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U Yè Tian-Shì on Vacuity Detriment: A Model for a Mode of Inquiry in Chinese Medicine

By Bob Damone

Vacuity detriment ( xu sun ), according to Wiseman and Feng (1998), is "any form of severe chronic insufficiency of Yin-Yang, Qì-Blood, and Bowels and Viscera arising through internal damage by the seven affects, taxation fatigue, diet, excesses of drink and sex, or enduring illness." I have found this Chinese disease category helpful in evaluating and formulating treatment strategies for patients with enduring diseases such as chronic fatigue syndrome, depression and fibromyalgia. TP PT These patients invariably have many concurrent, complicated and apparently contradictory symptoms and always present a formidable challenge to the clinician. Vacuity detriment is a useful conceptual template in such circumstances precisely because it provides the Chinese medical context in which to understand not only the complexities of serious and multiple vacuities but also their complications. As such, it gives clinicians insight into available conceptual models and treatment strategies for deeply vacuous patients. And when treating patients with complex diseases such as vacuity detriment, strategy often emerges as the decisive factor for attaining good clinical results.

Yè Tian-Shì, the preeminent Qing dynasty physician, who is perhaps best known in the West for his contributions to the Warm Disease School ( wen bìng xué pài ), also influenced many other aspects of Chinese medicine. One of the most famous works recording his case studies and teachings on various medical topics - A Clinical Guide with Case Histories ( lín zhèng zhi nán yi àn ) - was published in 1766. This text is organized by Chinese disease category P PT and each chapter typically contains many case studies followed by a summary essay in which Doctor Yè or one of his students eloquently transmits clinical guidance for treating that disease. Although I find the case studies fascinating and instructive, these challenging essays especially intrigue me.

I have translated the short summary essay on vacuity detriment contained in A Clinical Guide with Case Histories and offer it here. Any translation is fundamentally flawed, and as the classical Chinese used in the text is somewhat difficult to penetrate, I may have translated some of the text erroneously. However, I have done my best to faithfully render its intended meaning as I understand it. Additionally, and admittedly somewhat boldly, I have taken the liberty of offering my own comments on the text itself, which follow the essay in the "notes" section (the bracketed numbers in the text correspond to the number of the note). TP PT Lastly, I offer some opinions and conclusions I have come to from observing the mode of inquiry revealed in the text.

The Text

On the subject of vacuity taxation, the classics are quite detailed, though this condition has more than one name within these texts. When investigating the Inner Canon , TP PT one finds discussions about taxations of each of the five viscera and the many different treatments described for them. Later people were of the opinion that upper burner taxation is yáng and lower burner taxation is yin. Further, they did not treat this condition with acupuncture, but regulated it by using sweet medicinals instead. The Golden Coffer TP PT followed this principle and established xiao jiàn zhong tang (Minor Center-Fortifying Decoction) to rapidly fortify center burner qì so as to increase one's intake of food and drink and to thereby make fluid and blood effulgent. [1] Thus, abundant blood engenders essence, and one recovers from insufficiency of the true origin indirectly. [2] When sowing and reaping in this way, one may mainly use the sweet flavor; therefore, it is not necessary to use sour, acrid, salty, and bitter flavors. [3] However, one cannot build a barn with this method alone and likewise one must have other methods with which to treat. So, one can treat detriment and insufficiency of the upper burner yáng aspect by banking up the root of the lower burner true yin. Thus relying on doctor Zhang Zhòng-Jing, others derived formulas such as Heaven, Human, and Earth Decoction ( san cài tang ), Root-Securing Pill ( gu ben wán ), True Heaven Elixir ( tian zhen dan ), Great Creation Pill ( dà zào wán ), Cinnamon Twig Plus Dragon Bone and Oyster Shell Decoction ( guì zhi jiá lóng gu mu lì tan ), TP PT and Pulse-Restorative Decoction ( fù mài tang ), as well as various securing and containing formulas, and those methods that evenly supplement the three foot yin viscera. Thus, they treated vacuities of all five viscera simultaneously. This greatly relieved the ignorance of later people who then realized that these other methods could also be helpful in treating vacuity detriment.

The Golden Coffer also states that when a man has a large pulse, he has taxation, and that extreme vacuity is called taxation. A large pulse indicates even greater damage to the qì aspect than a fine pulse does. [4] It shows thought and preoccupation and depression and binding, Heart-Spleen construction detriment in the upper and center burners, and exhaustion of the construction aspect. It must be treated by formulas such as gui pí tang (Spleen-Returning Decoction), xiao jiàn zhong tang ( Minor Center-Fortifying Decoction), rén shén yang yíng tang (Ginseng Nutritive-Nourishing Decoction), TP PT sì jun zi tang (Four Gentlemen Decoction), wu wèi zi (schisandra, Schisandrae Fructus), TP PT and yì gong san (Special Achievement Powder). If the pulse is extremely vacuous, the condition is also called taxation. It is interior essence-blood despoliation and Liver and Kidney failing to naturally construct each other. [5] It must be treated by formulas such as liù wèi dì huáng wán (Six-Ingredient Rehmannia Pill), ba wèi dì huáng wán (Eight-Ingredient Rehmannia Pill), tian zhen dan (True Heaven Elixir), dà zào wán (Great Creation Pill), san cài tang (Heaven, Human and Earth Decoction), gù ben wán (Root-Securing Pill), fù mài tang (Pulse-Restorative Decoction), by methods that evenly supplement the three foot yin viscera, and by various securing and containing methods.

So, after Zhòng-Jing, heroes and virtuous people came forth in large numbers; however, how could they not expound on he whose teachings lay hidden behind their own? Moreover, how could so many doctors not study the teachings of their ancestors well? Thus, they wished to abandon doctor Zhòng-Jing's methods, and they believed they were capable of treating every person who has vacuity taxation by employing many different ideas. These included Dong-Yuán and Dan-Xi, TP PT famous doctors from earlier dynasties who disagreed with past treatments for detriment and instead mainly used ginseng ( rén shen , Ginseng Radix) and white atractylodes ( bái zhú , Atractylodis Macrocephalae Rhizoma), and they used many jin TP PT of each. The gist of their approach seems to be that since that which has form, namely essence and blood, is difficult to restore, they urgently supported the formless qì instead. [6] Thus, they expanded on Zhòng-Jing's various center-fortifying decoctions.

Later, there was Zhang Jing-Yuè, who considered life gate yin aspect insufficiency as vacuous yin within yin, and who mainly used zuo gui yin (Left-Restoring Kidney Yin Beverage) and zuo gui wán (Left-Restoring Kidney Yin Pill). Moreover, he considered life gate yáng aspect insufficiency to be yáng vacuity within yin and mainly used yòu gui yin (Right-Restoring Life Gate Beverage) and yòu gui wán (Right-Restoring Life Gate Pill). He did not deviate from formulas used by other doctors such as gù ben wán (Root-Securing Pill), tian zhen dan (True Heaven Elixir), and dà zào wán (Great Creation Pill), or from even supplementation of the foot three yin, or from various securing and containing methods.

In light of the above, subsequent people praised doctor Zhòng-Jing for being good at treating vacuity taxation; one should aspire to understand his intentions.

Enduring vacuity without recovery is called detriment, and extreme detriment without recovery is called taxation. These three - vacuity, taxation, and detriment - occur in succession. In reference to the causes of this condition, there is not only one origin; even after it comes about, it is difficult to make a detailed analysis of its causes. In most cases, the cause is vexation and taxation damaging qì. Doctor Zhòng-Jing treated the upper burner and the center burner, and therefore used sweet cool Lung-Stomach supplementation for clearing and moistening or emolliating formulas to nourish the construction-fluid of the Heart and Spleen. [7] Or, he used sweet flavors with warm qì to construct the center palace without causing the two qì to become inclined to one side by day, meaning that construction and defense should follow their normal cycles. And for those cases which are caused by sexual overindulgence damaging essence, one should treat the lower burner and simultaneously treat the eight extraordinary vessels as well. Also, one should know that to replenish and supplement essence-blood, one should supplement the essential qì aspect, boost fire, and enrich yin. Or, quiet and contain the controlling channel-yin, TP PT and warm and rectify the mysterious place's TP PT extraordinary yáng. If this is the cause, the condition will be defeated. For those with mixed and widespread disease, one should recognize all the details, follow the dynamics and circumstances and regulate. Following the intentions of the master, differentiate the constitution in terms of yin and yáng in order to ascertain the main points - upper, center, and lower - and take them all into consideration. Understanding the shift, passage, and transmutations of early and later heaven is decisively the key to life and death. If one pursues these details and inquires into them, one by one the roots can be considered and one can avoid merely haphazardly floating downstream and putting together a few supplementing medicinals randomly in an attempt to treat this condition. [8]

Notes

This strategy emphasizes that if the Spleen and Stomach are strong, their functions - decomposition of water and grain as well as movement and transformation of water and grain essence - will be more effective. The lung governs qì and is the place where ancestral qì is formed from a combination of water and grain essence (grain qì) and clear qì inhaled from outside the body. The heart governs blood. This function includes not only its action on movement of blood but also points to its role in engendering blood, which is described in chapter 5 of the Su Wèn (Plain Questions). Moreover, as the Spleen is "the origin of fluids," it plays a vital role in the initial creation of fluids. Thus, as the Spleen bears this water and grain essence upward to the lung and heart more efficiently, more qì, blood, and fluid can be engendered through their mutual actions and cooperation.
I believe this alludes to the transformation of surplus blood to essence through the mutual actions of the Liver and Kidney, and to the storage of that essence in the Kidney. In this way, later heaven essence can bank up early heaven essence.
I find this a very interesting choice of words. My hypothesis is that the use of the agricultural imagery in this sentence is meant to draw an analogy between supporting the center burner-earth and farming.
This is a direct allusion to chapter 6 of The Golden Coffer . It is imperative that we not misinterpret a large pulse that lacks force as a repletion pulse. At times, an inexperienced student or even a practitioner may misconstrue the largeness of an otherwise forceless pulse as an indicator of force, when in fact it indicates significant interior vacuity.
Here again there is a reference to the interrelationship between the Liver and Kidney summarized in the axiom: "The Liver and Kidney share the same origin." Under normal circumstances, there is some surplus blood stored in the Liver, which can be transformed into essence by the Liver and Kidney, and can then be stored in the Kidney to supplement early heaven essence. Conversely, when Kidney essence is being depleted, stored essence is transformed into blood to nourish the viscera-bowels, channels and network vessels, and the rest of the bodily form.
Supplementing formless qì to engender that which has form -- namely essence-blood -- is an important treatment principle to keep in mind for patients who have substance vacuity (i.e. essence and blood vacuity) but who also have vacuity-weakness of the center burner. Indeed, their essence-blood vacuity may be a direct result of their Spleen-Stomach vacuity. Although such patients require substantial nourishment - including medicinals with an affinity to flesh and blood (e.g. animal products) - they sometimes cannot tolerate them unless they are not either given with center fortifying medicinals, or given after a course of center fortifying treatment has been completed. I find that this dilemma is quite the rule in vacuity detriment conditions. This treatment principle also reveals that Yè, as well as Dan-Xi and Dong-Yuán, understood the human body as an integrated whole; thus, intervening at the formless qì aspect can eventually result in an increase in the substantial essence-blood aspect.
This appears to be alluding to mài mén dong tang (Ophiopogon Decoction) and gan mài dà zao tang (Licorice, Wheat and Jujube Decoction).
At the risk of reading too far into this last section, I sense Yè is reiterating the Inner Canon 's advice to treat the root of disease. Although there are a number of strategies used to treat patients with several concomitant patterns, and I have seen results from more than one of them, there is something to be said for seeking the root and focusing one's treatment on it rather than being distracted by the tip. For example, I have seen some complicated patients with vacuity detriment or vacuity taxation (some of who had even suffered from qì vacuity heat effusion or yáng vacuity heat effusion) and a history of digestive side effects from failed attempts at conventional and cloying supplementation. Many of these patients respond well to variations of the yin-yáng harmonizing formula xio jiàn zhong tang (Minor Center-Fortifying Decoction). In other words, for such cases, trying to nourish essence-blood directly with a complicated and multi-faceted formula is sometimes not as effective as doing so indirectly by first fortifying the center burner. When we understand the interrelationships among the viscera and bowels, and the mutual coordination between the Spllen-Stomach and the Kidneys, we see that the center burner is the source of later heaven essence, and that this essence can be stored in the Kidneys to bank up early heaven essence.

Conclusion

A careful reading of essays like this bears witness to the literate Chinese medical mind of Yè Tian-Shì as he grapples with the problems of human illness. From the fact that he searches the writings of his predecessors for solutions to these problems we may conclude that Yè (and by extension, other physician literati of his and the current era), viewed doctoring as both a scholarly and clinical pursuit. This bound literate Chinese doctors to the mastery of a specific medical corpus (even as they retained a certain critical yet respectful stance toward it). TP PT This is the only explanation for Yè's frequent reference to certain classic texts and his allusions to the clinical and theoretical perspectives recorded there by his predecessors. Yet to my reading, his essays do not emit a sense of blind allegiance to scripture-like dogma, but instead reveals a two-step process. Step one involves extracting the available and relevant writings including records of clinical experiences from within the medical corpus of Chinese medicine. Step two requires generating coherent arguments for new approaches when the existing ones are found to be unsatisfactory. This mode of inquiry is of much value to clinician-scholars and students of Chinese medicine in the West, as it provides a historically and empirically validated roadmap toward a mature understanding and more effective practice of Chinese medicine.

References

Bensky, D. and Scheid, V. (date unknown). " U Medicine is Signification: Moving Towards Healing Power in the Chinese Medical Tradition. U " Reprinted from the European Journal of Oriental Medicine. SIOM Resources On-line. H TU www.siom.edu UT H .

Damone (2003) "From Symptoms to Treatment in Four Easy Steps." Blue Poppy Seminars. Audio distance learning CEU seminar. Boulder : CO.

Flaws, B. (2004) (Trans.). U Treatise on the Spleen and Stomach. U Blue Poppy Press. Boulder : CO.

Scheid, V. (2003). "Ye Tian Shi's Strategies for the Treatment of Bloody Stools." Journal of Chinese Medicine, Volume 71 #41. United Kingdom .

Wiseman and Feng (1998). U A Practical Dictionary of Chinese Medicine U . Paradigm Publications: Brookline , MA .

TP PT I do not suggest, however, that this is the only effective approach. Certainly the work of Li Dong-Yuán and Zhu Dan-Xi, as Bob Flaws has pointed out, also has merit here. For example, see Flaws (2004).

TP PT I intentionally use the term "disease ( bìng )" here to distinguish from "pattern ( zhèng )" or "disease pattern ( bìng zhèng )." Although pattern discrimination is an essential component of Chinese medical diagnosis, we should not overlook the value of disease discrimination as an important diagnostic step. In fact, it provides an organizing principle around which pre-modern and modern Chinese physicians have focused their diagnostic and therapeutic decisions. See Damone (2003).

TP PT These comments are my own reflections on the text, thought they mirror Chinese medical ideas and opinions advanced by pre-modern and modern doctors in many other contexts. Also the excellent article by Scheid (2003) reveals there is an extant body of commentary on Yè's work. I have not consulted these in the preparation of this article.

TP PT Huáng dì nèi jing (The Yellow Emperor's Inner Canon, 1st century C.E.).

TP PT Jin guì yào lue fang lùn (On the Essential Prescriptions of the Golden Coffer, Eastern Hàn , Zhang Ji [Zhòng-Jing]).

TP PT This is a bit puzzling because this formula is attributed to Zhang himself.

TP PT In the text itself, only the words yang yíng appear here, which mean either "nourish construction," or "construction-nourishing." I suggest these words are serving as shorthand for Ginseng Construction-Nourishing Decoction, especially because the rest of the formulas in this sentence are also written in shorthand.

TP PT The text states wu wèi , which I assume to be shorthand for wu wei zi (Schizandra Fructus). Although it is odd that schizandra would be the only individual medicinal in a longer list of formulas, I am unable to find a supplementing formula for which it might be serving as shorthand for.

TP PT The reference here is of course to Li Dong-Yuán and Zhù Dan-Xi , who were arguably the two most influential doctors among the four great physicians of the Jin and Yuán period ( jin-yuán sì dà jia ).

TP PT A jin is a traditional Chinese measurement equivalent to 1/2 a kilogram.

TP PT Controlling vessel ( rèn mài )

TP PT The "mysterious place" or "mysterious house (mansion)" are allusions to the interstices ( cou li ) and are most often found in pre-modern texts.

TP PT See Bensky, D. and Scheid, V. in which Yè Tian-Shì is quoted as saying: "That which is referred to as reading the ancient [classics] but not getting bogged down by them, adopting their methods [or prescriptions] without being controlled by them, this marvel of transformative judgment, [unfortunately] is something of which people are capable only with difficulty."