In school, we learn simple, discrete patterns and then the simple, standard formulas for those patterns. Further, we are taught that we should not supplement vacuity before evils have been eliminated.However, in real-life practice, most patients with chronic conditions present multiple patterns simultaneously - in fact, typically not less than three and often as many as eight to 10 patterns at one time. Therefore, it is extremely important to realize that the instruction that one should not supplement until evils have been eliminated is not universal or absolute. It primarily has to do with the treatment of acute, external contractions, yet even here, this teaching is not categorical. What the Nei Jing (Inner Classic) actually says is:
Do not supplement until evils have been drained, unless the righteous qi has been damaged. [In that case,] one must drain and supplement at the same time.
The word damage (shang) in the above quote implies that the righteous qi is vacuous. Whether or not the evils have caused that vacuity, when evils exist at the same time as vacuity, based on the second part of the above saying, one must supplement and drain at the same time. The author(s) of the Nei Jing did not say one could, can or should; they said one must (bi) drain and supplement at the same time. Since it is the righteous qi that fights the evils and expels them from the body, if the righteous is vacuous and insufficient, there is no power or force to restore health and harmony.
While the second half of this teaching is important in the treatment of acute, externally contracted conditions, it is all the more important in the treatment of chronic diseases. This is because it is also said, "In acute conditions, treat the tip [or branch]; in chronic conditions, treat the root." Therefore, we sometimes can achieve the right results in acute conditions by simply draining repletions aggressively for a short period of time, even when there are minor vacuities. However, when vacuity and repletion are mutually engendering and bound together in close embrace, the key to successful treatment is to supplement and drain at the same time. An example of this is an article published by Zhang Bei-qin, et al., in Xin Zhong Yi (New Chinese Medicine) issue no. 4, 2003. Titled "A Study of the Therapeutic Efficacy of 38 Cases of Chronic, Nonmalignant Ulcerative Colitis Treated by Jian Pi, Wen Shen Qing Chang Tang (Fortify the Spleen, Warm the Kidneys and Clear the Intestines Decoction)," this article appeared on pages 27-28 of that journal. Because it is a good example of supplementing and draining at the same time in chronic conditions, a summary is presented below.
Fifty-one of the patients enrolled in this study were male; 32 were female. The oldest patient was 70 years old; the youngest was 20. The longest disease duration was 15 years, and the shortest was half a month. In 48 cases, the condition was chronic and relapsing, while in 35 cases, it was chronic and continuous. It was relatively light in severity in 31 cases and moderate in degree in 52 cases. There was rectal colitis in 12 cases; rectal and sigmoid colitis in 41 cases; left half colitis in 26 cases; and generalized colitis in four cases. All of these cases were categorized as active.
Chinese pattern discrimination was based on the 1987 National Symposium on Chinese Medicine Proctology Criteria published in Kui Yang Xing Jie Chang Yan Zhen Zhi Biao Sun (Standards & Criteria for the Diagnosis & Treatment of Ulcerative Colitis). Based on those criteria, 12 cases presented a pattern of damp heat brewing internally; 16 cases presented with qi stagnation and blood stasis; 41 cases presented with spleen-kidney dual vacuity; and 14 cases presented with yin & blood depletion and vacuity.
Jian Pi Wen Shen Qing Chang Tang consisted of 20 grams each of radix codonopsitis pilosulae (dang shen), radix astragali membranacei (huang qi), herba patriniae heterophyllae (bai jiang cao) and herba oldenlandiae diffusae cum radice (bai hua she she cao); 15 grams each of rhizoma atractylodis (cang zhu) and rhizoma drynariae (gu sui bu); 10 grams each of radix auklandiae lappae (mu xiang), semen myristicae fragrantis (rou dou kou) and radix lateralis praeparatus aconiti carmichaeli (fu zi); and six grams of mix-fried radix glycyrrhizae uralensis (gan cao). If dampness was heavy, bai jiang cao and bai hua she she cao were removed and 10 grams each of cortex magnoliae officinalis (hou po) and fructus immaturus citri aurantii (zhi shi) were added. If kidney yang was devitalized, 15 grams of herba cynomorii songarici (suo yang) was added. If intake was torpid, 15 grams each of stir-fried fructus germinatus oryzae sativae (gu ya) and fructus germinatus hordei vulgaris (mai ya) were added. If there was pus and blood in the feces, 15 grams each of radix pulsatillae chinensis (bai tou weng) and herba agrimoniae pilosae (xian he cao) were added.
One packet of these medicinals was administered in decoction two times per day. In addition, a retention enema was used consisting of radix sophorae flavescentis (ku shen - 50 grams), semen coicis lachyrma-jobi (yi yi ren) and rhizoma bletillae striate (bai ji). These medicinals were decocted to make 100-150 milliliters of medicinal liquid, to which was added two grams of powdered margarita (zhen zhu). The resulting liquid was administered as an enema, once per day, at 35-38 degrees Centigrade. Fifteen days of this treatment equaled one course, and five days rest were allowed between each successive course. Results were assessed after three successive courses.
Cure was defined as disappearance of clinical symptoms with return to normal of the intestinal mucosa and no recurrence within six months of stopping treatment. Marked effect was defined as basic disappearance of clinical symptoms and partial resolution of inflammation of the intestinal mucosa. Improvement meant that clinical symptoms and the intestinal mucosa improved somewhat, and no effect meant that there was no improvement in either symptoms or endoscopic examination. Based on these criteria, 51 cases were judged cured;14 got a marked effect; 10 improved; and there was no effect in eight cases. Therefore, the cure rate was 61.45 percent and the total effectiveness rate was 90.36 percent. Among the cured cases, four presented a damp heat, internally brewing pattern; seven presented a qi stagnation and blood stasis pattern; 32 presented a spleen-kidney dual vacuity; and eight presented a yin and blood depletion and vacuity pattern. Therefore, the therapeutic effect was relatively good in the spleen-kidney dual vacuity pattern patients. In terms of disease severity, 24 mild condition cases and 27 moderate condition cases were cured. Therefore, the protocol was more effective for those with light or mild conditions. There was no marked statistical difference in outcomes based on the anatomical location of the colitis.
According to the Chinese authors of this study, what is referred to as chronic nonmalignant ulcerative colitis in Western medicine corresponds to diarrhea in Chinese medicine, and Zhang Jing-yue, in his Jing Yue Quan Shu (Jing-yue's Complete Book) had this to say in his chapter on diarrhea:
The root of diarrhea is nothing other than the spleen and kidneys. The stomach is the sea of water and grains, while the spleen governs movement and transformation. Therefore, promoting the spleen's fortification and the stomach's harmony results in the rottening and ripening of water and grains as well as the transformation of qi and transformation of blood in order to move the constructive and defensive. If drinking and eating are not regulated, and rising and abiding are not timely, this may result in the spleen and stomach suffering damage which may further lead to water erroneously becoming dampness and food erroneously becoming stagnation. Thus, the qi of the finest essence is not able to be transported and transformed. Rather, these combine into filth which then descends and is downborne, provoking the onset of diarrhea and dysentery. If the spleen is strong, stagnation is removed and there is cure. ... If the spleen is weak, this causes vacuity resulting in easy diarrhea.
The implication of the above quote is that a spleen-kidney vacuity may lead to the internal engenderment of damp heat filth and turbidity. As the authors go on to state, the spleen governs the movement and transformation of the whole body, while the kidneys are the residence of the true yang of the entire body. "If the spleen movement and transformation lacks power, it is not okay not to (also) warm kidney yang."
Within the above formula, dang shen supplements the center and boosts the qi, while huang qi supplements the qi and upbears yang. Cang zhu dries dampness and fortifies the spleen. Mu xiang moves the qi and stops pain. It is an essential medicinal for intestinal and stomach qi stagnation. Rou dou kou warms the center, astringes the intestines and stops diarrhea. Fu zi warms the center and stops pain. It is able to warm both the middle burner and the lower source. Gu sui bu warms kidney yang. Bai jiang cao quickens the blood, scatters stasis and resolves toxins. It is an essential medicinal for dispersing inflammation and discharging pus as well as for dealing with damp heat with simultaneous stasis and stagnation. Bai hua she she cao clears heat from the intestines. Therefore, when all of these medicinals are used together, they fortify the spleen, warm the kidneys, clear heat and eliminate the intestines. Thus, this is a suitable formula for spleen-kidney dual vacuity chronic ulcerative colitis complicated by damp heat, qi stagnation and blood stasis, a commonly seen, complicated pattern in real-life practice.
In my experience as a teacher, when beginners see this kind of complex formula that supplements and drains at the same time, they commonly ask if the supplementing will not add qi to the evils. The answer to this is definitely not, as long as the supplementing is warranted by the patient's presenting patterns. If one supplements in the case of a pure repletion, this is equivalent to "repleting the repletion," as it is said in Chinese. However, when one supplements an existing vacuity at the same time as draining existing evils, one does not have to worry about the supplements somehow making the evils stronger. This is an extremely important point in clinical practice, and marks the divide between real-life and theoretical practice. It also marks the divide between beginning and intermediate practice. Unfortunately, here in North America, recent graduates have to "hit the ground running." Since often we do not work under the mentorship of senior practitioners, there is no one to look over our shoulder and guide us in our practice to a more mature understanding. Therefore, it is very important for students and younger practitioners not to shy away from supplementing and draining at the same time when vacuities and repletions exist simultaneously.
Click here for previous articles by Bob Flaws, LAc, FNAAOM (USA), FRCHM (UK).