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Herbs for Treatment of Shen Disorders
by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon
The earliest texts describing Chinese herbs include numerous ingredients that are said to affect the spiritual life of man. The first formal book of medicinal substances that survived to the present is the Shennong Bencao Jing (Shennong's Herbal Classic, attributed to one of the three divine helpers that came in human form, Shennong, and written around 100 A.D.), used as a source of the quotes in this section (1).
The way Chinese herbs are used for shen disorders has changed over time and is affected by cultural differences among the countries utilizing Chinese medicine. For example, the three syndromes describe in the previous chapter (and the contribution of "hidden water" or "water toxin") have been of interest in ancient times in China and in Japan today, but herb formulas presented in modern Chinese texts often have yet a different focal point, which will be described in this chapter.
Further, the selection of ingredients to use in treatments has changed, especially in recent years, and particularly as one takes the formulas from Asia and tries to utilize them in Western countries, where there are different concepts of what serves as an acceptable ingredient. For example, the most revered of the ingredients for shen disorders (and for several other conditions) in China throughout the past 2,000 years is one which we no longer would even consider using, but its ancient description is worth relaying:
Dansha is sweet and slightly cold. It treats hundreds of diseases of the five viscera and the body. It nurtures the essence spirit (jingshen), quiets the hun and po, boosts the qi brightens the eyes, and kills spirit demons and evil ghosts. Protracted taking may enable one to communicate with the spirit light and prevent senility….
This compound, cinnabar, was one of many mineral agents that were relied upon for such spiritual aims. It is a mercury compound that the Chinese believed was safe to use, and which had been used routinely until just a few years ago. The stories about "contaminated" Chinese herb products that are relayed in Western countries often reflected detection of mercury from cinnabar, as well as arsenic from realgar, two items that had been trusted by the physicians in China. This was not contamination, but intentional inclusion of the ingredients.
Animal parts were also used for the spirit remedies, including this one that we also don't use today:
She Xiang is acrid and warm. It mainly keeps off malignant qi, kills ghosts and [adverse] spiritual matters, [cures] malaria, gu toxins [certain types of parasites], epilepsy, and tetany, and removes the three worms. Protracted taking may eliminate evils to prevent depressive ghost dreams in sleep.
This substance, musk, is from an endangered deer species mainly found in the mountainous area of Tibet and adjacent mountainous Chinese provinces, and was commonly employed in remedies for reviving consciousness because of its potent fragrance. Endangered species concerns have eliminated from use numerous animal substances that were considered of great value. Further, European governments have somewhat arbitrarily restricted virtually all animal ingredients from use in "herbal" formulas.
A mineralized animal substance, dragon bone (fossilized bones of large mammals, so no animal material remains), was long employed as a spirit medicine:
Long Gu is sweet and balanced. It mainly treats heart and abdominal demonic influx, [adverse] spiritual matters, old ghosts, cough, and counterflow [of qi], diarrhea and dysentery of pus and blood….
Dragon bone is still in use; dragon teeth is collected from similar source materials and used similarly (though especially for treatment of disorders associated with fright). Fossilized tree resins, in the form of amber (also called succinum; the Chinese name is hupo, referring to the po soul of the tiger, which it is said to represent), are included in traditional and modern formulas for spirit disorders.
Ordinary plant materials are the main ingredients in spirit formulations, and the best known of these is ginseng. Due to attempts to vigorously promote its sale in the West, the applications of this herb have been altered to serving primarily as an energy tonic, a use quite different than in traditional Chinese medicine:
Ren Shen is sweet and a little cold. It mainly supplements the five viscera. It quiets the essence spirit [jingshen], settles the hun and po, checks fright palpitations, eliminates evil qi, brightens the eyes, opens the heart, and sharpens the wits….
The case of ginseng is an example of how information about herb use can become distorted. As a result, many people worry that ginseng will have an agitating quality when, in fact, it is used in the Chinese formulas as a calming substance.
There are some principles of therapy that have changed due to the developments of modern medicine. For example, throughout the history of Chinese medicine several shen disturbances, including loss of consciousness, mania, and emotional agitation, were understood to occur as the direct result of feverish diseases. Thus, herbs that purge fire, including rhino horn (no longer used), raw rehmannia (sheng di huang), coptis (huang lian), gardenia (shan zhi zi), moutan (mudanpi), and scute (huang qin), were sometimes key ingredients in the prescriptions. In modern times, most of these feverish conditions can be controlled with antibiotics, antipyretic drugs, and other modern therapies (or can be prevented outright by vaccination) so that the mind and brain disorders that are the subject of potential Chinese-herbal treatment today are rarely associated with febrile disease. While these same fire-purging herbs have some sedative effects, it is clear from the ancient formula descriptions that they were included mainly for their role in treating a febrile condition.
As a result of research done during the 20th Century, modern Chinese practitioners have turned much of their attention to the principle of treating blood stasis, which was less frequently described in ancient times. While xue dao zheng usually involved the problem of abdominal stagnation of blood flow, today's efforts are usually directed at blood stasis affecting the heart and brain, looking particularly at the problem of strokes and other diseases of aging associated with vascular blockage. Ingredients such as red peony (chi shao), cnidium (chuan xiong), persica (tao ren), carthamus (hong hua), and salvia (dan shen) are the most frequently relied upon for these purposes.
Thus, one can say that some principles of therapy now have less emphasis than before (i.e., clearing heat) and others have more emphasis than before (i.e., vitalizing blood), and this is important to recognize when analyzing formulas described in modern clinical reports from China. Similarly, some ingredients are less often used, such as animal substances, while others are more frequently used, especially those plant materials that have escaped worries about toxicity and endangered species status.
Basic Therapeutic Approaches
There are four main therapeutic approaches using herbs in traditional Chinese medicine to address the problems classified as spirit disorders:
Tonification therapy
The brain is described as an extension of the marrow which belongs to the kidney system, so herbs that nourish the kidney are understood to nourish the brain (and spinal cord). Lack of nourishment (particularly of the fluid component, that is, yin and blood) of any organ can lead to mental distress, due to the fact that the internal spirits cannot rest if their associated internal organs are "empty," that is, deficient in essential fluids. In particular, deficiency of liver and heart can easily cause disturbance of the mind (due to hyperactivity of the hun and shen). Weakness of spleen qi is often ultimately responsible for lack of nourishment of all the organs and the body; the spleen also promotes upward circulation of qi to reach the brain.
Regulating qi
The free flow of visceral qi, regulated by the liver, is understood to correspond to the mental condition, particularly the thought processes and the reactions to experiences. For example, stagnated (depressed) liver qi circulation corresponds to mental depression, repetitive thoughts, limited outlook, and other mental conditions that, in turn, cause problems in social situations, furthering the liver qi stagnation. Although anger is the emotion frequently cited as associated with the liver and its circulation of qi, in fact, other emotions also have various effects on the qi, and the consequence may be stagnation of liver qi circulation.
Calming agitation. Aside from the problem of deficiency that leads to unsettling of the spirit, the mind can be agitated as a result of heat, wind, or uprushing qi and yang, disorders that may be secondary to deficiency (e.g., yin deficiency of the liver yields liver fire and internal wind) or may be an excess pattern (from a pathogenic influence or from diet, excess emotions, etc.). Herbs are used to clear the heat (purge fire), sedate the wind, and settle the upward rising of qi and yang.
Clearing orifices of phlegm-mist
The connection between the heart and mind (or brain) is made by channels (orifices) that can become obstructed; the ultimate source of the obstruction may be weak stomach/spleen function leading to accumulation of phlegm, or fire syndrome damaging fluids and transforming them to pathological phlegm. Aromatic and penetrating herbs can clear the obstruction and phlegm-resolving herbs can help prevent the orifices from becoming obstructed again.
In designing a formulation, it is common to rely primarily on one or more of the first three methods listed here to treat shen disorders. In fact, tonification therapy is a part of nearly all the treatments used in modern practice. The fourth method (which will be analyzed more fully in the appendix to this chapter), is especially used in cases of severe disturbance, for ailments associated with the phlegm syndrome, and for treatment of elderly patients.
Tables 1-4 list some sample herbs in each of the four therapeutic areas of primary concern. The herbs were selected for inclusion in these tables on the basis of high frequency of use in treating mind and brain disorders as described in both the traditional and modern literature (the formulas for treating the disorders will be described in the next two chapters). Some items frequently mentioned in traditional literature (e.g., musk, rhino horn, cinnabar) and used until recently in China have been retained here to assist in the study of that literature.
Within each category, the herbs are listed alphabetically by common name (followed by pinyin and typical botanical source for clear identification). In the section of "main actions," the information is derived primarily from Oriental Materia Medica (2), with only those actions that are relevant to treatment of mental disorders included in the table. Since the concept of phlegm-mist is not often elucidated, an extensive explanation is presented in the appendix.
Table 1: Tonic Therapies Frequently Used for Shen Disorders.
Herb Main Actions Comments
Alpinia
Yi Zhi Ren
Alpinia oxyphylla supplements spleen, warms the kidney, astringes essence, fortifies qi The Chinese name means to enhance the disposition of the individual (increase wisdom, is one translation). It is thought to improve the thinking function associated with the spleen and the will associated with the kidney.
Asparagus
Tian Men Dong
Asparagus cochinchinensis nourishes yin, moistens dryness Asparagus is considered similar in nature, taste, and function to ophiopogon and is commonly used in combination with it to nourish the yin.
Astragalus
Huang Qi
Astragalus membranaceous supplements qi, increases yang Astragalus helps the spleen generate a pure and clear qi that rises upward to nourish the heart and brain
Atractylodes
Bai Zhu
Atractylodes macrocephalla supplements spleen, tonifies qi This aromatic tonic for the spleen disperses stagnated fluids that can obscure the heart orifices.
Cistanche
Rou Cong Rong
Cistanche salsa nourishes kidney essence, supplements yang The soft, black, salty herb is thought to quickly nourish the deficient kidney essence, invigorating yang without harming the yin.
Codonopsis
Dang Shen
Codonopsis pilosula invigorates the spleen and stomach, replenishes qi In China, codonopsis is almost always used as a substitute for ginseng as a stomach/spleen tonic, but it lacks the spirit-calming qualities of ginseng.
Cornus
Shan Zhu Yu
Cornus officinalis supplements liver and kidney, astringes essence The sour fruit is frequently used to astringe and nourish the essence and help prevent deterioration of health.
Cuscuta
Tu Si Zi
Cuscuta chinensis supplements kidney essence, clears vision The seed is thought to help prevent leakage of essence (as an astringent), therefore it is used to prevent deterioration. It gently tonifies yang, without harming yin.
Dioscorea
Shan Yao
Dioscorea batatas supplements spleen, stomach and kidneys, astringes essence Dioscorea is used in many treatments for weakening of the kidney essence; its ability to benefit the spleen at the same time is unusual among the Chinese herbs for that purpose.
Ginseng
Ren Shen
Panax ginseng replenishes and supplements original qi, benefits the five viscera, pacifies the spirit, soothes the soul, increases wisdom Ginseng is one of the original remedies for spirit disorders used in Chinese medicine; it has a calming nature and replenishes all deficiencies. In the West, ginseng has taken on the connotation of an energy stimulant; practitioners and patients often worry about the proclaimed stimulant action of this herb.
He shou wu
He Shou Wu
Polygonum multiflorum nourishes yin, replenishes essence and blood, tonifies liver and kidneys Ho-shou-wu is a famous "anti-aging" herb that is reputed to keep the body and mind young and active. By nourishing the kidney and liver, it nourishes the brain.
Hoelen
Fu Ling
Poria cocos strengthens spleen, harmonizes middle warmer, tranquilizes the heart, pacifies the spirit, resolves moisture Hoelen is used to soak up excess moisture and improve spleen function; it is also favored as a sedative. It has a mild action. The sedative fu-shen (see
Table 3) is from the same source.
Longan
Long Yan Rou
Euphoria longana supplements the heart, stabilizes the spirit, tonifies spleen, nourishes blood This sedative tonic has properties that imitate the actions of ginseng plus tang-kuei. It is primarily used in Ginseng and Longan Combination (Guipi Tang).
Lycium
Gou Qi Zi
Lycium barbarum supplements liver and kidneys, promotes production of essence and blood Lycium is commonly used in cases of essence deficiency and is considered especially useful because of its mild nature, not producing any adverse digestive effects even in large dosage.
Ophiopogon
Mai Men Dong
Ophiopogon japonicus nourishes yin, moistens dryness, removes heat, resolves phlegm, calms spirit This yin-nourishing herb is especially relied upon when there is phlegm accumulation and heart agitation; sometimes asparagus is added to enhance the heat clearing action.
Peony
Bai Shao
Paeonia alba supplements blood, vitalizes blood, cools blood, astringes liver yin, strengthens spleen Peony is the most commonly used blood nourishing herb because its other properties (vitalizing and cooling blood, astringing liver yin) take care of several requirements of the formulations.
Rehmannia
Shu Di Huang
Rehmannia glutinosa nourishes blood, yin, and essence, supplements kidney and liver This rich, black processed root is considered one of the most important herbs to nourish the liver and kidney. It is used to prevent and even reverse the deterioration associated with aging.
Tang-kuei
Dang Gui
Angelica sinensis supplements and moves blood This herb is used for nourishing the blood of the liver and heart, which has the effects of controlling emotional distress and relieving spasms.
Table 2: Qi-regulating Herbs.
Bupleurum is included in this table as an important qi regulating herb, particularly for shen disorders, but in the Materia Medica it is placed in the surface relieving category, which reflected one of its most frequent uses at the time the herb categories were established; magnolia bark is categorized with aromatic moisture resolving herbs, but it has an important role in regulating qi circulation and so is included here.
Herb Main Actions Comments
Bupleurum
Chai Hu
Bupleurum chinense regulates liver qi, raises yang qi Bupleurum strongly dredges liver qi; this action may be uncomfortable in those with blood deficiency (it is often administered with blood tonics); it also aids rising of qi, so that herbs to lower qi may be needed in the formula.
Chih-ko
Zhi Qiao, Zhi Ke
Citrus aurantium disperses central qi, regulates horizontal qi circulation; resolves phlegm Used for food stagnancy, epigastric aching, and lung congestion; it is often used to aid bupleurum in dispersing qi and to aid pinellia in resolving phlegm.
Chih-shih
Zhi Shi
Citrus aurantium (unripe fruit) disperses central qi, regulates vertical qi circulation; purges gallbladder, clears heat and phlegm Used for abdominal stagnation with constipation; helps direct qi flow downward. Chih-shih is helpful in reducing damp-heat and phlegm accumulation especially that associated with gallbladder stagnation or heat.
Citrus
Chen Pi
Citrus reticulata disperses qi, strengthens spleen, dries moisture and phlegm The most widely used qi-regulating herb; it is also used in treatment of most phlegm disorders, combined with pinellia. Citrus aids the spleen in dispersing moisture.
Cyperus
Xiang Fu, Xiang Fu Zi
Cyperus rotundus strongly disperses central qi, alleviates pain, regulates menstruation Analgesic for headaches and abdominal pains and alleviates qi stagnation; this is considered an important herb for treating depression.
Lindera
Wu Yao
Lindera strychnifolia disperses qi alleviates pain, warms the kidney This herb is used like bupleurum to disperse stagnant qi, but is especially used in cold syndromes and for weak kidney qi.
Magnolia bark
Hou Po
Magnolia obovata dries dampness, moves qi Mainly used for abdominal distention, uprushing of qi, food stagnation, obstruction of phlegm, and tightness of the diaphragm.
Saussurea
Mu Xiang
Saussurea lappa or Jurinea soulei disperses qi, alleviates pain, controls diarrhea, sedative Used for mainly for abdominal disorders that include diarrhea.
Table 3: Sedative Herbs.
Polygala, listed in the Materia Medica among the heart-nourishing herbs, has been listed both here and in the category of herbs to help resolve phlegm mist (Table 4).
Herb Main Actions Comments
Biota
Bai Zi Ren
Biota orientalis nourishes heart and calms mind This seed is very oily, so it is used only in moderate dosage if there is a spleen-damp syndrome, but is favored for constipation and dryness.
Cinnabar
Zhu Sha
mercuric sulfide sedates the heart and calms the mind This is the premier sedative of the Chinese tradition and mentioned in numerous ancient and modern formulas; however, it is avoided in the West due to its content of mercury, the active constituent.
Dragon bone
Long Gu
fossil bones pacifies the liver, restrains floating yang, sedates and calms the mind These are fossilized bones of ice age animals, comprised mainly of soluble minerals, such as calcium carbonate. It has a nutritive and calming action. It is also an astringent for kidney essence.
Dragon teeth
Long Chi
fossil teeth sedates and calms the spirit Like dragon bones, dragon teeth are fossilized; Chinese doctors regard them as especially useful for fright-induced mental disorders.
Fu-shen
Fu Shen
Poria cocos +
Pinus sp. sedative, moisture-resolving, strengthens spleen Fu-shen is mostly the same material as hoelen (see Tonics) with similar properties, but includes portions of pine root; the pine confers a sedative effect.
Oyster shell
Mu Li
Ostrea gigas pacifies the liver and restrains the floating yang Oyster shell is used to calm agitation; it has astringent properties and also reduces excess stomach acid. It mainly contains calcium carbonate.
Polygala
Yuan Zhi
Polygala tenuifolia stabilizes the heart, calms the mind, disperses phlegm Polygala is a nourishing sedative, often combined with zizyphus; it is commonly used with acorus to disperse phlegm-mist and enliven the mental functions.
Schizandra
Wu Wei Zi
Schizandra chinensis astringes essence, calms agitation Like cornus, it is relied upon to astringe essence and prevent deterioration of health; modern research has shown that it normalizes cerebral electrical discharges and is thus used in treatments for brain disorders, especially for insomnia and poor memory.
Succinum
Hu Po
fossilized resin sedates and calms spirit, vitalizes blood circulation This is the aged resin mostly from various pine trees; the ancient Chinese said that this material is actually the soul of tigers that have died, and it has a sedating quality that still imparts the tiger's power.
Zizyphus
suan Zao Ren
Zizyphus spinosa nourishes heart and calms spirit, nourishes liver The most commonly-used sedative especially treats mental disorders characterized by insomnia and agitation.
What is Phlegm-Mist Affecting the Orifices of the Heart?
Before presenting the herbs for phlegm-mist, the nature of this condition is first described. Although phlegm-mist can affect different parts of the body, the terminology of "phlegm misting the orifices of the heart" (tanmi xinqiao) is frequently used for the concept as it refers to function of the brain and the syndrome that produces or worsens shen disorders.
The condition is sometimes described as phlegm entering the heart, or as phlegm entering the heart meridian (or "channel"). The original description of meridians in the Chinese medical system is related to blood vessels. We know this, in part, because virtually all mentions of the flow of qi in the ancient texts are actually about the combined flow of "qi and blood." It is easy to become confused about the Chinese view of human physiology when modern writers describe meridians as pathways existing solely for the flow of qi, to be distinguished from blood vessels for the flow of blood, which is not consistent with the prior 2,000 years of Chinese literature. The fact that the meridian maps (for acupuncture) do not correspond with blood vessels merely indicates that what was eventually mapped for purposes of describing acupuncture therapies failed to follow precisely the underlying traditional conceptual framework. When describing long-held ideas about human physiology such as this, it is important to consider the context, and in this case, the flow of qi and blood were considered to be unified and involved the same "vessels."
Phlegm mist is a concept that can be traced back at least to the Song Dynasty. By that time, Chinese doctors were distinguishing "substantial" phlegm (such as sputum, which is described as "condensed pathological fluid") and "insubstantial phlegm" or "hidden phlegm" (such as the mist of the heart orifices; a "thin pathological fluid"). The substantial phlegm would mainly accumulate in the lungs and stomach and could be noted in the sinuses and throat, while the insubstantial phlegm would accumulate in the meridians, distributing to various parts of the body, such as the heart orifices and the brain (e.g., causing dizziness or loss of consciousness in severe cases), the lymph nodes (causing nodules and swellings), and the limbs (e.g., causing numbness). The two types of phlegm were thought to have the same origin and the same fundamental nature, but would permeate different parts of the body (the thick sputum could not penetrate the meridians, but the insubstantial phlegm could).
Further, insubstantial phlegm can combine with other pathological influences to yield phlegm-fire, wind-phlegm, and phlegm-turbidity. According to the doctrine that evolved, the phlegm mist when combined with the other pathological factors-such as fire, wind, or damp-could produce more severe symptoms. Its material nature would capture the more ethereal forces of fire or wind to make the disease persist; similarly, the phlegm mist could blend with damp to yield turbidity that obscures the clear flow of qi and yang to the brain, interfering with normal mental and sensory functions, though not completely blocking the circulation to the brain except in the worst cases, in which case one might suffer what we understand today to be a stroke.
Diseases and symptoms attributed to phlegm mist affecting the heart orifices in addition to stroke paralysis affecting the major muscles (hemiplegia), include dizziness, loss of consciousness (coma), mania (emotional outbursts, disturbed speech), convulsions (especially epilepsy), sudden sensory loss (deafness, blurred vision, loss of taste and smell, inability to speak), lockjaw, and stiff tongue. Several of these symptoms may be the result of strokes. Diseases currently treated in China by herbs that resolve phlegm-mist affecting the heart orifices also include manic-depressive disorder and senile dementia (Alzheimer's disease).
Table 4: Herbs that Clear Phlegm Mist and Open the Orifices.
In addition to herbs in the Materia Medica categories of opening orifices and resolving phlegm, this table includes curcuma, a blood vitalizing herb with phlegm-resolving action. Silkworm, a wind-calming herb, and polygala, a heart-nourishing sedative, both also help resolve phlegm mist, so are included here.
Herb Main Actions Comments
Acorus
Shi Chang Pu
Acorus gramineus opens orifices, expels phlegm and turbidity, replenishes intelligence This is the most commonly-used Chinese herb (of plant origin) for treatment of mental disorders. It is often used with polygala to open the orifices.
Arisaema
Tian Nan Xing
Arisaema consanguineum resolves phlegm mist, disperses accumulations, relieves convulsions Arisaema is described as having the power to vaporize phlegm accumulations; it is mainly used when treating phlegm obstruction of the orifices. Bile processed arisaema (dannanxing) is used for phlegm-mist associated with a fire syndrome.
Bamboo
Zhu Ru, Zhu Li, Tian Zhu Huang
Phyllostachys nigra removes heat, transforms phlegm, calms fright Bamboo shaving, leaves, juice, or dried secretion are all used to treat irritability, fidgets, and convulsions. They are particularly favored in treatment of children's disorders.
Borneol
Bing Pian
purified compound opens orifices, moves qi, vitalizes blood Borneol is a potent herb for invigorating circulation and opening orifices; it is often combined with musk and/or acorus to open orifices.
Curcuma
Yu Jin
Curcuma aromatica regulates flow of qi and blood, resolves phlegm Curcuma is best known for its ability to vitalize circulation of qi and blood, but it is useful in treating phlegm accumulation disorders, especially when there is qi stagnation.
Musk
She Xiang
Moschus moschiferus opens orifices, invigorates blood circulation, resolves turbidity Musk, with its penetrating aroma and stimulating quality, is mostly used for severe cases of brain disorder, especially when the person is losing consciousness or suffering from delirium.
Ox gallstone
Niu Huang
Bos taurus opens orifices, transforms phlegm, clears heat, removes toxin, calms fright Ox gallstone is utilized to correct gallbladder disorders that result in hot phlegm moving upward to cloud the consciousness. Bile acids and minerals are combined to make synthetic oxstone.
Pinellia
Ban Xia
Pinellia ternata harmonizes stomach, dries dampness, removes phlegm, disperses accumulation Pinellia is the most commonly-used phlegm-resolving herb in Chinese medicine; it is used to help prevent development of phlegm-mist and it settles uprising stomach qi.
Platycodon
Jie Geng
Platycodon grandiflorum resolves phlegm Platycodon is thought to direct the action of other herbs to the upper body; in addition, it helps to resolve phlegm-mist accumulation
Polygala
Yuan Zhi
Polygala tenuifolia stabilizes the heart, calms the mind, disperses phlegm Polygala is often used with acorus for resolving phlegm that obstructs the orifices of the heart.
It is tempting to try and correlate the traditional Chinese concept of phlegm-mist with a substance or condition defined by modern medicine so that the Chinese diagnostic category could be explained in terms of our current knowledge of physiology. Thus, for example, the condition of atherosclerosis, where plaques that include fatty materials (e.g., cholesterol and lipoproteins) coat the arteries, might be one case of phlegm-mist affecting the orifices; certainly, stroke is frequently associated with this type of blockage of the carotid arteries. The accumulation of amyloid plaques in the brain of persons with Alzheimer's disease might also correspond, to some extent, to phlegm mist. Disorders of the thick fluid in the ear drum, which might be depicted as a phlegm-type disorder (e.g., phlegm-turbidity), can yield dizziness. The formation of blood clots in the arteries or veins, while seeming to fit the category of blood stasis, may be an example of phlegm accumulation, in the sense that phlegm is a sticky substance and the clot forms by the coagulation of various blood components (such as fibrin and platelets) into a spongy mass. By contrast, extensive bruising, where clotted blood resides outside the vessels and forms a firm mass, more clearly fits the blood stasis description.
The ancient doctors saw phlegm-mist primarily involved with sudden and dramatic change: the person would faint, go into a convulsion, or suddenly erupt with crazy behavior. For example, as described in the Advanced Textbook on Traditional Chinese Medicine and Pharmacology (3): "voracious eating, overdrinking alcohol, and emotional irritation combine to cause food retention in the stomach, which causes stomach qi to disturb upward, blocking the clear cavity and thus resulting in loss of consciousness." The idea was that a substantial amount of phlegm would suddenly rush to the heart. Then, when the phlegm blockage cleared, the person would return to normal, though in some cases, there could be persisting symptoms (e.g., hemiplegia). The condition being described parallels what happens when a blood clot forms in the arteries supplying the heart or brain, causing the person to collapse. If the clot clears out quickly enough, the person recovers; if not, there may be persisting symptoms or the person may die.
This connection between the traditional concept of phlegm blockage and the modern understanding of formation of obstructive blood clots in the vessels was illustrated in a presentation at the 1987 TCM conference in Shanghai (4). The researchers differentiated the disease conditions of 158 patients who suffered from "upward disturbances of wind-phlegm and accumulation of phlegm-heat." Using the TCM criteria, they divided these cases as follows: 120 of "channel stroke" (phlegm blocking the heart orifices); 32 cases of fu-organ stroke (e.g., phlegm originating from the stomach or gallbladder); and 6 cases of zang-organ stroke (e.g., phlegm blocking the heart). Turning to Western medical diagnosis for these same patients yielded: 145 cases of thrombosis of the carotid artery system; 8 cases of thrombosis of the vertebro-basilar system; and 5 cases of embolism. The treatment administered to the patients was based on expelling phlegm and purging the intestines. After a few days of this purging therapy (generally less than two weeks), the focus of treatment shifted to "clearing heat, expelling phlegm, vitalizing blood, and invigorating the channels." Liquid bamboo sap (zhuli) was used as an essential ingredient in most of the cases.
As to the origins of the phlegm mist, the starting point is understood to be the generation of pathological phlegm (excess phlegm-fluid) which can be the result of external influences (six exogenous pathogenic factors), internal influences (abnormal emotional activities), and/or behavior (especially irregular diet, but also overeating rich foods and/or drinking excess alcohol). For phlegm mist to affect the heart orifices, which are at the top of the internal organs, it must rise upward, and that occurs through certain mechanisms such as uprising qi from the stomach; uprising damp-heat from the gallbladder (often due to persistent qi stagnation of the liver and rising liver yang); excessive "steaming" of water by kidney yang (due to kidney yin deficiency); and heart fire. Perhaps the most serious of the phlegm-mist syndromes is from a fire disorder (tanhuo raoxin). It is described in Chinese Herbal Medicine: Formulas and Strategies (5) this way: "The vigorous blazing heat scorches the fluids and causes them to congeal into phlegm. Heat and phlegm accentuate each other and completely veil the orifices of the heart, further disturbing the spirit and impairing the consciousness."
Persons with phlegm-mist syndrome need not have obvious phlegm excess (substantial phlegm), such as coughing up sputum, runny nose, obesity (the excess fatty tissue is now considered a type of phlegm mass), or phlegm-nodules (e.g., lipomas), but the problems of substantial phlegm and insubstantial phlegm often go together because of common underlying causes. Usually, the patient suffering from phlegm-mist will display at least some subtle signs of phlegm, such as slippery and smooth tongue coating or slippery pulse. In the ancient Chinese texts, there are stories about treating patients with phlegm-mist disorder using herbs that induce vomiting: discharge of copious amounts of mucous fluid from the stomach occurs, followed by alleviation of the symptoms.
Several ingredients used in the traditional formulas for phlegm-mist disorders are problematic for Western practitioners. For example, neither ox gallstone nor musk are readily available, and sometimes the dosage of borneol used in Chinese formulas can be risky (it acts as a heart stimulant in high doses). But, other ingredients are considered acceptable and the most commonly used ones are the pair of acorus and polygala, usually combined with herbs that are considered heart sedatives (e.g., zizyphus and biota seed); additionally, the pair of bamboo with arisaema, often with herbs that resolve phlegm-damp (e.g., pinellia, citrus, and hoelen) is a common treatment approach. It is worth illustrating here how some of the ingredients described above are utilized for the phlegm-mist conditions. A good example is Anshen Dingzhi Wan, which is comprised of acorus, polygala, dragon teeth, fu-shen, ginseng, hoelen; another is Ditan Tang, which is comprised of bamboo, arisaema, pinellia, citrus, chih-shih, hoelen, ginseng, acorus, and licorice. Both formulas include ginseng, hoelen, and acorus, where ginseng and hoelen tonify the spleen (to help prevent phlegm-fluid accumulation) and calm the heart (fu-shen is a type of hoelen with greater calming qualities), and acorus is used to clear phlegm mist from the orifices. Acorus is indicated for phlegm-damp obstructing the heart and for cases due to dampness retained in the center (i.e., stomach/spleen).
The idea of phlegm-mist has evolved over time, and this entity is now included as a diagnostic category for certain chronic ailments that do not necessarily have sudden onset, as occurs with some cases of depression, deterioration of memory, or gradual onset of a seizure disorder, as well as for the prolonged period of post-stroke syndrome. In such cases, milder agents (other than the highly aromatic musk and borneol) are relied upon. As an example, Clinic of Traditional Chinese Medicine (6) recommends a formula for treating a syndrome of "depressive psychosis" marked by conditions such as emotional depression, apathy, dementia, muttering to oneself, frequent outbursts of crying or laughing for no apparent reason, and low desire for food; the formula is comprised of acorus, polygala, arisaema, curcuma, pinellia, citrus, chih-shih, cyperus, hoelen, licorice. In the book Traditional Chinese Treatment for Senile Diseases (7), a similar formula is suggested for cases of senile dementia with depression and other symptoms such as those just mentioned, with the herbs chih-shih and licorice removed and replaced by gardenia. These formulas are modifications of the traditional Shunqi Daotan Tang (Smooth the Qi and Purge the Phlegm Decoction).
For the long-term therapy of patients suffering from phlegm-mist disorder, dietary adjustments are considered very important. Fried foods, heavily salted foods, and foods that are difficult to digest are eliminated to avoid the problem of producing pathological phlegm from undigested food. Herbs that promote digestion are also potentially of value. If constipation is present, this disorder is to be addressed because it contributes to abdominal stagnation and the increased possibility of upward flow of qi and fluid to affect the heart and its orifices.
Resolving Fluid Accumulation
As noted at the end of Chapter 6, one of the potential contributors to shen disorders is accumulation of fluids. Herbs that resolve fluid accumulation are included in three of the tables presented in the current chapter. For example, in the group of tonic herbs, atractylodes and hoelen are used for getting rid of stagnated fluids; herbs that tonify the spleen, such as astragalus, ginseng, codonopsis, alpinia, and dioscorea assist its function in distributing fluids. In the group of qi resolving herbs, most of the herbs also disperse stagnant fluids, and all of the citrus-based materials (citrus, blue citrus, chih-shih, and chih-ko) have a drying effect; magnolia bark is especially valued for dispersing accumulated fluid. In the group of herbs for phlegm mist, all the herbs resolve fluid accumulation, particularly the thickened fluids categorized as phlegm. Only the sedative herbs (Table 3) have limited capability to resolve fluids (fu-shen functions like hoelen to resolve moisture; polygala helps get rid of phlegm-mist), and these are almost always used with fluid-resolving herbs from the other categories. Hence, as an underlying therapeutic principle, getting rid of accumulated fluids that may be causing physical and mental disorders is almost always a part of treating shen disorders.
References
Yang Shou-zhong (translator), The Divine Farmer's Materia Medica, 1998 Blue Poppy Press, Boulder, CO.
Hsu HY, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA.
State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, (Vol. 2) 1995-6 New World Press, Beijing.
Editorial Committee, International Conference on Traditional Chinese Medicine and Pharmacology Proceedings, 1987 China Academic Publishers, Beijing.
Bensky D and Barolet R, Chinese Herbal Medicine: Formulas and Strategies, 1990 rev. ed., Eastland Press, Seattle, WA.
Zhang Enqin (chief editors), Clinic of Traditional Chinese Medicine, 1989 Publishing House of Shanghai College of Traditional Chinese Medicine, Shanghai.
Hou Jinglun Geng Xiu'e (chief editors), Traditional Chinese Treatment for Senile Diseases, 1997 Academy Press, Beijing.