pathology and the therapeutic approach described in ancient texts implicitly recognizes this in formula design.

Fruehauf discusses two basic gu patterns. The first is more of the dampheat pattern we have been discussing so far. The recommended formula is called su he tang and was originally recorded in Zhi Gu Xin Fang (New Methods for Gu Treatment, Lu Shunde, Qing Dynasty). Since this formula also includes cooling moistening herbs and mild yin tonics like sheng di, xuan shen, huang jing and bai he, it is as much of an homage to zhu dan xi as li dong yuan, perhaps. Remember, it was zhu who focused on the enduring damage to yin fluids that was caused by dampheat, which itself arose due to qi mechanism disruption. There seems to be something counterintuitive about choosing such herbs in a bloated digestive condition, yet Fruehauf puts great emphasis on herbs like sheng di, xuan shen, huang jing and bai he in this condition, as well as qi lifting tonics like huang qi.

Bob Flaws has pointed out that zhu dan xi actually wrote about gu in his seminal Ge Zhi Yu Lun.41 The chapter in question is titled “Drum Distension” (chinese: gu zhang). While the gu that means drum is a different character than the gu that means “worm”, the worm-gu is often substituted for the drum-gu in the term gu zhang. This is because drum distension is often related to gu poison. Drum distension is a severe form of abdominal pain. According to Wiseman in his Practical Dictionary of TCM, drum distension is almost always related to liver spleen disharmony. It is often caused by alcoholism, as well as gu poison. According to both Flaws and Fruehauf,42 Zhu appears to state that drum distension is essentially synonymous with gu-worm distension.

However, Zhu’s indicated formulae focus on supplementing deficiency, rather than attacking gu poison directly. While there is definitely similarity between Zhu’s herb selection and that of Fruehauf, the absence of penetrating wind medicinals and anti gu toxin clearing herbs is notable. Like Fruehauf, Zhu makes the point that gu is a severe deficiency condition and treats accordingly. Yet the absence of herbs that directly attack worms leads me to believe that Zhu was using the term gu-worm in a more general sense of poison penetrating the system, yet not involving parasites. Zhu also uses Ginseng, which Fruehauf has declared a prohibited herb in gu syndrome, a point Flaws disputes.43 Nevertheless, Zhu’s explanation of the gu pathomechanism and formula selection is instructive for us. He puts considerable emphasis on the qi mechanism and dampheat, as we would now expect. In his own words,

“The seven affects damage the internal, the six environmental excesses invade from outside, food and drink are had without restraint, and chamber taxation causes vacuity. [Any of these causes may] damage spleen earth yin [and consequently,] the office of transportation and conveyance may fail to carry out its duty. Although the stomach [still] receives grains, [the spleen] cannot transport or transform them. As a result, yang keeps on upbearing itself and yin keeps on downbearing itself, resulting in the disadvantageous divorce between heaven and earth. When this happens, clearness and turbidity are confused together and the tunnels are congested and held up. Qi transforms into the turbid, and blood becomes stagnated with depressive heat [being generated]. When heat remains for long, qi transforms into dampness. Dampness and heat mutually engender, thus giving rise to distention and fullness. This is what the classic calls drum distention because, though hard and full, the abdomen is empty with nothing inside, [thus] resembling a drum. The disease is persistent, firmly fixed, and difficult to cure. It is also called gu. Because it is as if [one were] invaded and being eaten by worms, therefore, [this kind of distention] is called gu.”44

Fruehauf also presents a cold gu syndrome and his chosen formula, jia jian su he tang, is very similar to variations of li dong yuan’s famous bu zhong yi qi tang (minus the ginseng, of course). Unlike zhu’s variation, Fruehauf’s does not use cooling herbs, but actually warming and qi moving herbs at this stage, so he is obviously describing a more classic cold condition in this case, rather than a yin fire syndrome.45 In clinic, one may actually prescribe something more between the hot and cold type gu formula. The net result would probably look a lot like the formulae recommended by both Zhu dan xi and li dong yuan for this type of condition (i.e. chronic illness rooted in vacuity with concomitant heat and stasis). What this reinforces is that there are multiple causes of qi mechanism disharmony and treatment varies accordingly. In some cases, similar strategies may be used for diverse etiology, so it is always vital to evaluate the case carefully. Gu syndrome is a difficult diagnosis to make properly. In ancient times, it was largely a diagnosis of exclusion, determined by failure of other therapies. In modern times, the presence of parasites in a stool culture are highly indicative of gu, however the absence of these pathogens does not rule out gu. In some cases, the pathogen is gone and only the poison remains.

It is not surprising that gu syndrome is treated with methods that seem to borrow from the methods of Li Dong Yuan and Zhu Dan xi. After all, the gu specialists culminated their theories in the late qing dynasty. They were no doubt familiar with the works of these great masters, who lived many centuries before and were both well known in qing times. In addition to treating enduring yin damage with cooling herbs, gu formulae also address dampheat without overuse of harsh bitter cooling herbs. So, as well as using herbs like lian qiao and jin yin hua instead of ones like huang lian and huang bai, the inclusion of chai hu and sheng ma as additional standard ingredients surely also represent the influence of Li Dong Yuan. The formulae are notable for their inclusion of qi movers, but the absence of herbs that either purge the bowels or disinhibit urination. Thus, a sophisticated variation on the treatment of yin fire emerges, as Flaws has suggested.

The gu specialists of the qing were also familiar with warm disease theory and the concept of gu has much in common with the concept of fu xie or hidden pathogens. Fu xie are pathogens that enter the bloodstream directly, via the digestive tract and perhaps venereally. They may remain latent for long periods, slowly brewing dappnesss into heat, phlegm and blood stasis. AIDS has been suggested to have element of fu xie and hepatitis C is perhaps the best recent example of a long simmering pathogen that has been causing damage for decades until a crisis ensues (like ascites). Fu xie are said to hide in the blood or ying phase of the four levels of warm disease. They may involve both dampheat, especially in the early stages, but later, yin vacuity, from longterm heat brewing. Treatment of blood and ying phase pathogens is marked by the use of herbs that moisten yin, the same herbs that are used in gu syndrome. Both gu syndrome and fu xie represent yin type diseases. The pathogen is lodged deeply and the zheng qi is weakened. The qi mechanism is severely disrupted. In such cases, it is necessary to use a complex prescription. In light of this, it can be argued that gu therapy provides one approach to treating chronic fu xie.

LESSON 8

In modern times, considerable clinical research has been done around the concept of blood stagnation. One of modern China’s great TCM masters, Yan de xin, has also contributed an important text on this subject called Blood Stasis and Aging: A new TCM approach to Geriatrics. Subhuti Dharmananda, Ph.D. frequently mentions this subject in his writings and has devoted several papers to the topic available through ITM (see resource list). This topic is amongst the most frequently mentioned in the Abstracts of Chinese Medicine, as well. According to Yan de xin, blood stasis is always present in all cases of geriatric illness, moreso than any other cause of chronic illness.61 It is implicated in heart disease, cancer and autoimmune disorders, as well as the complications of diabetes, liver disease, arthritis, chronic renal failure and fever of unknown origin. While blood stasis as an herbal therapy goes back to the Jin gui Yao Lue, it was made prominent by Wang qing ren during the late 18th century. The influence of the west prompted wang to get permission to do autopsies on criminals. He wrote a book that was supposed to correct ancient errors of anatomy in the classics. As Heiner Fruehauf relates the tale, Wang was a rather poor dissector. His technique caused blood to pool in the upper chest. Since his cadavers were all stroke victims, he reasoned that stasis of blood in the upper chest, which he termed the mansion of blood, caused stroke. Of course he was wrong in anatomical terms, but he devised a combination of si ni san and tao hong si wu tang that has turned out to be one of the most important formulae in Chinese medical history, xue fu zhu yu tang.62

According to Yan, spurred by the idea that blood stasis is often at the root of chronic illness that is difficult to treat with conventional methods, modern Chinese researchers began to explore several avenues. They reached a consensus on what constituted blood stasis from a TCM perspective. They identified patients with blood stasis and determined the common biochemical and physiological abnormalities from a modern perspective. They found that many chronically ill patients had signs of blood stasis. In many cases, the only TCM sign might be a purple tongue or distended purple veins under the tongue or maybe a choppy, wiry or irregular pulse.

However, modern analysis always reveals the culprit in the form of increased platelet aggregation and decreased microcapillary circulation.63 These two factors make the blood sticky and prevent all tissues from being properly nourished and detoxified. Sticky blood is prone to tumor formation, atherosclerosis and autoimmune complexing. It is also implicated in depression and other mental illnesses.

Yan de xin has written at length on this subject and he returns always to his central premise. Which is that qi and blood disharmony are the root of aging and chronic illness, while vacuity is the branch.64 While Yan uses yin and yang tonics in his formulae, he is always on the lookout for blood stasis. In his fifty years of practice, he has become convinced that blood stasis is almost always present in chronic illness of long duration, a point underscored repeatedly in his treatment selection throughout his text. While yan has used the tools of TCM and modern science to document his claims, he explicitly refers to the qi mechanism in his work, noting that it is the only by the proper ascent of the pure and the descent of the turbid that the qi and blood can flow smoothly and the essences be replenished. Like many physicians before him, Yan feels that tonics are often misused to the detriment of the patient.65 If the qi mechanism is impaired, then tonics will not reach their destination, so what’s the use?

Yan emphasized the use of blood movers and qi regulators to accomplish his goal of restoring the qi mechanism. While the earth school emphasized spleen and stomach vacuity, Yan addresses the qi mechanism via the heart and liver mainly. This is not surprising, since these two are the organs most involved with blood flow. Yan does acknowledge that qi xu can lead to blood stasis and one of his flagship formulae takes this into account. However, it is certainly the common herbs salvia, persica, carthamus, cnidium and dang gui, which are chosen most frequently to invigorate and harmonize the blood.

Wang Qing ren, as we mentioned above devised a formula called xue fu zhu yu tang. Yan’s modern formulae all owe their debt to wang. It was wang who institutionalized the combination of blood movers and qi regulators that seems only so natural now. Wang indicated xue fu zhu yu tang for a variety of painful conditions, chronic depression and wind stroke prevention. He has turned out to be right on the money in all these cases. According to Fruehauf, one of his chief contributions was was that he significantly downplayed fears about the side effects of using vigorous blood moving formulae. His approach has opened up new avenues to treat knotty diseases. His observation of blood clots in the brains of stroke victims led him to develop the still standard treatment for post stroke paralysis, bu yang huan wu tang. We remember Wang because whether he intended this or not, his formulae make sophisticated use of the concept of the qi mechanism.66

Wang qing ren’s use of zhi ke, niu xi, chai hu and jie geng to regulate the up down dynamics of qi flow in the chest is almost ironic. Since wang was a disparager of the ancient classics, even writing a book called Correcting the Mistakes of Former Medical Books, it is perhaps coincidence that he chose si ni san as his base formula. This granddaddy of all qi mechanism formulae was discussed in a previous lesson. According to Fruehauf, Wang chose it because it was cheap and because it freed the chest and directed other herbs to that location. He did not believe in traditional concepts like the qi mechanism, so that was not the basis of his prescription.67 However, he ended up with a blood mover that had elegant effects on the qi mechanism. It was left to a later generation to clearly describe the dynamics of this formula in the context of TCM history.

Wang’s work really came to prominence in the modern age. With the high incidence of cardiovascular and autoimmune disease which was unprecedented in history, it became necessary for TCM once again to search through its voluminous archives to come up with therapies for these modern scourges. Many avenues were pursued, but the blood stasis approach, owing much to the pioneering of wang qing ren, soon emerged as the major strategy. Because of the success of this method, yan de xin was inspired to explain Wang’s methods using the TCM and classics that wang himself abhorred. Of course, zhi ke descends the qi and buplerum raises it, just as in si ni san. In xue fu zhu yu tang, the ascent is potentiated with jie geng, because it focuses on the chest. Descent is potentiated with niu xi, a powerful herb that draws blood away from the head. Together, this elegant combination rectifies the qi mechanism at its root. To this base is added tao hong si wu tang, a formula that directly harmonizes and moves the blood. Nothing can substitute for Yan’s own words on the qi mechanism, thought by many to be the most eloquent modern exposition on this subject. Yan says:

“The transportation and stirring of the qi is known as the qi mechanism. The activities which occur within a person’s tissues and viscera and bowels and those which take place between these tissues all occur due to a unity of opposites where the activities of upbearing, downbearing, entering and exiting jointly bring to completion the metabolic processes of the entire organism. These activities ceaselessly take in food from the outside, and, through the functioning of qi transformation, upbear the clear essence, downbear the turbid and absorb the finest essence to nourish the whole body. At the same time, these activities discard metabolic waste products outside the body so as to maintain the dynamic balance between the metabolism of matter and its conversion into energy. ” 68

Yan obviously writes as someone dedicated to TCM classics but who happens to live in the modern world of concepts like matter/energy conversion. He is a good example of the integration of east and west that respects the place of both and does not try and reduce one to the other. Yan goes on to say, “This clearly points out that the dynamic balance of upbearing and downbearing, transportation and movement of the qi mechanism is the key to maintaining normal physiological function”.69 Thus, conversely, an impaired qi mechanism is the root of chronic abnormal physiological functioning.

The stirring force of the qi mechanism is the propelling force for blood circulation, according to Yan. If this mechanism is hindered, the blood will not be moved freely and stagnation will occur. This free movement must be balanced by the force that secures the blood within the vessels (which is also called qi). Old, static blood will interfere with the formation of healthy, new blood and pathological products like phlegm will be formed instead.70 Then heat, cold, vacuity and repletion occur as a matter of course. But wait, yan seems to turn modern TCM on its head. Doesn’t hot, cold, xu and shi lead to phlegm and blood stagnation, not vice-versa? Well, yan, being a classicist at heart, actually does come at things from a different perspective than most modern followers of the yin supplementing school. He reasons that unless the qi mechanism is disturbed, there is no way for evil to enter the body and the organs will be continually replenished by the assimilation of good foodstuffs.
However, this is a very yellow emperor type concept, if you follow me. The Nei Jing emphasizes the flow of qi as central to good health and that all disease stems from this root. As mentioned earlier, Heiner Fruehauf has pointed out that the Nei Jing and Shang Han Lun both embraced a very dynamic view of health and disease. As the centuries passed, this dynamic view was gradually encroached upon by a more materialistic bent. Thus, the regulation of the qi mechanism was the chief therapeutic method used by scholarly physicians in ancient China. However, the use of nourishing tonics became very widespread after the days of Li dong yuan and zhu dan xi. This was not the intent of these two qi mechanism masters, but it was a common theme in illiterate ancient China. Thus, the use of tonics became quite abused due to a misunderstanding of the great masters words.

From Fruehauf’s persepctive, modern TCM is heavily influenced by this more materialistic, less dynamic, tonic oriented approach.71 Yet yan is not standing TCM on its head as much as he is restoring its roots. In a long line of reformers, including Li and Zhu, yan takes the familiar role of advocating for a dynamic approach to understanding the genesis of chronic illness. As such, he winds up focused on the qi mechanism. With si ni san as the base formula with which sophisticated blood moving is accomplished, wang qing ren brought us full circle to zhang zhong jing and the origins of the qi mechanism as a therapeutic concept. Thus, yan de xin is actually quite in line with the other physicians we have discussed so far. For example, while dampheat is not his main frame of reference, yan implicitly recognizes this pathogen to be a result of abnormal regulation of the qi mechanism. Amongst the most prominent formulae he introduces in his text is a variation of xue fu zhu yu tang that adds huang qin to clear dampheat (heng fa er hao). Yan indicates this formula for a wide range of serious chronic conditions, including stroke, hypertension, chronic prostatitis, chronic bronchitis, cervical degeneration and senility.72

Afterword

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 Z’ev Rosenberg 75, 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 “toxins”.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 (AKA 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, “reducing oxidative stress [in the gut] can help break the vicious cycle that makes other conditions worse.”

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 doesn’t 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? Well, here we are on the brink of the twenty-first century and we have followed the development of the concept of the qi mechanism through various permutations, including a modern perspective on this apparently timeless topic. Remember, we began with Zhang zhong jing and the six stage theory at the end of the han dynasty. However if we go even deeper, according to Heiner Fruehauf, the roots of chines medicine are actually to be found buried in the dao. While Confucianism has strongly influenced the development of TCM, especially in the past 800 years, the concept of the qi mechanism brings us full circle to an even more remote period in chines history. Zhang created a style of herbalism that was dynamic and yang qi oriented largely because his influences dictated this. As Fruehauf has pointed out, Chinese medicine has become less dynamic over the centuries, yet it was originally codified in the Nei Jing. In the Nei Jing Su Wen, chapter one, it is said that in ancient times, people lived in harmony with nature and used their minds to move their qi and maintain their health. These sages had no need for acupuncture and herbs. Nothing could be more dynamic than this. Pure qi gong.

What is the connection between our discussion of the qi mechanism and a cryptic passage from a 2,700 year old dialogue between the yellow emperor and his teacher? The qi gong or Taoist yoga that Qi Bo describes to Huang Di has continued to be practiced in countless forms right up until modern times. Some of you probably study or have studied tai ji or qi gong at some time. Or perhaps some other styles of yoga or breathing exercises, as well. A recurrent theme in many yogic techniques involves consciously ascending and descending the qi, usually via a combination of visualization and specialized breathing techniques. One is Mantak Chia’s highly popularized microcosmic orbit meditation which uses breathing to visualize the rising of qi along the governing vessel up over the head and down the conception vessel. This is considered the first stage in distributing qi to the entire body, just as the qi mechanism likewise must first function unimpaired in order for qi from food to circulate freely. Air qi and grain qi.

Another method that is mentioned frequently in various sources is the heart/kidney meditation. This method visualizes heart fire descending to warm kidney yang and and kidney water ascending to nourish heart spirit. This method is not food or herb based, so rather than emphasizing the spleen and stomach, the focus is on the heart and kidneys. This is because the jing, which is the source of all transformation, physical, mental and spiritual resides in the kidneys. And the shen, which is the rarefied essence which emerges from the transformation of jing, rests in the heart. But the Taoist alchemist uses a triad of shen, Qi and jing. If one overlays the jing-qi-shen triad over the tai ji diagram from lesson 6, jing goes with water and shen goes with fire, yet implicit in the transformation of jing to shen is the role of qi. Qi is associated with earth at the center of all the permutations. While jing is the source of transformation, providing the “stuff” that is transformed, it is the qi that does the actual transforming.

So just as the central qi transforms and transports digestate, it is the mental activity associated with the spleen that transforms essence into spirit. While the negative quality of the spleen is worry or pensiveness, the positive flipside is reflection and concentration. In order to use mental methods like qi gong in order, one must be able to concentrate. This is the basis of qi gong. One learns to identify, gather and manipulate their own qi. Thus, the role of the center is inherent in the spiritual process as much as in digestion. It is worth considering how overloaded we all are with sensory impressions, which perhaps keeps us from fully digesting our mental and emotional diets, causing an impairment in our ability to transform spiritually. The qi mechanism is of the bodymind and spiritual indigestion is perhaps the most significant factor in its impairment. So one cannot overlook the importance of this factor in understanding the cause and proper treatment of chronic illness. Robert Svoboda, a well known ayurvedic physician, once commented that the only styles of medicine that would last forever are those which are rooted in something eternal like the Tao, rather than something fleeting, like science. He suggested TCM is one such example of this and so it seems it is and will be, as long as we continually return to the source for replenishment. I suspect that the study of the qi mechanism in all its permutations is one such path to this eternal source.

Endnotes

1. Li Dong-Yuan’s theory of Yin Fire & Difficult to Treat, Knotty Diseases/Flaws, Bob 2. Chen and Chen, pg.36
3. Wiseman, Ellis, pg. 298
4. Bensky – see Ban Xia xie Xin Tang

5. Bensky – see san ren tang
6. Bensky – see huo xiang zheng qi san
7. Chen and Chen, pg.180
8. Bensky – see hao qin qing dan tang
9. Li Dong-Yuan’s theory of Yin Fire & Difficult to Treat, Knotty Diseases/Flaws, Bob, 10. Ibid
11. Bob Flaws, Personal Correspondence, 9/24/99
12. Fruehauf, Heiner, classnotes
13. Unschuld 1986, pp. 25-27
14. Zeng
15. Allergies, Autoimmune diseases and Yin fire/Flaws, Bob
16. Intestinal dysbiosis, Leaky gut syndrome, Candidiasis and Yin Fire/Flaws, Bob,
17. Li Dong-Yuan’s theory of Yin Fire & Difficult to Treat, Knotty Diseases/Flaws, Bob 18. Ibid

19. Fruehauf, Heiner, classnotes
20. Li Dong-Yuan’s theory of Yin Fire & Difficult to Treat, Knotty Diseases/Flaws, Bob,
21. Li Dong Yuan, pg. 101-102
22. Unschuld 1990, pg. 357
23. Yang Shou Zhong, The Heart and Essence of Dan Xi’s Methods of Treatment: A translation of the Dan Xi Zhi Fa Xin Yao, pg 31
24. Ibid, pg 31
25. Yang Shou Zhong, Extra Treatises Based on Investigation and Inquiry: A Translation of Zhu Dan Xi’s Ge Zhi Yu Lun, pg xi
26. Li Dong Yuan, pg. 85
27. Li Dong Yuan, pg. 86-87
28. Yang Shou Zhong, Extra Treatises Based on Investigation and Inquiry: A Translation of Zhu Dan Xi’s Ge Zhi Yu Lun, pg. xii
29. Yang Shou Zhong, The Heart and Essence of Dan Xi’s Methods of Treatment: A translation of the Dan Xi Zhi Fa Xin Yao, pg. 75
30. Yang Shou Zhong, The Heart and Essence of Dan Xi’s Methods of Treatment: A translation of the Dan Xi Zhi Fa Xin Yao, pg 135
31. Luger, Todd, “Explorations in the Treatment of Diabetes Mellitus with Chinese Medicinal Substances”, International Journal Of Oriental Medicine, March 1995
32. Yang Shou Zhong, The Heart and Essence of Dan Xi’s Methods of Treatment: A translation of the Dan Xi Zhi Fa Xin Yao, pg xiv
33. Yang Shou Zhong, Extra Treatises Based on Investigation and Inquiry: A Translation of Zhu Dan Xi’s Ge Zhi Yu Lun, pg. 16
34. Fruehauf, Heiner, “Gu Syndrome: A Forgotten Clinical Approach to Chronic Parasitism”, Journal of Chinese Medicine #57, pg. 11
35. Ibid, pp. 13-14
36. Flaws, Bob, Gu Parasites & Yin Fire Theory
37. Fruehauf, Heiner, “Gu Syndrome: A Forgotten Clinical Approach to Chronic Parasitism”, Journal of Chinese Medicine #57, pg. 13
38. Bob Flaws, Personal Correspondence, 9/24/99
39. Fruehauf, Heiner, “Gu Syndrome: A Forgotten Clinical Approach to Chronic Parasitism”, Journal of Chinese Medicine #57, pg. 13
40. Ibid, pg. 15
41. Flaws, Bob, Zhu dan-xi on Gu Conditions
42. Fruehauf, personal correspondence, 10/21/99
43. Bob Flaws, Personal Correspondence, 9/24/99
44. Flaws, Bob, Zhu dan-xi on Gu Conditions
45. Fruehauf, Heiner, “Gu Syndrome: A Forgotten Clinical Approach to Chronic Parasitism”, Journal of Chinese Medicine #57, pg. 16
46. Clavey, pg. 4
47. Ibid, pg. 5
48. Ibid, pg. 4
49. Ibid, pg. 7
50. Ibid, pg. 8
51. Fruehauf, classnotes
52. Clavey, pg. 226
53. Ibid, pg. 241, note 4

54. Yang Shou Zhong, The Heart and Essence of Dan Xi’s Methods of Treatment: A translation of the Dan Xi Zhi Fa Xin Yao, pg. 31
55. Clavey, pg. 268, note 12
56. Ibid, pg. 244
57. Ibid, pg. 249
58. Ibid, pp 252-53
59. Ibid, pg. 249
60. Ibid, pg. 258-62
61. Yan, pg. 47
62. “Treatment of Stroke and Post Stroke Syndrome”, Fruehauf, Heiner, Journal Of Chinese Medicine #44, 1/94, pp. 30-32
63. Yan, pp. 56-58
64. Yan, pg. 34
65. Yan, pg. 72-73
66. “Treatment of Stroke and Post Stroke Syndrome”, Fruehauf, Heiner, Journal Of Chinese Medicine #44, 1/94, pg. 31
67. Ibid, pg. 31
68. Yan, pg. 30
69. Ibid, pg. 31
70. Ibid, pg. 31
71. Fruehauf, classnotes
72. Yan, pp. 96-99
73. Flaws, Bob,Intestinal dysbiosis, Leaky gut syndrome, Candidiasis and Yin Fire
74. Fruehauf, Heiner, The Five Organ Networks of Chinese Medicine/ Portland, OR: Institute for Traditional Medicine 1998, pg. 82
75. Rosenberg, Z’ev, A Chinese Look at Western Pharmaceuticals/Acupuncture.com
76. Appleton
77. Ibid
78. Ibid

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