This is a long and involved
discussion of a chinese herbal formula in Chinese medical terms.
It may be too much for the casual reader. It's best suited
for Chinese medical students and practitioners.
A patient enjoying her decoction
The Use of Gui Pi Tang in TCM Internal Medicine
The Zang-fu organ relationship is a detective game in which externally
manifested symptoms give clues to the pathological underlying
mechanisms that occur within the body. These symptoms and signs
are then broken down in a symptom differentiation (Bianzheng).
This allows the physician to metaphorically look inside the body
and understand which organ(s) is diseased, the pattern or movement
of the disharmony from one organ to another and its origin. This
is because Traditional Chinese Medicine (TCM) chiefly focuses
on the difference of the pathogenesis, that being the syndrome
rather than the disease itself. From there a treatment strategy
is employed, (Lunzhi) to either treat the branch (Biao) (often
the presenting symptoms) or the root (Ben) cause. Therefore, the
aim of this essay is to discuss the Bianzheng Lunzhi of Gui Pi
Tang in terms of the theory of treating different diseases with
the same method.
Gui Pi Tang (Restore the Spleen Decoction) was first recorded
in the classic Ji Sheng Fang (Formulas to Aid the Living) in 1253AD
by Yan Yonghe and is derived from the modification of Si Jun Zi
Tang. However, it wasn't until three to four centuries later that
the Ming and Qing physicians completed its actions, indications
and symptom complexes. It is categorised as a formula that tonifies
Qi and Blood. Gui Pi Tang is used to treat different diseases
with the same method. This method implies that the same principle
and method may be applied for different diseases on condition
that they share some pathological syndrome conditions (Bo 2000).
When prescribing any formula, the physician should always consider
the action of supporting the Zheng Qi (genuine) and dispelling
the Shi Qi (evil). The pattern of Zheng Qi and Shi Qi can one
- Excess: Right and Evil are strong.
- Deficiency: Right and Evil are weak.
- Complex: Deficiency complicated by excess and visa versa.
When treating the complex patterns, the physician must employ
one of the following strategies listed below. Gui Pi Tang acts
to tonify the Spleen and nourish the Heart Blood, therefore strengthening
the Zheng Qi.
- Strong Zheng Qi: .Drain/Tonify:
- Not so strong Zheng Qi: First, drain, second tonify.
- Weak Zheng Qi: First tonify, second drain (Wahnish 2000).
The abnormality of Qi and Blood are closely and directly connected
with the functions of the Zangfu. The Lung dominates Qi, the Heart
controls the circulation of Blood, the Spleen is the source of
Qi and Blood and keeps it flowing, the Liver stores Blood and
regulates the flow of Qi and the Kidney governs the reception
of air and stores essence which shares a common source with Blood
In TCM, the Spleen and Stomach are regarded as the 'Sea of Qi
and Blood'. This symbolism refers to the Spleen being the source,
origin or reservoir of Qi and Blood. The Stomach stores the food
stuffs and then the Spleen transforms and transports the Gu Qi
to the Lung. From there it is mixed with air to form Zong Qi.
It is then transported to the Heart where it is transformed into
Blood (Maciocia 1989). There are several schools of thought in
TCM. One of these is the Li Kao school, which states that a large
number of rooted Zangfu disharmonies are cured by treating the
Spleen and Stomach. A deficient Spleen will lead to a reduction
in Qi and Blood production and will have a major influence on
the rest of the Zangfu organs moreover than any other organ because
a lack of generated Qi and Blood will lead to a lack of Qi to
correctly maintain the Zangfu organs and dysfunction will occur.
Therefore, the importance of Gui Pi Tang is greatly exuberated
by the condition it treats, that being; Spleen Qi and Heart Blood
deficiency. The composition of Gui Pi Tang is given below with
the original dosage. The modern dosage is shown in brackets. All
the herbs should be cooked together as a decoction using water.
Ren Shen (Radix Ginseng) 15g (3-6g)
Huang Qi (Radix Astragali Membranacei) 30g (9-12g)
Bai Zhu (Rhizoma Atractylodis Macrocephalae) 30g (9-12g)
Fu Ling (Sclerotium Poriae Cocos) 30g (9-12g)
Suan Zao Ren (Semen Zizyphi Spinosae) 30g (9-12g)
Long Yao Rou (Arillus Euphoriae Longanae) 30g (6-9g)
Mu Xiang (Radix Aucklandiae Lappae) 15g (3-6g)
Zhi Gan Cao (Honey-fried Radix Glycyrrhizae Uralensis) 7.5g (3-6g)
Dang Gui (Radix Angelicae Sinensis) 30g (6-9g)
Zhi Yuan Zhi (Honey-fried Radix Polygalae Tenuifoliae) 30g (3-6g)
Sheng Jiang (Rhizoma Zingiberis Officinalis Recens) 5p
Da Zao (Zizyphi Jujubae) 1 piece
(Bensky and Barolett 1990).
Analysis of Formula
- Ren Shen, Huang Qi, Bai Zhu and Gan Cao tonify the Qi and
strengthen the Spleen.
- Dang Gui and Long Yan Rou nourish the Blood, whilst Da Zao
stops sweating and strengthens the Heart and calms the Shen.
- Yuan Zhi and Fu Ling also strengthen the Heart and calm the
- Sheng Jiang and Da Zao strengthen the Spleen and stomach to
promote the production of Qi and Blood.
- Mu Xiang promotes the circulation of Qi and strengthens the
Spleen's transportation function thereby avoiding excessive
Actions: Tonifies the Qi and nourishes the Blood. Strengthens
the Spleen and nourishes the Heart.
- Dream disturbed sleep
- General debility
- Irregular menstruation
- Low grade fever
- Night sweats
- Pale, swollen tongue with a thin white coating
- Poor appetite
- Poor memory
- Swallow complexion
- Weak and thin pulse
- Withdrawal (Qiao and Stone 2000).
Every disease has its own pathogenesis and can be categorised
into three essential patterns:
- excess or deficiency of the vital Qi
- the imbalance of Yin and Yang and
- the abnormality of Qi and Blood (Bo 2000).
Any Zangfu disorder will fall into one of these three patterns.
In this Bianzheng, we are concerned with the inadequacy of Spleen
Qi and Heart Blood; both being a deficiency type.
To understand how Gui Pi Tang acts to treat several disorders
with the same method, we have to first look at the relation between
the Spleen and the Heart. In the Five phase theory as laid down
by the Huang Dei Nei Jing, the Heart is Fire and the Spleen is
Earth. Fire produces ashes, which will turn into Earth, hence
the Heart is the mother and the Spleen is the son (see figure
1). Therefore the Heart may have a greater effect upon the Spleen
than any other Zangfu organ within the Five phase theory.
Along with the Five phase theory is its controlling sequence
(figure 2). Here, each organ as defined by its phase controls
the next organ. Thus the Spleen controls the Kidney, as Earth
controls Water. Therefore when there is a deficient Spleen it
will adversely affect the Kidney. The majority of syndromes that
Gui Pi Tang treats will not only show symptoms of a deficient
Spleen but also symptoms of a deficient Kidney.
Figure 1. The generating sequence
of the Five phases.
We have seen how the Spleen dominates the body's Qi and Blood
with the Li Kao school of theory, yet the Heart also has this
function, but within a Zangfu hierarchy framework. This is because
the Heart houses the Shen (mind) and is the organ that controls
all the Zangfu, as the Su Wen chapter 8 states:
"As the heart is the monarch in the organs, it dominates
the functions of the various viscera." (Wu and Wu 1997).
As the Heart houses the Shen and the Spleen is associated with
pensiveness, any excessive thinking will also affect the Shen.
This will affect the Spleen again and lead to a deficiency of
the Spleen's ability to produce Qi and Blood resulting in a further
weakened Heart, as the son (although indirectly) insults the mother.
This creates a cycle in which both organs will mutually adversely
affect each other.
In the case of forgetfulness (Jian Wang) the dysfunction of the
brain is brought about by a deficiency of Qi, Blood and essence.
The Heart and Spleen are impaired by anxiety and worry which will
cause a deficiency of Blood as the weakened Spleen Qi is unable
to produce sufficient quantities of Qi and Blood leading to a
deficiency of Heart Blood and a restless Shen. Essence is depleted
as the Kidney is weakened by sexual hyperactivity and in its role
of supplementing post-heaven Qi due to a deficiency of Spleen
Qi. In this relationship between the Heart, Spleen and Kidney,
the Spleen dominates the syndrome as it is the origin of Qi and
Figure 2. The controlling sequence
of the Five phases.
An important action of Gui Pi Tang that lies outside its standardised
actions is its ability to nourish the Heart to warm the Spleen
and Stomach. As the Spleen is warmed it allows the food to be
further cooked and transformed and transported. Gui Pi Tang also
acts directly upon the Spleen to nourish it. This principle of
tonifying both the Heart and the Spleen is known as the combined
method of treatment (Williams 1992).
Generally, a deficiency of Spleen Qi will manifest itself as
fatigue, tiredness, weariness and a weak pulse, all of which are
Yang deficiency type symptoms. Secondly, it acts upon the Heart
Blood which is the Yin aspect. A deficiency of Heart Blood can
cause the patient to manifest a pale complexion due to a lack
of circulating Blood, whilst dizziness is due to a lack of circulating
nutritive Blood supplying the brain. Listlessness is also due
to a lack of Blood as Blood transports nutrients to the tissues.
A thin pulse is a Blood aspect as a reduction in the quantity
of circulating Blood with lead to a thin movement of Blood through
The pathological mechanisms involved with insomnia (Bu Mei) of
a deficient type is when Blood fails to nourish the Heart and
therefore cannot house the Shen due to a deficiency of Heart Blood.
This leads to a restless Shen causing the sufferer to experience
difficulty in falling sleeping as the Shen spirit has trouble
'falling' into its residence, the Heart. The sufferer may also
experience excessive dreams and be easily woken from their sleep
for the same reason of a disturbed Shen.
A deficiency of Heart Blood can lead to palpitations (Xin Ji)
as the lack of Heart Blood fails to fill the vessels and therefore
will lead to a lack of nourishment to the tissues, brain and Shen.
The night sweating (Dan Han) accompanying this syndrome is the
result of the consumption of Heart Blood in the form of sweat,
as sweat is the Yin aspect of the Heart. Therefore, the patient
will have Blood deficiency symptoms, i.e. a pale complexion, pale
tongue, tiredness, etc.
An important syndrome treated by Gui Pi Tang is bleeding (Xue
Zheng). The mechanisms involved in bleeding syndromes are more
complex than the previous aspects looked at so far. Here, the
physician may need to take into account other Zangfu organs, i.e.
the Stomach. Gui Pi Tang can only treat bleeding syndromes caused
by a deficiency in cases of epistaxis, haematemesis, haematuria
and purpura. They are all categorised by the failure of Spleen
Qi to command Blood (Pi Tong Xue). The mechanism of bleeding is
when the Spleen fails to assists the Blood to circulate inside
the vessels, and no extravasation occurs, therefore 'the Spleen
controls Blood' (Shousheng 1996). Another explanation of the Spleen's
controlling functions of Blood can be related to its phase, Earth,
as stated in the Classic of Difficulties (Nanjing):
"The spleen contains the blood. This function of the spleen
is evocative of the characteristics of earth, just as rivers and
streams are contained by an earthen bed, the body's blood is contained
in the channels" (cited in Dharmananda 2002).
A person's constitution will also have a major influence upon
the location of any bleeding. For example, in relation to the
Stomach, bleeding can occur in the gums, nose and in the Stomach
itself. The root cause usually lies with insufficient amounts
of Kidney Yin. If there is a deficiency of Kidney Yin then there
is not enough water to balance Yang, leading to Stomach Fire.
Again this can often be traced back to a deficient Spleen, which
is unable to supply the correct quantity of Qi and Blood causing
the exhaustion of Kidney essence/Yin. The different locations
of bleeding can be contributed to the Stomach meridian itself.
It starts at the eyes and ends on the foot making it one of the
longest and extensive meridians. Another pathological mechanism
involved in bleeding is when the Stomach meridian has several
weaknesses along its pathway where exogenous or endogenous evils
may attack. The success of an evil attack depends upon the Zheng
Qi. The struggle between Zheng Qi and the evil Qi can also lead
to bleeding as the two struggle for dominance and generate Heat
causing the Blood to boil out of the vessels. The strength of
the Zheng Qi is largely based upon pre and post heaven Qi, that
being again the Spleen and the Kidney. In cases such as these,
Gui Pi Tang acts to tonify Qi and Blood and therefore strengthening
the Zheng Qi in its ability to ward-off evil Qi.
Epistaxis is usually associated with bleeding gums and haematohidrosis.
The typical Spleen Qi symptoms of listlessness, pale complexion
and dizziness are also prevalent along with tinnitus and a thready
pulse. Tinnitus is attributed to a deficiency of Kidney Qi. The
lack of Qi and Blood will cause the extra depletion of Jing essence
stored in the Kidneys leading to a deficient Kidney and therefore
poor hearing as the bodily functions must be maintained from any
available energy source. Again it is seen how the Spleen controls
the Kidney. In these instances a modification of Gui Pi Tang is
used to treat the syndrome, with the addition of Xian He Cao to
restrain the leakage of Blood, E Jiao to nourish the Blood and
stop bleeding and Qian Cao Gen, which also stops bleeding. The
mechanism in cases of spermatorrhoea is the same as above, as
overwork injuries the Spleen and leads to the use of Kidney essence
as a source of energy.
With haematemesis the palpitations indicate a deficiency of Heart
Blood but this is not as serious or prevalent than with insomnia.
Again Gui Pi Tang is modified to include herbs whose sole action
is to stop bleeding; Xian He Cao, as we saw with epistaxis, along
with other herbs such as Bai Ji, Jiang Tan and Hai Piao Xiao.
The breathlessness seen with haematemesis syndromes indicates
a deficiency of Kidney Qi due to a depletion of Jing caused by
a deficiency of Blood. The Kidney Yang then fails to grasp the
Lung Qi resulting in shallow breathing and breathlessness.
Haematuria symptoms are very similar to that of the previous
two bleeding syndromes, except that in this instance we may also
see bleeding gums and breathlessness with a low voice. The mechanisms
of these additional symptoms are the same with the previous bleeding
disorders; a deficiency of Spleen Qi, which failures to command
Blood, a weakness of the Stomach meridian along various parts
of its course and a deficiency of Kidney Qi.
Purpura, macules, papules and haematohidrosis are often seen
with typical Spleen deficient symptoms of listlessness, dizziness
and a pale complexion. However, the purpura is often accompanied
with signs of Blood stasis with a dull purple colour to the skin,
all of which are aggravated by overwork. This is due to the depletion
of more notably Qi than its counterpart Blood. Overwork will exhaust
an already depleted quantity of Qi to the point at which Qi cannot
hold the Blood within the vessels. In this case the modification
of Gui Pi Tang is used with the addition of Xian He Cao, Zhong
Lu Tan, Di Yu, Pu Huang, Qian Cao Gen and Zi Cao.
As we have seen in the latter syndromes, Gui Pi Tang is modified
to include herbs whose sole action is to directly stop bleeding
in addition to the reinforcing of Spleen Qi and the nourishing
of Heart Blood. By doing so, the formula is not only able to strengthen
the Spleen's function of controlling the Blood and keeping it
housed within the vessels in a general broad sense but also has
the ability to stop bleeding locally.
In most instances looked at so far, the syndrome manifests the
typical symptoms of either a deficient Spleen Qi or Heart Blood.
However, in the case of Xu Re (deficient fever), we see that the
deficiency of Qi and Blood, are unable to hold the Yang, causing
it to float upwards and outwards and manifest as fever. By tonifying
the Spleen Qi and Heart Blood it is possible to restrain the upward
floating Yang Qi thereby balancing Yin and Yang.
An example of how Gui Pi Tang can employ the principle of treating
different diseases with the same method can be expressed in the
following case where the chief complaint is ulcers of the mouth.
The clinical features include, recurrent mouth ulceration of the
tongue, and to a lesser extent the gums and buccal cavity, dizziness,
light headedness, blurred vision, pale complexion, fatigue, pale
nails, lethargy, weakness, spontaneous sweating, a low weak voice
and a shortness of breath. The pulse is thready and weak whilst
the tongue is pale with a thin white coating. All these indicate
a deficiency of Qi, Blood and Spleen Qi. The Spleen and Heart
both influence the tongue and weakness of these two organs can
lead to a general failure of Qi and Blood nourishment in the tissues
of the mouth (Maclean and Lyttleton 2002). The fact that no nourishment
is reaching these areas of the mouth indicates a deficiency of
Qi and its ability to move nourishment to these areas of the body
whilst the deficiency of Blood and its Yin aspect means there
is no nourishment to move to the mouth. Gui Pi Tang is used to
tonify the Qi and Blood and also calm the Shen, which may be restless
as ulcers are commonly associated with anxiety and stress.
Gui Pi Tang acts to treat many disorders with the same principle;
tonify the Spleen Qi and nourish the Heart Blood. It acts upon
these two important organs that either generate Qi and Blood or
control the Zangfu as a whole, whilst indirectly it allows the
other Zangfu to function correctly without any adverse effects.
In the case of the Kidney, it safeguards any potential unnecessary
lose of essence resulted by the Spleen attacking the Kidney. It
therefore, truly encompasses the theory of treating different
diseases with the same method and TCM's philosophy of treating
the whole person; the body and the mind in one treatment as one
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