The Use of Gui
Pi Tang in TCM Internal Medicine
The Zangfu organ relationship is often a ëblindí 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 wasnít 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 of three:
- 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 (Bo 2000).
In TCM, the Spleen and Stomach are regarded as the ëSea of Qi and Bloodí. 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) 1p
(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 Shen. Sheng Jiang and Da Zao strengthen the Spleen and stomach to promote the production of Qi and Blood. Whilst Mu Xiang promotes the circulation of Qi and strengthens the Spleenís transportation function thereby avoiding excessive tonification (Junying 1991).
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 element 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 Element theory.
Along with the Five Element theory is its controlling sequence (figure 2). Here, each organ as defined by its element 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 Elements.
We have seen how the Spleen dominates the bodyís 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:
ìAs the heart is the monarch in the organs, it dominates the functions of the various viscera.î (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 Spleenís 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 amnesia (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 Blood.
Figure 2. The controlling sequence of the Five Elements.
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 vessels.
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 ëfallingí 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 ëthe Spleen controls Bloodí (Shousheng 1996). Another explanation of the Spleenís controlling functions of Blood can be related to its element, Earth, as stated in the Classic of Difficulties (Nanjing):
ìThe 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 bodyís blood is contained in the channelsî (cited in Dharmananda 2002).
A personís 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 (see figures 3 and 4). 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.
Figure 3. The pathway of the Stomach meridian on the face (Qiu 1993).
Figure 4. The pathway of the Stomach meridian on the body (Qiu 1993).
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 Spleenís 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 TCMís philosophy of treating the whole person; the body and the mind in one treatment as one entity.
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