ZHU DAN-XI ON GU CONDITIONS

by Bob Flaws, Dipl. Ac. & C.H., FNAAOM

INTRODUCTION
In previous essays I have discussed some of the common points between gu condition (gu zheng) theory as described by Heiner Fruehauf and Li Dong-yuan's yin fire theory. In continuing to think about these issues, it occurred to me to see if Zhu Dan-xi has a chapter on gu conditions in his book Dan Xi Zhi Fa Xin Yao (The Heart & Essentials of Dan-xi's Methods of Treatment). Although Zhu Dan-xi is remembered as the fourth of the Four Great Masters of the Jin-Yuan dynasties in his own right, he basically accepted all of Li Dong-yuan's ideas and then further refined them. The Dan Xi Zhi Fa Xin Yao is a clinical manual on the treatment of disease. Each chapter deals with a different disease, and typically those treatments are practical applications of Li's yin fire theories.

When I looked at Zhu's Table of Contents, I could not find any chapter with the word gu in it. Therefore, I looked at the chapter titled "Drum Distention" since abdominal distention is one of the main symptoms of gu conditions. Happily, my conjecture proved correct. In this chapter, Zhu succinctly says that, "Drum distention is also known as gu." He then says that details about this can be found in another of his books, the Ge Zhi Yu Lun (Extra Treatises Based on Investigation & Inquiry). (Both these books are available in English as part of Blue Poppy's Great Masters Series.) However, before turning to that book as Zhu suggests, I would like to repeat how he ends the paragraph containing the above quote:

The treatment method is to greatly supplement the center qi and move dampness as a rule. Since this is [a disease of] extreme spleen vacuity, it is necessary to keep away from music [made with wooden instruments] and refrain from [foods with] thick flavors.

In other words, Zhu thinks that gu conditions involve an extremely vacuous spleen engendering dampness and that its treatment requires careful dietary therapy. Here we are definitely in the realm of yin fire theory. Therefore, I will let Zhu speak for himself. The following is the entire chapter on drum distention, a.k.a. gu condition, from Zhu Dan-xi's Ge Zhi Yu Lun:

TREATISE ON DRUM DISTENTION
The heart and lungs, which are ascribed to yang, are located above, while the liver and kidneys, which are ascribed to yin, are located below. The spleen, located in the center, which is also yin, is ascribed to earth. The classic [the Nei Jing] states:

Drink and food enter the stomach which floats essence qi and transports it up to the spleen. [Then] spleen qi spreads the essence which comes up home to the lungs to free and adjust the flow of the water passageways, transporting [water] down to the urinary bladder. Water essence spreads in the four directions and the five channels run side by side.

Thus the spleen gains the tranquil virtue of earth and has the vigor of the movement of heaven. For that reason, it enables the yang of the heart and lungs to descend and the yin of the kidneys and liver to ascend, resulting in the advantageous communication between heaven and earth. Such is [the state] of a healthy person.

The seven affects damage the internal, the six environmental excesses invade from outside, food and drink are had without restraint, and chamber taxation causes vacuity. [Any of these causes may] damage spleen earth yin [and consequently,] the office of transportation and conveyance may fail to carry out its duty. Although the stomach [still] receives grains, [the spleen] cannot transport or transform them. As a result, yang keeps on upbearing itself and yin keeps on downbearing itself, resulting in the disadvantageous divorce between heaven and earth. When this happens, clearness and turbidity are confused together and the tunnels are congested and held up. Qi transforms into the turbid, and blood becomes stagnated with depressive heat [being generated]. When heat remains for long, qi transforms into dampness. Dampness and heat mutually engender, thus giving rise to distention and fullness. This is what the classic calls drum distention because, though hard and full, the abdomen is empty with nothing inside, [thus] resembling a drum. The disease is persistent, firmly fixed, and difficult to cure. It is also called gu. Because it is as if [one were] invaded and being eaten by worms, therefore, [this kind of distention] is called gu.

In reference to the method of treatment [for this condition], it is justifiably appropriate to supplement the spleen, and it is also necessary to nurture lung metal to restrain wood in order that the spleen is freed from the worry of bandit evils. [One should also] enrich kidney water to restrain fire in order that the lungs are enabled to exercise purification. Abstain from salty flavor lest it should assist the evil and cut off frenetic desire in order to protect the maternal qi. Thus there are none who are not [subsequently] at ease.

[However,] some physicians, unaware that [this] disease originates from vacuity, are eager for a rapid effect to show off their ability and to seek for reward. And patients, bitterly [distressed] by urgent distention, prefer [qi-]moving and disinhibiting medicinals just to seek [some] temporary relief, not knowing that relaxation for a day or a half may only be followed by more serious swelling. The disease evils (then) become more serious, and the true qi is damaged. [In this case,] death is not far off. Of ancient formulas, only Yu Yu Liang Wan (Limonite Pills), also named Shi Zhong Huang Wan (Inside Stone Yellow Pills) or Zi Jin Wan (Purple Gold Pills), restrain the liver and supplement the spleen with an exceptional specific efficacy. However, these, too, should be added to and subtracted from in accordance with the signs and seasons.

My friend, Yu Ren-shu, a Confucian scholar and physician [himself], who had been struck by continual family mishaps, contracted this kind of disease at 50 years of age. He took self-prepared Yu Yu Liang Wan. I examined his pulse which was choppy and rapid. [I] said that those pills were newly prepared and still retained the furnace's fire evil and that they contained too many warm and hot medicinals. He should have made additions and subtractions [to the formula]. One should not stick to a formula [with no adaptation according to the patient's individual situation]. Yu smiled, saying that contemporary people are inferior to the ancients and that this formula allows for no additions or subtractions. After one month's administration, [he] bled at the mouth and nose, became scrawny and emaciated, and then died.

Again, Yang, a friend aged nearly 50, was addicted to wine. Having been diseased with malaria for half a year, [he] contracted the disease of distention. Assuming that he was bound to die, he came over for a treatment. I examined his pulse which was wiry and choppy and large when pressure was applied. His malaria remained to be overcome, and he had thin hands and feet with an enlarged belly like a spider. I instructed [him] to use Radix Panacis Ginseng (Ren Shen) and Rhizoma Atrac-tylodis Macrocephalae (Bai Zhu) as sovereigns, Radix Angelicae Sinensis (Dang Gui), Radix Ligustici Wallichii (Chuan Xiong), and Radix Paeoniae Lactiflorae (Shao Yao) as ministers, and Rhizoma Coptidis Chinensis (Huang Lian), Peri-carpium Citri Reticulatae (Chen Pi), Sclerotium Poriae Cocos (Fu Ling), and Cortex Magnoliae Officinalis (Hou Po) as assistants, all of which were to be boiled with a small amount of uncooked Radix Glycyrrhizae (Gan Cao) into a thick decoction and drunk. He needed to take this three times a day and, in addition, to strictly abide by the prohibitions and commandments. A month later, his malaria was cured following perspiration. Half a year later, his urination became long and the distention was overcome. During [this] course [of treatment, the formula] underwent [various] additions and subtractions in a small way. Throughout, the fundamental objectives remained the supplementation qi and removal dampness.

Again, a Master Chen, aged over 40, was addicted to wine. He occasionally had had blood in (his) stools, and, in the spring, began to suffer from distention with a black complexion and enlarged abdomen. [He] looked like a ghost. I felt his pulse which was rapid and choppy and somewhat weak when pressure was applied. I prescribed Si Wu Tang (Four Materials Decoction), adding Rhizoma Coptidis Chinensis (Huang Lian), Radix Scutellariae Baicalensis (Huang Qin), Caulis Akebiae Mutong (Mu Tong), Rhizoma Atractylodis Macrocephalae (Bai Zhu), Pericarpium Citri Reticulatae (Chen Pi), Cortex Magnoliae Officinalis (Hou Po), and uncooked Radix Glycyrrhizae (Gan Cao). These were taken in the form of a decoction. Less than a year and [he] was at ease.

First, supplement the qi. Secondly, supplement the blood. Other medicinals [than these two kinds in my prescriptions] vary largely. But each case [I have attended] has been cured with their heaven- decreed life span preserved. Some may ask, "Qi [distention admits of] no supplementing method. How can your honor succeed in achieving recovery through supplementing qi? Is there really a theory that warrants your approach?" My reply is that it is the layman's assertion that qi [distention] admits of no supplementing method. In diseases caused by qi, [such as] glomus depression, congestion, and obstruction, it may seem hardly [possible to apply] supplementation for fear that it may worsen the disease condition. [But] what is not taken into consideration is that this disease is produced because the righteous qi is vacuous and no longer able to circulate and because the evil is stagnated and fixed and refuses to come out. The classic states: "Once sturdy, qi moves, effecting a cure; once dwindled, [qi] is fixed, producing disease." Suppose qi is dwindled but supplementation is not used, by what strength can it circulate?

Some may comment, "Your prescription is indeed carefully considered. But how slow it is in achieving an effect! Patients, long bed-stricken, must be tired of your roundabout way and pressing for a rapid [result]." My answer is that this kind of disease arose possibly three or five or even more than 10 years ago. Its root is deep and its condition is hideous. If one is anxious for a rapid effect, one is asking for a disaster. [Only] those who know the kingly dao are capable of treating this disease.

Some may ask, "Should one never prescribe disinhibitors at all in distention disease?" My answer is that if it is obviously known not to have arisen out of vacuity, if the disease [is] shallow, if the spleen and stomach are still robust, and if the accumulated stasis is not inveterate, and, in addition, if there are signs otherwise indicating precipitation, it is appropriate to administer coursing and abducting [medicinals] in a small way. [Some] may routinely take Zhang Zi-he's prescription, Jun Chuan San (Dredge the River Powder), or Yu Gong Wan (Yu's Merit Pills) to carry out a rapid attacking policy, [but I] really dare not.

BOB'S CONCLUSION
In the second paragraph of this chapter, Zhu says that drum distention or gu conditions may be caused by the seven affects or emotions, the six environmental excesses, from dietary irregularities, and from sexual taxation, all of which may damage the spleen. If clear and turbid are hence not separated as they should be, then this gives rise to blood stasis, depressive heat, and/or damp heat. However, the hub or axis for the generation of these evil qi is spleen vacuity. Zhu goes on to say that this disease

is persistent, firmly fixed, and difficult to cure. It is also called gu.

If one looks at the formulas Zhu prescribed in two out of the three case histories presented in this chapter, one will clearly see that they are both based on Li Dong-yuan's principles for dealing with yin fire. In the first case, extreme, prolonged stress was the cause of the patient's condition. The patient, a physician himself, prescribed himself the wrong medicine which was only attacking and draining and, therefore, died. The other two cases were caused by addiction to alcohol, a damp, hot, fermented product. Zhu prescribed yin fire type formulas with spleen supplements, heat-clearers, qi-rectifiers, and blood quickeners and nourishers, and the patients lived. Zhu also says that

this kind of disease arose possibly three or five or even more than 10 years ago. Its root is deep and its condition is hideous. If one is anxious for a rapid effect, one is asking for disaster. [Only] those who know the kingly dao are capable of treating this disease.

This kingly dao is nothing other than supplementing and draining at the same time, using bitter, cold medicinals and sweet, warm medicinals, and windy, acrid all at the same time. If one tries to use simpler protocols which only either attack or drain, support or dispel, one will not get the right result and may even worsen the situation.

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