Development of Pi Wei (Spleen-Stomach) Theory in Early Chinese Medical Classics

Transcription

1 Development of Pi Wei (Spleen-Stomach) Theory in Early Chinese Medical Classics Oregon College of Oriental Medicine DAOM Program 2010 Fang Zhang, LAc, M.Med (China) December 2011 Fang Zhang, LAc, M.Med (China) - 1 -

2 Acknowledgement My first deeply appreciation would go to my parents. I have observed and experienced traditional Chinese medicine since my early childhood from my parents, who both are Chinese medicine doctor in China. Without their inspiration, I would have not chosen Chinese medicine as my career. With years of teaching at the Chinese medicine university and practicing in the hospital as internal medicine doctor, I found that the most challenging is how to understand Chinese classics and apply them into daily practice and modern diseases. Later, I had opportunity to study Chinese classics with the guidance of famous Chinese classics scholar and practitioner, Dr. Xin Song from Chengdu University of Traditional Chinese Medicine for three years. The study had really let me appreciate the rich history of Chinese medicine and broadened my knowledge in Spleen and Stomach theory. I am so grateful and would give my sincere gratitude to him. I would especially like to thank my mentor, Dr. Guohui Liu, who is wisdom of Chinese classics and is able to recite most of original texts of Huang Di Nei Jing, Shang Han Za Bing Lun and Wen Bing Xue. His guidance has helped me tremendously to put the capstone project together. Lastly, I would also like to acknowledge support of both my family and the administrators of Oregon College of Oriental Medicine, and the gentle guidance of OCOM doctoral program teachers, especially Dr. Beth Burch, Dr. Zhaoxue Lu, and Dr. Tsuey-hwa Lai. Without their support and guidance, I would not be able to finish the doctoral program. Fang Zhang, LAc, M.Med (China) - 2 -

3 Table of Contents Introduction Development of Theory 1. Huang Di Nei Jing laid the theoretical foundation for Pi Wei (Spleen-Stomach) theory Anatomy of Spleen and Stomach Physiological function Etiology and pathogenesis of diseases from dysfunction of Spleen and Stomach Prevention of diseases of Spleen and Stomach Therapeutic treatment of diseases of Spleen and Stomach 2. Shang Han Za Bing Lun established the basic treatment principles based on syndrome differentiation Emphasize the importance of treatment principle of strengthening the Function of Spleen Elaborate the outline of the diseases of Spleen and Stomach Emphasize the importance of harmonizing Stomach to secure the root of the life Stress the cooking methods of herbal decoction Clarify the application of four diagnostic methods in treating diseases caused by dysfunction of Spleen and Stomach Contribution to health and preventive medicine Fang Zhang, LAc, M.Med (China) - 3 -

4 3. Yi Shui school formally found and explained the basic Pi Wei (Spleen-Stomach) Theory and its application Zhang Yuan-su: advocated to set up treatment principles based on the nature of disease, such as deficiency, excess, heat or cold. Li Dong-yuan: composed the classic book Pi Wei Lun (Pi Wei Treatise) Hao-gu Wang: clarified the Yin pattern of Spleen and Stomach Tian-yi Luo: treated diseases due to dysfunction of Spleen and Stomach with San Jiao theory Conclusion Reference Index: A Case Study: Treatment of GERD with Classic Chinese Herbal Formula-Under the Guidance of Pi Wei Theory Fang Zhang, LAc, M.Med (China) - 4 -

5 Introduction Theory of Pi Wei (Spleen-Stomach) has been considered as one of the most important component of Traditional Chinese Medicine. Since Jin and Yuan dynasty, Pi Wei theory has become a unique and popular academic school and served as a very practical tool in the TCM field after being developed and polished by ancient physicians. Overall, Spleen and Stomach has been considered as the sea of food and body fluid, the source of the production of both Qi and Blood and the pivot of the Function of Zang and Fu organs. Therefore, they are called the root of post-heaven Qi and the dysfunction of Spleen and Stomach is one of the major causes of various diseases. Pi Wei theory acts as an important guidance in the physiology, pathology, diagnosis and treatment of various diseases in clinic. The collection and research on successive achievements that related this theory from ancient physicians shows important practical significance on inheriting and carrying forward the work of traditional Chinese medicine. Based on the review various original classic literature and commentaries, this paper will focus on the establishment and development of the Pi Wei (Spleen-Stomach) theory, particularly at the important historical periods and medical classics including Huang Di Nei Jing, Shang Za Bing Lun and Yi Shui School. In the end, a case is presented from my practice in the regard of application of Spleen-Stomach theory for modern disorders. Development of History 1 Huang Di Nei Jing has laid the basic foundation of theory of Spleen and Fang Zhang, LAc, M.Med (China) - 5 -

6 Stomach Huang Di Nei Jing should be considered as the earliest medical classic to set the foundation of the Pi Wei (Spleen-Stomach) Theory. It has description in detail of the anatomy, physiological functions of the Spleen and Stomach, and the etiology, pathology, prevention and treatment of the Pi Wei diseases. 1.1 The anatomy of the Spleen and Stomach There is no systemic record related to the anatomical structure of the stomach in Huang Di Nei Jing but the anatomical structure of the stomach was discussed in Lin Shu, one part of this classic. Only Stomach is mentioned in Ling Shu. In the chapter of Chang Wei (The Intestine and Stomach), it says: The body of the Stomach is tortuous, bending and stretching, its length is two Chi and 6 Cun (Chi and Cun are ancient length measurement; its circumference is one Chi and five Cun; its diameter is five Cun and its capacity is three and half liters (Wang, 1963). There is not too much other discussion related to this until the Nan Jing was written. Nan Jing started to have more detailed description about anatomy of Spleen and Stomach in terms of their shapes, weight and volume. In the chapter 42 of the Nan Jing where it says: The Spleen weighs two Jin and one Lian (Jin and Lian are ancient units for weigh measurement), and it is three Cun wide, five Cun long and has half Jin of fatty tissues surrounding it (Qing,1956). Comparing the description of Spleen and Stomach in both Nei Jing and Nan Jing to the modern biomedical view, they both share some similarity as well as difference. For example, Nan Jing mentions that There is half Jin of fatty tissue surrounding the Spleen (Qing,1956). Fang Zhang, LAc, M.Med (China) - 6 -

7 which is slightly similar to the pancreas form modern anatomy. According to the classic description mentioned above, it seems that the size and weight related to the Spleen and Stomach in ancient Chinese texts is based on its actual cut and open inspection. Otherwise, it is unbelievable how these estimates are close to ones in the modern anatomical decription. Meanwhile, the TCM tends to pay more attention to the Function of the internal organs than its pure anatomical structure, All the function of internal organs will reflex to the surface of the body, based on method of observation from the outside to estimate the inside. 1.2 The physiological function of the Spleen and Stomach There are a few aspects regarding the physiological functions of the Spleen and Stomach in Nei Jing, which can be summarized as follows: The Spleen and Stomach takes charge of transportation and transformation of water and food. Spleen and Stomach can digest food, transport the nutrients and are related to water metabolism. Su Wen Ling Lan Mi Dian Lun (The Confidential Collections in the Royal Library about the functions of the Twelve Viscera in Su Wen) The Spleen is like an officer who is in charge of the digesting, absorbing, spreading and storing of the essence of food; all five tastes are from there. Su Wen Jing Mai Bie Lun (Further Comments on Channel in Su Wen) states that when the food enters the Stomach, after being digested, its refined substance is transported to the Liver to moisture the tendons of the whole body. The channel-qi circulates in the channels and goes up to the Lung. After the various Fang Zhang, LAc, M.Med (China) - 7 -

8 channel-energy being converted in the Lung, it is transported to the skin and hair. When the water enters the Stomach, it evaporates the refined energy and spreads it to the Spleen above; and the Spleen spreads the essence into the Lung above; the Lung energy communicates with the water passway, and transports the essence to the bladder. In this way, with the production, circulation activity of the vital energy and the promotion of the water, the refined energy is spread to the skin and hair of the whole body, circulated in the channels of five Zang-organs and is kept in accordance (Ni, 1995). From the description, the understanding of physiological function of Spleen and Stomach is very similar to the function of digestive system in modern western medicine The Spleen and Stomach are the sources of Qi and Blood. Nei Jing believes that the Qi and Blood in human body is generated after the consumption of food and water. Therefore, the energy of Spleen and Stomach in middlejiao for Qi and Blood generation is of critical importance. In the chapter of Ling Shu Xie Ke says: After the five cereals enters into the Stomach, it divides into dross, body fluid and initial energy (Ying-Qi), which flow to the lower, middle and upper Jiao (burner) respectively in three routes. The initial energy accumulates in the chest (becomes into Chest Qi), comes out from the throat, links up the Heart and carries out the respiration. The Ying-Qi (nutrient Qi) permeates the body fluid and pours into the channels; then it turns into Blood to nourish the four extremities outside; and pours into the solid and hollow organs inside of the body in the speed of fifty cycles a day and night or a hundred graduations of the clepsydra. The Wei-Qi (defensive Qi) has the property of being valiant and swift, moving along the muscle and the skin unceasingly (Wang, 1963, Ni, 1995). Fang Zhang, LAc, M.Med (China) - 8 -

9 This means that Zong-Qi (Chest Qi), Ying-Qi (nutrient Qi), Wei-Qi (defensive Qi) and the Blood generated by the Ying-Qi are originally derived from water and grain in the Stomach. In the chapter of Lin Shu Wu Wei (The Five Tastes) also says: The Stomach is like the sea for converting the nutrition of the five solid organs and the six hollow organs, as well the water and cereals enter into the Stomach, so, all the five solid organs and the six hollow organs will receive the refined energy formed by the digestion of the Stomach. In the chapter of Su Wen Yu Ji Zhen Zang Lun (The Valuable Collection of the Jade Plate on the Pulse Condition Indicating the Exhaustion of the Visceral-Qi) also said: The nourishment of the energies of the five viscera depends on the refined substance of water and cereals of the Stomach, so, Stomach is the root of the five viscera (Wu, 1997) In short, despite the production of Ying, Wei, Qi, Blood, body fluids is a complex process involving the five Zang, six Fu-organs, congenital, acquired and other factors, but all depends on the transportation and transformation of water and grain in the Spleen and Stomach to complete. This is very similar to modern western medicine that the digestive system is critical for digestion and absorption of food nutrients in order to maintain normal activities of life activity The Spleen and Stomach are related to muscles and four limbs It was first proposed in Huang Di Nei Jing that the Spleen has the function of controlling the muscles and the four limbs. The Nei Jing chapter 5 - Su Wen Yin Yang Ying Xiang Da Lun (The Corresponding Relation between the Yin and Yang of Man and All Things and That of the Four Seasons) says that the normal function of Spleen can promote the generation of the muscle. Fang Zhang, LAc, M.Med (China) - 9 -

10 The Su Wen in chapter 44 (Su Wen Wei Lun) says: The Spleen governs the muscles of the whole body. The Su Wen in chapter 18 (Shu Wen Pin Ren Qi Xiang Lun) says that the Spleen is to store the muscular-qi mainly. As for the relationships between the Foot Yangming of the Stomach and muscle, it has been mentioned in the Su Wen chapter 31 Su Wen Re Lun (On Febrile Disease). It states that the Yangming Channel governs the muscle; in its course of running, it clips the nose and surrounds the eyes. In chapter 29 it says: The four limbs depend on the Stomach for Qi, but Stomach-Qi can only reach the channels through the transmission of the Spleen. If the Spleen is diseased it cannot transport the fluids of the Stomach, with the result that the four limbs cannot receive the Qi of food (Wang, 1963, Wu,1997). All these descriptions have explained that both Spleen and Stomach share the similar function of the nourishing and controlling the muscle for the whole body. As far as the particular relationship between the four limbs and Spleen and Stomach, it is fully reflected in the discussions in the Su Wen chapter 19 Su Wen Yu Ji Zhen Zang Lun (The Valuable Collection of the Jade Plate on the Pulse Condition Indicating the Exhaustion of the Visceral-Qi) and chapter 29 Su Wen Tai Yang Yang Ming Lun (On the Relations Between the Superficies and Interior of Taiyin and Yangming Channel). For example, it states that the Spleen associates with earth and it is a solitary viscus which has the function of moistening all around and other viscera, and all the four limbs are nourished by the Stomach-Qi. All these statements show the normal functions of the Spleen and Stomach play essential roles on the formation of the strong muscles and robust limbs. In contrast, the status of the Qi of the Spleen and Stomach such as abundance or declining can be speculated based on the physical condition of the muscle Fang Zhang, LAc, M.Med (China)

11 and four limbs. It should be noted that the transformation and transportation of the food essence and generation of the Qi, Blood and body fluid can only be completed normally if there is harmonized complement between the Spleen and Stomach. In the Su Wen chapter 29 Su Wen Taiyin Yangming Lun (On the Relations between the Superficies and Interior of Taiyin and Yangming Channel), the detailed explanations are given through three reasons. Firstly, they physiologically connect each other with only a piece of membrane. Secondly, they connect each other through the channel relationship. The Spleen channel of foot Taiyin is interiorly-exteriorly coupled with the Stomach channel of foot Yangming. Just as mentioned in this chapter, The Foot Taiyin channel is surrounding the Stomach, connecting the Spleen and clipping the throat, so, the Yangming energy can be transported by the Taiyin Channel, and makes it enter into the three Yin channels of Hand and Foot; the Foot Yangming Channel of Stomach is the superficies of the Foot Taiyin Channel of Spleen and is also the sea of nutrition of the five Zang and six Fu, so the Stomach Channel can also transport the Qi of Taiyin into the three Yang channels of Hand and Foot. (Wang, 1963, Wu,1997). Thirdly, functionally they complement each other. The four limbs are nourished by the Stomach for Qi, but Stomach Qi can not reach the four limbs directly except with the help of the transmission of the Spleen which can convert the food and water into food essences. Overall, the structural configuration of the Spleen and Stomach is also reflected in the Functional connections The Spleen and Stomach have open orifice of the mouth In addition to the influence played on the digesting and absorbing of water and food, Fang Zhang, LAc, M.Med (China)

12 transporting, distributing and transforming of the nutrients and nourishing the muscles and limbs, Spleen also opens into the mouth as stated in the Ling Shu chapter 17 Mai Du (The Length of Channels) says: The Spleen-Qi communicates with the mouth orifice, and when the Spleen function is balanced, the mouth can distinguish the fragrances of the five grains. That is why in the Nei Jing chapter 5 Su Wen Yin Yang Ying Xiang Da Lun (The Corresponding Relation between the Yin and Yang of Man and All Things and That of the Four Seasons) says mouth is the orifice of Spleen (Wang, 1963, Wu,1997) Therefore, a complete digestive system is formed including the mouth, Spleen, Stomach, small intestine, and large intestine, etc The Spleen and Stomach are also associated with certain mental and spiritual activities The connection between the status of the function of the Spleen and Stomach and mental activity has been discussed in the Nei Jing because Spleen is related to Ying-Qi (nutritive Qi) and idea. The Ling Shu chapter 8 Ling Shu Ben Shen (The Diseases Caused by Spiritual Activities) says: The Spleen stores the Ying-Qi, and idea adheres to the Ying- Qi. When the Spleen-Qi is deficient, it will cause dullness of the motions of the four limbs and the disharmony of the five viscera; when the Spleen-Qi is obstructed, it will cause abdominal distention, menoxenia, dyschesia (Qing, 1956). The Su Wen chapter 5 Su Wen Yin Yang Ying Xiang Da Lun (The Corresponding Relation between the Yin and Yang of Man and All Things and That of the Four Seasons) claims Spleen affects the ability of thinking and excessive thinking would damage the normal function of the Spleen. It even influences the content and nature of the dream. The Su Wen chapter 80 Fang Zhang, LAc, M.Med (China)

13 says: If the Spleen is deficient, one dreams of being hungry; if the dream takes place in late summer, one dreams of building a house. and the Ling Shu chapter 43 says: If the Spleen is in excess, one dreams of singing and being very heavy if the Spleen is deficient one dream of abysses in mountains and of marshes (Wang, 1963, Wu, 1997, Zhu, 2001). All of these confirm the close connection between Spleen and spiritual activities. 1.3 Etiology and pathology of the Spleen and Stomach disease There are so many etiological and pathological factors causing the diseases, including six kinds of exogenous pathogenic evils, abnormal stimulation of seven abnormal emotions, injury by irregular diet or over taxation, trauma, insect-bite, etc. Additionally, some pathological products such as blood stasis and phlegm generated by various dieases are also can cause the diseases as well. Like other ogans, the spleen and the stomach are commonly affected by those pathologic factors, among which irregualar diet plays an important role in the theory of the spleen and the stomach because of the close relatiohsip between the diet and these two organs Irregular diet Diet always needs to be balanced from both quantity and quality. Through long term clinical practice, the ancient Chinese physicians realized that the combination of appropriate amount of food and balanced variety of food were essential for maintaining normal physical activities as it provides Qi and Blood to supplement whole body. Firstly, regulating the amount of food intake is important since overeating or hunger may Fang Zhang, LAc, M.Med (China)

14 give rise to damage of Spleen and Stomach. The Su Wen chapter 43 Bi Lun (On Bidisease) says that if the food and drink are taken excessively, the intestine and the Stomach will be injured. Another good example can be seen in from Su Wen chapter 3 Sheng Qi Tong Tian Lun (On the Human Vital Energy Connecting with Nature). It explains the possible damage to the body from over eating or drinking after external wind invading (Qing,1956). Overeating makes the stomach and the intestines so full that the tendons will become loose. If the intestine stores up with the undigested food for a long time, usually the tendons will be kept loose constantly; and this could eventually develop bloody stool or hemorrhoid. In similar situation, excessive consumption of liquor causes rebelling of Lung Qi. On the other hand, excessive hunger causes malnourishment of the body and leads to insufficient supply of Qi and Blood, which causes general body weakness. Hence, appropriate amount of food intake is considered as one of the key for health care in Nei Jing. Secondly, indulging in a particular kind of food or flavor of food can cause imbalance of internal organs as well. Different flavors are connected with respective internal organs through the corresponding meridians. Therefore, they have their corresponding important impact upon the different internal organs. In order to explain the dialectical relationship between the function of internal Zang organs and consumption of five flavors of food, the Su Wen chapter 3 Sheng Qi Tong Tian Lun says that the the nourishments of the five viscera are stemmed from the five flavors (acrid, sweet, sour, bitter and salty flavors are considered as tastes of food); but when the five tastes are taken excessively, they will damage the five viscera. In the same chapter, it sets out a few detailed examples regarding excessive consumption of certain flavor of food bringing on pathological Fang Zhang, LAc, M.Med (China)

15 changes on its coreresponding internal organ. It says: The sour taste acts on the Liver; if sour taste is taken excessively, it will make the Liver to have too much body fluid which causes weakness of Liver-Qi, which will restrict the Spleen-earth and make the Spleen-Qi vanishing. The salty taste acts on the Kidney. As Kidney determines the condition of the bone, and salty taste can soften the hardness and damage the Qi and Blood; so when the salty taste is taken too much, it will damage the bone and muscles; the Heart-Qi will be restrained in the end. The sweet taste acts on the Spleen, and the property of sweet taste is sluggish and greasy. If the sweet taste is excessively taken, dyspnea will happen. When the Spleen is abnormal, it will restrict the Kidney-water. When the Kidney-water is restricted, the Kidney-Qi will be abnormal to become ill. The bitter taste acts on the Heart; if the bitter taste is taken excessively, the Heart will be hurt. When the Heart is hurt, the Spleen-earth will fail to be moistened. When the Spleen is not moistened, it can no more do the transportation work for the Stomach, thus, the dry-evil of the Stomach will become abundant and the disease of the distension of the Stomach-Qi will happen. The acrid taste acts on the Lung; if the acrid taste is taken excessively, the Lung-Qi will become abundant, and the abundant Lung-metal will restrict the Liver wood. As Liver determines the condition of the tendons, when the Liver is restricted, the tendons will become loose. Due to the acrid taste also has the function of dispersing, the excessive taking of acrid flavor will consume the spirit as well. It also advocates: the five tastes should be adjusted in a harmonious condition without taking them excessively, the whole body will obtain ample source of nourishment, and the tendons, bones, energies, Blood and striae of skin will be kept in a strong and normal condition. Thus, the one who is good at adjusting the five tastes can live a long life (Wang, 1963, Wu, 1997, Zhu, 2001, Qing, 1956). Fang Zhang, LAc, M.Med (China)

16 1.3.2 Damage from imbalanced emotions Imbalanced emotions may affect Spleen and Stomach functions directly or indirectly. The normal emotions could turn into evils to cause internal impairment whenever there is sudden strong or persistant emotional stimulation, which surpasses a human being's physiological endurance and disturbs the function of the relevant internal organs. Because the Spleen houses thought, the Su Wen chapter 5 Yin Yang Ying Xiang Da Lun (The Corresponding Relation between the Yin and Yang of Man and That of the Four Seasons) says: excessive thinking/anxiety may damage the function of the Spleen. The Ling Shu chapter 8 Ben Shen (The Diseases Caused by Spiritual Activities) points out: When the excessive melancholy can not be removed, the idea will be injured; when it is injured, the patient will become depressed, disquieted and reluctant to lift the limbs due to the weakness of them; when the disease develops further to cause the patient s hair to become withered and the complexion to become abnormal, he will die in spring. (Wang, 1963, Wu,1997) Damage from external pathogens Zhi Zhen Yao Da Lun (The Various Changes in the Dominations of the Six Energies and their Relations with the Disease) says: Spleen pertains to Yin earth and Zang; it desires dryness and is of aversion to dampness; it is healthy in ascending; The Stomach pertains to Yang earth and Fu organ; it is incompatible with dryness but desires moisture; it is secure (health) in descending. In general, the humidity and dampness predominantly damage the Spleen. All the syndrome of edema and fullness caused by the dampness Fang Zhang, LAc, M.Med (China)

17 evil pertain to the Spleen. When the energy of Taiyin is retaliating, the disease of dampness energy will occur; the patient will contract heaviness of body, fullness of the chest, indigestion of food, adverseness of Yin-Qi. When the dampness energy of Taiyin is partial overabundant and invaded, the fire energy is stagnated inside of the body distention of Stomach distention of lower abdomen watery diarrhea heaviness of the head, swelling of the tibia of foot, and edema in the upper part of the body due to the fluid retention inside(wang, 1963, Wu,1997). Yu Ji Zhen Zang Lun says: The evil-qi was transmitted from Liver to Spleen to cause spleen wind-syndrome, jaundice, hot of the abdomen, irritability and yellow urine. Re Lun (On Febrile disease) says: On the second day, the evil is transmitted into the Ynagming Channel. The Yangming Channel takes charge of the muscle, in its course of running; it clips the nose and sleepiness (Wang, 1963, Wu,1997). Ben Zang (The Various Conditions of Internal Organs Relating Different Disease) says: When the Spleen is small, the Spleen-Qi will be stable, and one can hardly be injured by the exogenous evil; when the Spleen is large, it will often cause pain in the empty and soft part under the hypochondria and one will not be able to walk fast. When the position of the Spleen is high, it will have drawing pain under the hypochondria; when the position of the Spleen is low to attach the large intestine, the Spleen is apt to be injured by the exogenous evil. When the Spleen is firm, the Spleen-Qi will be harmonious and the Spleen can hardly be injured by the exogenous evil; when the Spleen is fragile, one will apt to contract diabetes and he is apt to be injured by exogenous evil. When the position of the Spleen is upright, the Spleen energy will be harmonious, and one can hardly be injured by exogenous evil; when the position of the Spleen is slanting, one will Fang Zhang, LAc, M.Med (China)

18 apt to contract colonic convulsion and abdominal distention (Wang, 1963, Wu,1997). 1.4 Prevention of Spleen and Stomach disease Nei Jing Ping Ren Qi Xiang Lun (On the Normal Pulse of a Person) says: The normal pulse energy stems from the Stomach, and the Stomach-Qi is the main pulse energy of a normal person. If the Stomach-Qi is absent in one s pulse, it is called the adverse condition, which may cause the death. Therefore, no matter the self damage of Spleen and Stomach or the result from damage by other organs, we should pay attention to the prevention. There are two types of prevention. One is to prevent the occurrence prior to actual happening and the other one is to prevent the progression and conversion when it is ill. Su Wen Si Qi Tiao Shen Da Lun(On preserving Health in Accordance with the Four Seasons) says: When a sage treats a patient, precaution is always emphasized If the disease is treated after it has already been formed, or try to calm down the disturbance after it has already taken shape, it will be too late, just like to dig a well until one is thirsty, or to cast the weapon after the war has already broken out; when one is completely free from wishes, ambitions and distracting thoughts, indifferent to fame and gain, the vital-qi will come in the wake of it. When one concentrates his spirit internally and keeps a sound mind, how can any illness occur? Shang Gu Tian Zhen Lun (On Human Preserving Health Energy in Ancient Times) says: The right-qi exists inside; evils cannot make disturbance (Wang, 1963, Wu,1997). The temperature of the food is particularly mentioned when try to avoid Spleen and Stomach issues in Nei Jing. Shi Chuan (Treating Instructions Imparted by Precedent Masters) says: In taking food and drink, avoid taking that of excessive heat and cold, but Fang Zhang, LAc, M.Med (China)

19 keep them in moderate temperature, in this way, the healthy-qi can be maintained in the body so that the invasion of the evil-qi which causes disease may be avoided. In Ling Shu Ben Zang (The various Conditions of Internal Organs Relating Different Disease), it says: When one can adapt the changes of the cold and hot weather, the function of transporting and transforming of the six hollow organs will be normal; the arthralgia due to wind-evil will not occur; the channels will be unimpeded, and the activities of the four extremities will be normal. (Wang, B. 1963, Wu,1997) 1.5 Treatment of Spleen and Stomach disease Treatment with acupuncture From the record of Ling Shu Bing Chuan(The Transmission of Disease), breathing exercises, massage, moxibustion, topical application of heated herbs, acupuncture, burning therapy and the administration of herbal decoction multiple treatments can be used to treat all kinds of diseases. But nine needling technique is in the first priority. Regarding the acupuncture treatment for Spleen and Stomach disorder particularly, it is spread in many different chapters(wang, B.1963, Wu, 1997, Zhu, 2001, Qing, 1956).. Re Lun (On Febrile Disease) says: It should base on the conditions of the solid and hollow organs of various channels. Ci Re (Acupuncture for Treating the Febrile Disease of the Viscera) says: prick Foot Taiyin and the Foot Yangming channels. Ke Lun (On Cough) says: When treating the cough of the five solid organs, prick the Shu-points; when treating the cough of the hollow organs, prick the He-points; to the patient of edema caused by cough, dredge the channel by pricking the points of the Fang Zhang, LAc, M.Med (China)

20 related channel. Wei Lun (On Flaccidity) says: When treating the flaccidity, it should treat the Yangming Channel alone. etc Treatment with herbs Regarding the treatment with herbs, there are only 13 formulas mentioned in total in Nei Jing. Besides topical formulas, there are only two herbal formula particularly related to the treatment of Spleen and Stomach. In Xie Ke (Retention of the Evil), the Ban Xia Tang(One liter of husked sorghum and half liter of Zhi Ban Xia),is classically used for insomnia due to disharmony of the Stomach. In Su Wen Qi Bing Lun (On Extraordinary Disease), the Lan Cao Tang is use to treat Pi Dan (pre-diabetes condition). Some people have sweet taste in the mouth, what is the disease, and how does it come about? Qibo said (In Nei Jing): it was due to the overflowing of the earth-qi, and the disease is called Pi Dan It should be treated with stem of the orchid which can remove the staleness heat. The other name of Lan Cao is Pei Lan, which is aromatic and able to transform turbidity, promote the Spleen Function to eliminate dampness. Although only a small number of herbs mentioned in Nei Jing, the ancient physicians had already got great experience how to treat Spleen and Stomach disease and some methods have been upgraded to the level of therapeutic principles for the later age. For example, in the chapter of Su Wen Zang Qi Fa Shi Lun (On the Relation Between Energies of Five Viscera and the Four Seasons), it says: The evil-qi of Spleen should be moderated with sweet herb; when purgation is needed, herb of bitter taste should be used to purge the Spleen; when invigoration is needed, herb of sweet taste should be used to replenish the Fang Zhang, LAc, M.Med (China)

21 Spleen; when there is an abdominal flatulence, therapy of promoting digestion can be used ; when the disease associates with excess syndrome, it should be treated with dispersing therapy. In Su Wen Liu Yuan Zheng Ji Da Lun (On the Changes and Symbols of the Five Elements, it says When the earth-qi is suppressed, it should be attacked hastly (Wang, 1963, Wu, 1997). Those treatment principles had been followed by the later ancient physician, as a basis to establish comprehensive herbal prescription system. 2 Shang Han Za Bing Lun has established the basic treatment principles of Pi Wei Theory based on syndrome differentiations In the Eastern Han Dynasty, Zhang Ji (also known as Zhang Zhong-Jing) put theoretical principles established in the Nei Jing and Nan Jing into clinical practice. Since then, ancient physicians have considered Shang Han Za Bing Lun as the ancestor of Chinese medical prescriptions. This monumental work has been recognized as the first classic that not only combined theories with clinical practice from the prespective of six stages differentiation.., but also opened up broad prospects for the clinical application of the Pi Wei (Spleen-Stomach) theory. Zhang s contribution to the Spleen and Stomach theory mainly includes in the following areas: 2.1 Emphasis on the importance of the rule of Maintain the strength of the Spleen and apply it in the prevention and treatment of diseases. In terms of the treatment of complex diseases, Zhang Ji was the first physician to propose treating diseases through strengthening the function of the Spleen based on the theories from Nei Jing. In the chapter of Jin Gui Yao Lue, Zang Fu Jing Luo Bing Mai Zheng Di Fang Zhang, LAc, M.Med (China)

22 Yi, Zhang pointed out that Liver disease eventually transfers to the Spleen; therefore first of all the strength of the Spleen needs to be maintained when the liver disease presents; one should be aware that the liver disease might affect or progress to the spleen. So the priority of the treatment should be placed on strengthening the spleen (Zhang, 1963). This is also the so-called In any season when the Spleen is vigorous, it will not contract any ailment. Therefore, a physician who can treat disease before its onset is called a superior physician. Only when Spleen Qi is sufficient, will the Qi of the Heart, Liver, Lung and Kidney be abundant because the Spleen is the postal-natal foundation which supplements the other Zang and Fu organs. Conversely, various diseases occur whenever the Qi of Spleen and Stomach is damaged. Indeed this point of view has opened the precedent of Spleen and Stomach theory and drew the ancient physicians close attention, which was particularly reflected in Li Dong-yuan s Pi Wei Treatise 2.2 Elaborate the outline of pattern differentiation and treatment of the diseases of Spleen and Stomach Nei Jing has set up the principles of treatment based on identification of patterns according to the channels and the internal organs which has been fully inherited and carried forward in the Shang Han Za Bing Lun. Zhang s major contribution to the treatment of diseases of Spleen and Stomach is the outstanding achievements in various areas including the methods of pattern differentiation, treatment principles and the selection of effective herbs, etc The application of Six-Channel Theory on the pattern differentiation and Fang Zhang, LAc, M.Med (China)

23 treatment of Spleen and Stomach diseases Six-Channel Theory is the core of Shang Han Lun. It has provided the basic treatment principles not only for treating externally contracted diseases, but also for treating miscellaneous diseases. According to the discussion of six channels from Su Wen Discourse of Febrile Disease, Zhang Ji developed and completed the Six-channel theory. He divided the whole course of externally contracted diseases into six stages which was associated with six channels including Tai Yang, Yang Ming, Shao Yang, Tai Yin, Shao Yin, Jue Yin, etc. In the Shang Han Za Bing Lun, Zhang Ji attached great importance to Yang Ming disease in conjunction with his clinical practice and summarized it as "Stomach domain is replete". Thus it confirmed that the nature of Yang Ming disease in Shang Han Lun belonged to interior heat repletion patterns and could be further divided into 3 types: Taiyang, Yangming (The evil passes from the Tai Yang channel into the Yangming channel), ZhengYang Yangming (The evil invades directly into the Yangming channel) and Shaoyang Yangming (The evil passes from the Shao Yang channel into the Yang Ming channel). The causes of Taiyang Yangming and Shaoyang Yangming are related to depletion of body fluid due to inappropriate promotion of sweating, urination and bowel movement. The major symptoms to indicate a channel pattern include generalized heat effusion, spontaneous sweating, and no aversion to cold; but aversion to heat accompanied by thirst, large pulse, red facial complexion, etc.; while the typical symptoms of a bowel pattern include failure to defecate, internal repletion, and difficult defecation accompanied by tidal heat effusion, dry stool, focal distention, abdominal fullness, abdominal pain, a tense and firm abdomen, etc. Even unconsciousness like delirium can be seen in the severe cases. In order to treat excessive heat in Stomach and Fang Zhang, LAc, M.Med (China)

24 Intestine, the treatment principle is to clear heat and remove pathogens from Yang Ming by choosing herbs with the nature of acrid cold, bitter cold and even salty cold. Zhang Ji characterized the main symptoms of Tai Yin disease as abdominal fullness and vomiting, inability to get food down, severe spontaneous diarrhea, and periodic spontaneous abdominal pain. The main pathogenesis includes either constitutional Spleen Yang deficiency which contracts wind-cold, direct internal damage to the internal organs from external cold, or damage to the Spleen when a condition is not treated or treated inappropriately. As a result, some herbs and herbal formulas which are good at either tonifying deficient Qi in middle Jiao or warming Yang Qi in Middle Jiao are widely used such as Ren Shen, Bai Zhu, Gan Cao, Fu Zi, Gan Jiang in single herb and Li Zhong Tang, Si Ni Tang in formula. Comparing Yang Ming disease to Tai Yin disease, the nature of Yang Ming disease tends to be more excessive, hot and Yang, while Tai Yin disease tends to be more deficienct, cold and Yin. In terms of location of the pathogens, the Yang Ming disease is more superficial and Tai Yin disease is more interior. This so-called excess is in Yang Ming, deficiency is in Tai Yin (Wang, Qi, 1988) Among the dysfunction of six channels, diseases of Spleen and Stomach are accounted for two of six. As for the diseases deriving from dysfunction of other four channels are concerned, Shang Han Lun has emphasized on treating them through protecting the Stomach Qi and keeping liquid because the nature of the earth is the center and the pivot of reference for all the other elements The application of eight therapeutic methods in treatment of the Spleen and Stomach diseases Fang Zhang, LAc, M.Med (China)

25 Although eight therapeutic methods were first organized by the Qing dynasty physician Cheng Zhong-ling in his book Yi Xue Xin Wu (Medical Revelations), its clinical application were found in Zhang Ji s-work originally. Even the eight therapeutic methods were not originally designed for the spleen and stomach or Tai Yin and Yang Ming diseases, they have indeed refected Zhang Ji s idea in supporting, and protecting Qi of Spleen and Stomach organs as the key when composing the formulas. Therefore, Zhang attached great importance to the role of the Spleen and Stomach when treating three Yins and three Yang diseases. For example: Diaphoresis: Physiologically, Spleen governs transportation and transformation of nutrients and body fluids and control muscles. The Spleen also has the physiological characteristic of desiring dryness but aversion to dampness. Therefore, a dysfunction of the Spleen in transportation and transformation due to the deficiency of the Qi of the Spleen is susceptive to generating dampness, while excessive dampness will most likely disturb the Spleen. Moreover, the Spleen is also easily attacked by external dampness. External dampness manifests various symptoms, such as a feeling of tiredness, heaviness of limbs or head and abdominal distension, etc. In this case, Zhang Ji treated the symptoms by adding herbs which can strengthen Spleen to resolve dampness into formulas to release the exterior syndrome. For example, in Jin Gui Yao Lue (Zhang, 1963), he used Ma Huang Jia Zhu Tang to treat generalized vexation and aching due to invasion of wind-dampness or damp-cold in the interior in patients with chronic dampness due to Spleen deficiency. When originally there was Tai Yang disease, but the physician used purging method incorrectly, and consequently there was abdominal Fang Zhang, LAc, M.Med (China)

26 fullness with periodic pain, which belongs to Tai Yin disease. Gui Zhi Jia Shao Yao Tang is based on Gui Zhi Tang with increased dosage of Shao Yao and is a classic formula to address this condition Purgation:It is appropriate for the Qi of the Spleen to ascend, and for the Qi of the Stomach to descend. Purgation is one of common methods widely applied in the diseases of Spleen and Stomach, especially whenever there is abdominal fullness and pain accompanied by difficult bowel movement and dry stool due to excessive Stomach and/or Intestinal heat with damage of body fluid. In Shang Han Lun, Zhang Ji has come up several formulas to target this condition in purging by descending Stomach Qi. Da Cheng Qi Tang, Xiao Cheng Qi Tang, Tiao Wei Cheng Qi Tang and Ma Zi Ren Wan are four main formulas to treat this kind of abdominal disharmony Emesis: According to the chapter 74 in Su Wen, it states that if the location of disease is at the upper part of the body, it should be treated with a method to lead it up and out. Emesis is this kind of a special and strong therapeutic strategy expel phlegm, saliva, undigested food or toxic substances that retain in the throat, thoracic cavity or Stomach, mainly for the removal of the phlegm and saliva clogging in the throat, or the stubborn phlegm retaining in the thoracic cavity in the Stomach. Emesis can be induced either by sticking a feather probe into the patient s throat or using Chinese herbs. The selection of herbs is based on the nature of syndromes. For excess syndromes, Gua Di, Li Lu and Dan Fan are chosen; at the same time, Ren Shen is chosen for patients with deficiency syndrome. In the Shang Han Lun line 166(Mitchell ect, 1999), Gua Di San is Fang Zhang, LAc, M.Med (China)

27 used for eliminating phlegm retention in the upper Jiao by causing the patient to vomit. On the other hand, if there is vacuity vexation and inability to sleep or anguish in the Heart or vomiting, it can be treated with Zhi Zi Chi Tang and Zhi Zi Sheng Jiang Tang, etc. The Dan Dou Chi in Zhi Zhi Chi Tang and Sheng Jiang in Zhi Zi Sheng Jiang Tang are used for protecting Stomach Qi Harmonizing: Harmonizing is mostly used to treat half-exterior and half-interior syndrome by harmonizing or regulating the functions of different levels or organs, including harmonizing the Shao Yang, venting the membrane source, harmonizing the Liver and Spleen and regulating the Stomach and Intestine. It can be used in treating disease of Spleen and Stomach through regulating Middle Jiao Qi. Just as Line 30 in the Shang Han Lun(Mitchell etc 1999): When in Yangming disease, there is hardness and fullness under the rib-side, inability to defecate, retching, and white coating on the tongue, one can give Xiao Chai Hu Tang; the upper burner will unblock, liquid and humor will be able to descend, stomach-qi will thereby become harmonious, and then there will be generalized streaming sweat, bringing about resolution. In addition, Sheng Jiang Xie Xin Tang can treat water and heat complexes or Stomach deficiency with food stagnation and suspended fluids lingering internally by using acrid herbs to disperse clumping, using bitter herbs to descending Qi downward, and using sweet herbs to benefiting and harmonizing the Middle Jiao Qi. After pathogens blocked in the Middle Jiao is removed as well as Zheng Qi is supplemented, the balance in the Middle Jiao is back to normal Warming: According to the chapter 74 in Su Wen, it states that when treating the Fang Zhang, LAc, M.Med (China)

28 cold disease, apply the hot herb; when treating the hot disease, apply the cold herb. Warming method is used to treat both excess cold syndrome and deficiency cold due to Yang Qi deficiency. Spleen and Stomach is considered as the post-natal foundation and is responsible for digestion and nutrition. There are different formulas discussed in Shang Han Lun to work on deficient cold in Middle Jiao. For example, Li Zhong Tang is the one to treat abdominal fullness and pain accompanied by vomiting, watery diarrhea with undigested food, and lack of thirst due to Yang Qi deficiency in the Middle Jiao. In addition, Da Jian Zhong Tang was recorded in the Jin Gui Yao Lue for relieving severe epigastric and abdominal pain and vomiting due to Middle Jiao Yang Qi deficiency with Stomach Qi rebelling Clearing heat: This therapy is used to clear heat of the Stomach with representative formula Bai Hu Tang. If there is a impairment of body fluid, Ren Shen is added to Bai Hu Tang to supplement Qi and generate body fluid, therefore it is called Bai Hu Tang Jia Ren Shen Tang; if there is lingering heat located in the Lung and Stomach which already damage the Qi and body fluid, Zhu Ye Shi Gao Tang is the one to clear residual heat, nourish body fluid, tonify Qi and harmonize the Stomach. Furthermore, when there is jaundice resulting from the combination of heat and dampness in the middle, Yin Chen Hao Tang was mentioned in Shang Han Lun line 236 and 260 to treat this condition Elimination: Zhang Ji applied the strategy of elimination to resolve the abdominal fullness and distension. For example, he used Hou Po Sheng Jiang Ban Xia Fang Zhang, LAc, M.Med (China)

29 Gan Cao Ren Sheng Tang to relieve abdominal fullness and distension resulted from sweating. Originally, it is Gui Zhi Tang syndrome and but mistreated with Ma Huang Tanng. After excessively sweating promoted, the exterior syndrome is relieved; however, Yang Qi is impaired due to inappropriate sweating and there is also Qi stagnation because of the dysfunction of the Spleen. This is a conflicted situation because of the nature of the disease. If pure tonifying method is used, the Qi stagnation will be worsened; if pure eliminating method is applied, the Yang Qi deficiency will become more severe. Thus the function of this formula is to treat both conditions simultaneously. In this formula, Ren Shen, Gan Cao and Sheng Jiang are used to tonify Yang Qi; Hou Po and Ban Xia are for moving Qi of Spleen. The elimination method is widely used in the clinic with good success Tonification: According to Su Wen chapter 20, whenever there is deficiency syndrome, tonifying method is appropriate to be utilized. Zhang applied the treatment strategy of tonification in different ways, but one of his major treatment methods to compose his formula is to build up and tonify Middle Jiao. The formulas reflecting this composition include Xiao Jian Zhong Tang, Shu Yu Wan, Fu Mai Tang and Huang Tu Tang, etc. In addition, when tonifying was not his main treatment focus, however, he still added small amount of tonic herbs to the formulas which are composed of other treatment strategies, such as sweating, vomiting, purgation, harmonizing, warming, clearing heat and elimination. His purpose of using tonification here is to remove pathogens and rebalance the body through tonifying Zheng Qi and harmonizing the Middle Jiao. Fang Zhang, LAc, M.Med (China)

30 In short, there are plenty of descriptions either in brief form or detailed form on the application of the "Eight TherapeuticMethods" on the treatment of diseases of the Spleen and Stomach in Shang Han Za Bing Lun. Even to date, they are very useful for clinical practice. 2.3 Emphasize the importance of harmonizing Stomach and tonifying Spleen Qi In Shang Han Za Bing Lun, Zhang Zhong-Jing often used the herbs of harmonizing the Spleen and Stomach as assistant herbs in the formulas of attacking pathogenic factors in order to avoid the damage of Zheng Qi (vital Qi). It reflects two basic characteristics of the composition of attacking-pathogen formula. The first one is to eliminate pathogenic factors with a mild tonifying method; and the other one is to emphasize on harmonizing Stomach to consolidate the root of the body. For instance: Gan Cao is in the formula of Ma Huang Tang which is the basic exteriorreleasing formula; Sheng Jiang, Da Zao and Gan Cao are seen in the Gui Zhi Tang which is the major formula to harmonize Yin and Wei; Ren Shen, Gan Cao, Sheng Jiang and Da Zao are in the formula of Xiao Chai Hu Tang which is the main formula to treat Shao Yang disease; Geng Mi and Gan Cao are in the Bai Hu Tang which is for Yang Ming channel syndrome; Gan Cao is in the Tiao Wei Cheng Qi Tang to harmonize Stomach, etc. Even there is no herb such as Gan Cao etc.to harmonize Middle Jiao in the Da Cheng Qi Tand and Xiao Chen Qi Tang, special attention was paid in terms of administration method for both of formulas. Discontinue these two formulas once bowel movement has been induced, which can prevent damage of Zheng Qi due to over-dosage. Fang Zhang, LAc, M.Med (China)