The presenter of TCM Seminar, Robin Marchment, says in her introductory article: "Chinese medical theory is very simple. It is only in its application that we find difficulty. The essence of effective treatment is a sophisticated approach to fundamental theory and the refinement of diagnostic skill. This means insight into the patient's condition, the understanding of the various interconnections which illuminate the pathogenesis, thus clarifying our treatment principles. Chinese Medicine is simple in its basic tenets, but highly sophisticated in its application."

In this newsletter I have attempted to find answers to two basic challenges in the application of Chinese Medicine. One common challenge is how to get a good feel of the basic makeup of a patient, in spite of the maze of conflicting signs and symptoms that seem to obscure the patient's basic nature: What is the patient's element, what are the strengths that drive his health and what individual weaknesses tend to cause disease? As an answer, the TCM Principles article forms part one of a series on the Five Element Theory in everyday life and clinical practice. Although aimed at relative beginners, advanced Practitioners may find the sections "The Search for Our Personal Element" and "The Element Wood and Personality Traits" helpful as well.

The other challenge is multiple patterns. Hardly any textbooks mention the existence of multiple patterns, yet most patients come to the TCM Practitioner long after the first stages of disease when the disorder has become chronic and no other treatment works, and the beginning pattern has affected other zang fu systems. This creates by-products that give rise to stasis and heat and affect the normal functioning of the internal organs, causing deficiency. Bu Zhong Yi Oi Tang [Ginseng & Astragalus Combination] and the concept of yin fire provide answers and show how to tackle the complexity of what is the real life patient.

The formula Bu Zhong Yi Qi Tang and the concept of yin fire originate from the "Treatise on the Spleen & Stomach" (Pi Wei Lun) by Li Dong Yuan (1180-1251), one of the four great masters of the Jin/Yuan Dynasties. At the beginning of the Jin/Yuan Dynasty, the practice of Chinese Medicine had become somewhat stifled by the classics and was not in tune with the clinical reality of the time. Doctors seemed to place more confidence in strict application of scarcely modified jing fang (classical prescriptions) than the extremely fluid and versatile way of diagnostics and treatment principle that makes Chinese Medicine great. The practice of Chinese Medicine was leaving clinical reality for dogma. Li Dong Yuan and the other masters re-injected dynamic thought back into the clinical practice of his time.

The struggle for dynamic thought is as relevant and needed today as it was 800 years ago. If the challenge then was dogmatic interpretation of the classics, the struggle now is giving up on the classics altogether because interpretation seems difficult. However, the effort is well worth it. As Todd Luger says in his article The Role of the Qi Mechanism in the Treatment of Knotty Diseases: "When the modern textbooks were written, several factors influenced their utility in America. First, communist oversight promoted the creation of a superficially monolithic TCM. Second, the actual patterns chosen to be recorded in texts reflected the clinical realities of post revolutionary China, where disease patterns and etiology were markedly different than in the West. Third, in order to actually understand how to use TCM to treat complex diseases, it is necessary to study the classics. This puts formulae into deep context. Thus, while a book may say that Bu Zhong Yi Qi Tang is one possible formula to treat myasthenia gravis or atony pattern, only reading the Pi Wei Lun (or being instructed in its content) will reveal to the Practitioner the proper application of this formula. The same is true of all the classical formulae. What the so called classics and other source texts offer the Practitioner that textbook TCM does not is something dynamic. The core of Chinese medical philosophy emphasizes the dynamic nature of existence. Life is change and transformation perpetually.

TCM clinical references instead offer static snapshots of disease states. However, while this approach has clinical utility, it often fails in the face of chronic illness. Thus, one refers to the classics to read about the dynamics of pathology and health and the formulae themselves in the words of their creators and learned commentators. Therein the process of disease is revealed."

Li Dong Yuan's work focuses on the importance of the spleen and stomach as the basis of health and immune function. Hence, Li's treatment strategies emphasise strengthening the spleen and stomach before treating other affected organ systems. Li Dong Yuan also developed the much debated concept of yin fire, a concept of which there are no records of clear explanation by Li Dong Yuan himself. Yin and fire 'seem to be opposing concepts, yin being cold and fire being hot.

Amongst others, the Pi Wei Lun mentions yin fire in chapter two Treatise on Initiation of Heat in the Centre Due to Damage by Food and Drink and Taxation Fatigue: "Dietary irregularity and immoderate (eating of) cold and warm (foods) damage the spleen and stomach. Joy, anger, worry, and fright consume and bring detriment to the original qi. If spleen and stomach qi become decrepit and original qi becomes insufficient, heart fire becomes effulgent on its own. This heart fire is a yin fire. It starts form the lower burner and its ligation links to the heart. The heart does not reign (personally). (Rather,) ministerial fire is its deputy. Ministerial fire is the fire of the pericardium developing from the lower burner. It is a foe to the original qi. (This yin) fire and the original qi are irreconcilable to each other. When one is victorious, the other must be the loser. When spleen and stomach qi becomes vacuous and (their qi) consequently runs down into the kidneys, yin fire is given a chance to overwhelm the earth phase."

Based on this original citation, yin fire seems to be defined as:

1. Fire engendered by diet, taxation fatigue, or joy, anger, anxiety, and thought.
2. Heart fire.

At a superficial glance, this seems hardly exciting stuff if you are in the middle of a case of say Chronic Fatigue Syndrome (CFS) with every conflicting pattern under the sun present at the same time.

Here is how this classical passage comes to live with an interpretation by Bob Flaws. In his article Li Dong Yuan's Theory of Yin Fire and Difficult to Treat, Knotty Diseases Flaws explains: "Yin fire refers to an evil heat, often damp in nature, which develops from the lower burner but which then counter-flows upward. ...If one looks at every instance

in this monumentally important book (available in English as part of Blue Poppy's Great Masters Series) where 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 and blood vacuity
5. Stirring of ministerial fire

...the reader should understand that these five disease mechanisms are all mutually interdependent. This means that anyone of these mechanisms can result in the creation of any of the others. Because of this, real-life patients do not typically exhibit only one or another of these five, but rather three, four, or all five at one time." Now this sounds more like our CFS patient. It still doesn't tell us what to do though.

What many of us have been doing with a multi-pattern case is what Flaws calls a "peeling the onion" treatment strategy: First treat the root, or first treat the tip, or first treat what makes the patient most uncomfortable. The result is often that the treatment plateaus and then often reverts to something close to the original condition. This is not surprising as the concurrent patterns do not co-exist in isolation but are mutually engendering. For example: Over-thinking, not enough exercise, bad diet -> impaired spleen -> dampness -> dampness obstructs free flow of yang qi -> stagnant yang qi transforms into heat -> heat may bind with dampness -> damp heat -> damp heat may percolate down to lower burner AND heat may counterflow upward, damaging yin fluids and qi of the spleen, stomach, heart and lungs. Also the impaired spleen -> blood vacuity ->kidney yin vacuity. Treat any of those patterns in isolation, and success will be moderate to non-existent. Treat them all at once, and improvement will be faster and stable. According to Flaws, the concept of yin fire is central in getting a grasp on the pathogenesis of many present-day multi-faceted clinical scenarios, such as allergies, autoimmune disease, mental emotional disease, intestinal dysbiosis, leaky gut syndrome, candidiasis etc, on each of which Flaws has written an article.

How, then, to treat yin fire conditions? Flaws and his friend Charles Chace studied the formulas mentioned in Li Dong Yuan's most famous works, Pi Wei Lun and the Lan Shi Mi Cang (The Orchid Chamber Secret Treasury), and came up with five treatment principles:

1. To fortify the spleen and boost the qi so that the clear can be upborne and the turbid downborne. Medicinally, it is sweet, warm medicinals which mostly do this.
2. To disinhibit the qi mechanism and promote the free flow of upbearing and downbearing. Medicinally, this is primarily accomplished by acrid, qi-rectifying, exterior-resolving medicinals.
3. Clear whatever kind of evil heat is present. Medicinally, this mainly implies using at least some bitter, cold medicinals.
4. Identify whatever disease mechanisms are also at work and also use ingredients which rebalance those mechanisms. Therefore, if there is blood stasis, use blood-quickening medicinals. If there is phlegm, use phlegm-transforming medicinals. If there is disquieted spirit, use spirit-quieting medicinals, etc. In other words, do whatever else is necessary.
5. Determine the relative strengths and priorities between the above four principles and compose your treatment plan accordingly.

Bu Zhong Yi Qi Tang

Bu Zhong Yi Qi Tang is the chief formula for treating yin fire. Let's have a look at the formula in light of the above first three treatment principles.

The dosages in the original formula are quite small and dosages used today are significantly higher (today's dosages in brackets). The original Bu Zhong Yi Qi Tang formula from the Pi Wei Lun:

Huang Qi [Astragalus] 1.5 g (24 g)

Zhi Gan Cao [Mix-fried Licorice] 1.5 g (6 g)

Ren Shen [Ginseng] 1 g (15 g)

Dang Gui [Angelica Sinensis]   0.6 g (10 g)

Chen Pi [Citrus] 0.6 to 1 g (9 g)

Sheng Ma [Cimicifuga] 0.6 to 1 g (6 g)

Chai Hu [Bupleurum] 0.6 to 1 g (6 g)

Bai Zhu [Atractylodes, white] 1 g (10 g)

Huang Qi [Astragalus] strongly augments the qi. As lung is the root of qi, it is the chief medicinal to support the lung. Ren Shen [Ginseng] supports the original qi, fortifies the spleen, boosts qi. Gan Cao [Licorice] harmonizes the centre and boosts the spleen. In combination with the above two it clears heat. Li Dong Yuan considered this combination as excellent for eliminating vacuity heat vexation. Bai Zhu [Atractylodes, white] dries damp and strengthens the spleen. Dang Gui [Angelica Sinensis] harmonises the blood and yin.

Chen Pi [Citrus] harmonises the flow of qi, balances the contending of ciean and turbid qi, and prevents sweet flavoured medicinals from causing fullness and stagnation. Sheng Ma [Cimicifuga] and Chai Hu [Bupleurum] upbear the clear yang of the yang ming and shao yang and also lift the downward falling clear qi of the middle jiao. When clear yang ascends, turbid qi descends. Now see Bu Zhong Yi Qi Tang applied in the following case history by Greg Bantick.

Case History: Chronic Colitis

Case: Female, 50. Five year history of recurrent abdominal pain and diarrhoea. She was diagnosed with chronic colitis. She has been through two courses of biomedical treatment without long-term relief. For the last year, she has experienced exacerbation of the abdominal pain, diarrhoea, and intestinal rumbling. Currently she has five to six bowel movements a day containing undigested food and a large amount of reddish-white mucus. Her stool is positive for both red and white blood cells. She also reports a scorching hot sensation in her abdomen, a sagging sensation, complexion is sallow yellow, appetite is poor, she is thin and fatigued.

Tongue: pale red body, yellow and slimy coat.

Pulse: soggy, rapid, and forceless.

Diagnosis: Spleen qi vacuity with damp-heat brewing in the intestines.

Formula: Bu Zhong Yi Qi Tang [Ginseng & Astragalus Combination]

Huang Qi [Astragalus] 30 g

Dang Shen [Codonopsis] 30 g

Bai Zhu [Atractylodes, white] 20 g

Zhi Gan Cao [Honey fried licorice] 5g

Dang Gui [Angelica sinensis] 15g

Chen Pi [Citrus] 10 g

Sheng Ma [Cimicifuga] 10 g

Chai Hu [Bupleurum] 12 g

Additions:

Ku Shen [Sophora Root] 30 g

Bai Jiang Cao [Patrinia scabiosaefolia] 30 g

Huang Lian [Coptis] 10 g

Zhi Shi [Citrus sinensis] 12 g

After three doses/days, she expelled a large quantity of mucoid matter with the stool, after which the abdominal pain, diarrhoea, and intestinal rumbling decreased and her appetite increased. The original dosages were divided in half and the formula was continued for another 20 packs. After finishing this prescription, the patient was switched to Bu Zhong Yi Qi Wan (pills) for maintenance. Her stool analysis had become normal and an investigation of the bowel about a month later was normal with the exception of some mild scarring.

Useful Modifications of Bu Zhong Yi Qi Tang