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Tangs, Wans, Sans and More

by Toni Narins, L. Ac.

I remember my first encounter with Chinese herbs as if it were yesterday. I was a new student, and wanted to start taking formulas so that I could speak to my future patients with more confidence. I chose Si Wu Tang (Four Substance Decoction), because it was a "simple, safe, woman's formula". After my first taste of this decoction, I questioned my sanity at entering this field, and wondered why I hadn't chosen pharmacology instead.

After this incident, I switched my attention to those little brown "beebees." After all, I argued, Americans are more used to taking pills, and if I could find what I needed in pill form, why should I ask my patients to drink tree roots? I started using them whenever I felt a cold, flu, or other acute condition coming on. With the exception of "Curing Pills," I found the results mostly disappointing. I looked at the little beebees, and concluded that the problem was probably in the dosage - I figured I'd have to swallow half a bottle at once to get enough. I began to understand why Americans prefer Tylenol.

It is now many years later, and I have been studying and experimenting with different delivery systems of herbs, from hot liquids to those "beebees" - which are actually concentrated herbs. In my practice today, I treat different patterns of disease, sometimes within the same patient, using combinations of tinctures, powders and large, chewable, honey pills. I will give an example from a recent case to illustrate my point.

Miss B., a 34-year-old woman, came to my clinic with chronic fatigue, always feeling cold. Depression and insomnia were her chief complaints. Additionally, she was bothered by the fact that the "cold sore" on her lip had recently erupted again. "It always does when I'm under stress," she said. As we spoke, her voice and her manner did not suggest any fatigue. But she told me that while she did manage to get through her work day, she was always tired.

"I've been depressed for at least four months. Not a debilitating depression, but just unable to get out from under a gray cloud hanging over my head," she confessed. A few months ago, she had moved in with a new roommate and they were getting along very well. She was facing some career decisions though, and could not make up her mind whether to stay in town or to relocate. (She had several offers.) She also stated that she often experienced low-grade, low back pain.

As far as her sleep was concerned, she had problems mostly with falling asleep, but also experienced some difficulty staying asleep. She would wake sometimes at around 5 am, unable to get back to sleep. She reported no other symptoms during the intake.

Her complexion was pale, and her hands were quite cold when I took her pulses, which were generally thin and deficient. Her tongue was pale, with normal moisture, slightly puffy, and a somewhat reddish tip. Her feet were also cold, and she said that the rest of her body felt cold too - not just her hands and feet.

I diagnosed her problems as Kidney Yang vacuity with underlying Spleen Qi vacuity. Not only were her sensations of coldness due to Kidney Yang vacuity, but also her depression, which stemmed from the accumulated cold blocking the Yang Qi. Without Yang Qi circulating freely, her spirit was constrained, or "depressed." Additionally, without the aid of sufficient Kidney Yang, the Spleen Qi had become weak. She therefore suffered from Qi and Blood vacuity, which was the basis of her chronic fatigue. Her cold sore and insomnia could potentially be explained in one of two ways. In addition to the Kidney Yang vacuity, a Kidney Yin vacuity could exist in which the Kidney water fails to anchor the fire. Or the problem could be attributed to weakened Spleen Qi. In the five element system, if Spleen Qi is weak, it will drain the Heart (its "mother") creating the potential for insomnia and skin lesions. I will address my approach to this issue later in this article.

I began by selecting K'an Herbal's "Dynamic Warrior" (based on Jin Gui Shen Qi Wan) as the starting point. K'an has modified the original formula by removing Ze Xie, Fu Ling and Mu Dan Pi - the draining, cooling herbs aimed at the Kidneys, Spleen and Liver. They then replaced those with herbs which are essentially warm, such as Du Zhong (Cx. Eucommiae), Ren Shen (Rx. Ginseng), Ba Ji Tian (Rx. Morindae), etc. Even though this makes the formula warmer than the original, I wanted to boost the warming effects still further. I gave her powdered Rou Gui (Cx. Cinnamomi) - one of the herbs in Dynamic Warrior - thereby increasing its dosage. This powerful warming herb provides a strong sense of "movement" - an ability to break through cold which has become frozen and blocked. I instructed her to put a quarter of a teaspoon of it in a cup, pour on some hot water to dissolve it, then add the dropper of Dynamic Warrior. By administering the herbs in this fashion, she got to drink them as a full cup of hot liquid, instead of an eyedropper at room-temperature. In addition, adding Rou Gui made the formula taste better - a powerful incentive to comply!

I wanted to address her insomnia and her cold sore as well as her Kidney Yang vacuity. I decided to start her on Tian Wang Bu Xin Dan in a large, chewable, honey pill ("wan"), taken twice a day. My reasoning for using this formula was twofold: first, to concentrate the initial therapy on the Kidneys, avoiding a "shotgun" approach of attempting to address all possible organ systems at once. Also, the formula nourishes the Blood as well as the Yin, and so helps to accomplish a long-term goal. Why did I choose the wan, since K'an also makes this formula as an extract? For several reasons. First, I opted for the wan because the large, chewable, dense pills are heavy, and therefore have the ability to "weigh" things down, or settle them. Additionally, there is more dense substance in the wan, and since I wanted to nourish the Blood and enrich the Yin, a thicker, denser substance was more desirable. Moreover, I have found that giving my patients formulas to take in different forms increases compliance rates. I therefore rarely give two extracts to a patient to take at the same time.

On her next visit, she reported that she had felt better from the first dose of her formula. Her depression lifted within a day or two, and her hands and feet began feeling warmer within the week. Her sleep was somewhat improved, although she reported being awakened one night by a disturbing dream. Her energy levels were better but still low, and her cold sore was practically gone. Her pulses showed increased strength and resilience, but were still weakest in the middle and third positions on both sides.

At that point I felt we had made the initial "breakthrough" I was looking for, and felt we could begin to address her Spleen Qi vacuity. Since the Yang Qi was now clearly circulating more freely, I switched her formula to K'an's Gather Vitality based on Gui Pi Tang, and eliminated Tian Wang Bu Xin Dan. However, I continued to have her use the powdered Rou Gui, both as an inducement to drink a hot beverage, and also to continue the circulation of Yang Qi. At the time this article was written, three weeks had passed since her initial visit. She has reported feeling more energetic than before. She also says she is feeling warmer than she used to feel at this time of the year. In the spring, with the return of warmer weather, when life's Yang energy begins to circulate more, I'll re-assess her formula and continue to modify it as needed.

Two important points regarding this case must be made. First of all, before selecting any formula at all, I did a thorough history of her diet. Without addressing her diet first, it would have been like Sisyphus rolling the rock up the hill only to have it roll down again and again. Fortunately in this case, the patient was very aware of her diet. The few modifications which were necessary were minor and easily incorporated by her.

Secondly, I'm a believer in using the finest herbs available. I'm convinced that the results I got and how quickly I got them are tied to the quality of the herbs I work with. The Rou Gui I use costs $10 an ounce, not $4.50. You can smell it through a sealed plastic bag. I might have achieved the same results if I had used the cheaper herbs, but it would have taken much longer, and therefore would have actually cost more. Many years ago, in reading a magazine on building wooden boats, I saw an axiom which I have applied to my life ever since: In the long run, you can afford the better tool.