Scatology Redux

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

A number of years ago I wrote a book titled Scatology & the Gate of Life. This book was an attempt to describe candidiasis and intestinal dysbiosis from the point of view of Chinese medicine. At the time I wrote that book, I shared clinic space with a Western naturopath, and I was interested in exploring ways in which Chinese medicine and naturopathy could enrich each other. During that time, I was very influenced in my thinking by two books on candidiasis in particular, The Yeast Connection and The Yeast Syndrome. Both of these books discuss polysystemic chronic candidiasis (PSCC) and its relationship to a host of other commonly seen but often "knotty, difficult to treat" diseases. It seemed to me that, from a Western point of view, there is a relationship between PSCC, food and other allergies, leaky gut syndrome, and a number of immune deficiency and autoimmune diseases. Recently, Stefan Chmelik, the publisher and editor of RCHM News, wrote me concerning Scatology. His letter has prompted me to write this addendum to that book, since the theories and protocols described in that book are no longer representative of either my thinking or practice.

At the time I wrote Scatology, I was giving a large proportion of my patients a combination of Chinese herbal medicine and Western nutritional supplements. This was complemented by a rice-based, hypoallergenic meal replacement at first and then moving on to a yeast-free, anticandidal diet secondarily. In terms of Chinese herbal formulas, based on TCM pattern discrimination, most of my patients with PSCC seemed to require a combination of sweet, warm spleen-supplementing medicinals, acrid, warm and acrid, cool qi-rectifying medicinals, and bitter, cold, heat-clearing, dampness-eliminating medicinals. In other words, most of my patients with PSCC had mixed vacuity and repletion and mixed hot and cold patterns according to TCM pattern discrimination.

In Scatology, I discussed the Chinese medical concept of chong or worms (i.e., parasites). I also explained how Candida albicans, at least as it relates to vaginal yeast infections, is categorized as a species of chong in the Chinese medical literature. Chong in Chinese medicine are traditionally treated by a combination of three flavors: bitter, acrid, and sour. I also made reference to how Western research has determined that a large number of commonly used bitter, cold, heat-clearing and dampness-eliminating medicinals are fungicidal, while many acrid, warm medicinals are antihistaminic (i.e., anti-allergic). Therefore, I rationalized the composition of my Chinese herbal formulas largely on the TCM principles of killing or expelling chong corroborated by Western medical notions of killing yeast and preventing allergic responses. While the addition of spleen-supplementing, qi-boosting medicinals was in response to my patients chronic and consipcuous fatigue.

Soon after writing Scatology, I was charged with practicing medicine without a license due to a complaint not from a patient but from an MD. At that time, acupuncturists were only legally allowed to do acupuncture in the State of Colorado. We were not allowed to prescribe or perform any other treatment. That included Chinese herbal medicine and Western nutritional supplements, even though any individual can buy nutritional supplements on their own without a prescription. The up-shot of my prosecution was two-fold. First, it provided the impetus for legalizing the inclusion of Chinese herbal medicine, moxibustion, tui na, Chinese dietary theory, and qi gong as part of the legal scope of practice of licensed acupuncturists in this state. Secondly, I had to sign an agreement with the Colorado State Attorney General agreeing that, in the future, I would not practice Western medicine. As defined by the State Board of Medical Examiners, Western medicine includes vitamins, minerals, amino acids, enzymes, and all homeopathic medicines.

Whether or not this makes any sense, and especially to my U.K. counterparts who practice under the permissiveness of English Common Law, is not the point. The point of this tale is that I was suddenly no longer allowed to use anything in my practice what are commonly defined as traditional Chinese medicinals. This caused me to focus even more closely on the fine points of Chinese medicine. I could no longer bail out and use a naturopathic "shot-gun approach" to therapy. I had to do what I needed to do with my patients using only acupuncture, Chinese medicinals, and Chinese dietary therapy. Although the legal wrangling that lasted more than 18 months was no fun, the bottom line of this experience was that it forced me to become a much better TCM practitioner.

At the same time, I was also spending more and more time teaching myself how to read medical Chinese. This gave me access to parts of the Chinese medical literature which were not currently available in English translation. One of the books that I worked on as part of Blue Poppy Press's Great Masters Series was Li Dong-yuan's Pi Wei Lun (Treatise on the Spleen & Stomach). Although the title of this book might lead the uninitiated to think that it deals with diarrhea, vomiting, and indigestion, if one knows anything about the clinical presentations of diseases such as multiple sclerosis, lupus erythematosus, rheumatoid arthritis, etc., one will immediately recongize that it is those kinds of allergic, autoimmune, and immune deficiency diseases which are the main concern of the Pi Wei Lun.

The main topic of the Pi Wei Lun is the spleen's role in the disease mechanisms of yin fire (yin huo). Yin fire is not the same as vacuity heat. Vacuity heat is a type of yin fire, but yin fire is more than vacuity heat. According to Li, yin fire is a pathological heat associated with life gate or ministerial fire originating in the lower source but which stirs upward, causing various disturbances to the viscera and bowels. This upward stirring of ministerial fire can be due to:

1. Spleen vacuity
2. Damp heat
3. Liver depression/depressive heat
4. Blood vacuity, i.e., yin vacuity
5. Any excessive physical, mental, emotional, or sexual stirring

Although these five basic mechanisms of yin fire must be presented one after the other when writing or speaking about them, in actuality, they tend to occur together. Most patient's suffering from yin fire scenarios have three, four, or even all five of these mechanisms. If one understands basic Chinese medical theory, it is not hard to understand how one of these five can give rise to or be aggravated by any of the other four. Once these mechanisms get put in train, they quickly mutually reinforce each other, and, therefore, they become very hard to deal with if one tries to attack them one by one.

In fact, Li Dong-yuan suggests that one cannot attack them one by one. Rather, he describes very beautiful and sophisticated protocols in which he deals with the "whole enchilada" all at one go. A typical Li Dong-yuan formula will include:

A. Sweet, warm, spleen supplements
B. Acrid cool and/or acrid warm qi-rectifiers
C. Bitter, cold heat-clearers

In addition, there will be blood-nourishers, fluid-enrichers, wind damp dispellers, dampness-percolators, or whatever else are necessitated by the combination of patterns and presenting symptoms. Depending on the case at hand, the mix of these three or more groups of ingredients is proportionalized to the exigencies of the case at hand. However, the overhwelming majority of Li Dong-yuan formulas will have the first three categories of medicinals as well as at least two other categories of medicinals. Therefore, Li's formulas are warm and cool or cold simultaneuosly, supplement and drain, support and attack at the same time. They are complex formulas for complex conditions. Below is a typical Li Dong-yuan formula with an analysis of its ingredients.

Qing Shu Yi Qi Tang (Clear Summherheat & Boost the Qi Decoction)

Radix Astragali Membranacei (Huang Qi)
Radix Panacis Ginseng (Ren Shen)
Rhizoma Atractylodis (Cang Zhu)
Rhizoma Atractylodis Macrocephalae (Bai Zhu)
mix-fried Radix Glycyrrhizae (Gan Cao)
Tuber Ophiopognis Japonici (Mai Dong)
Radix Puerariae (Ge Gen)
Fructus Schisandrae Chinensis (Wu Wei Zi)
Radix Angelicae Sinensis (Dang Gui)
Pericarpium Citri Reticulatae (Chen Pi)
Pericarpium Citri Reticulatae Viride (Qing Pi)
Rhizoma Cimicifugae (Sheng Ma)
Cortex Phellodendri (Huang Bai)
Rhizoma Alismatis (Ze Xie)
Massa Medica Fermentata (Shen Qu)

Within this formula, Astragalus, Ginseng, the two Atractylodes, and mix-fried Licorice all fortify the spleen and boost the qi. They are warm, supplementing medicinals. The two Atractylodes are also quite drying. Aged Orange Peel, Green Orange Peel, and Cimicifuga all rectify the qi. Phellodendron clears heat and eliminates dampness. It clears and eliminates damp heat in the lower burner and clears vacuity heat counterflowing upward to the head and face. Cimicifuga, besides rectifying the qi and upbearing yang, clears heat in the head and face. Therefore, the combination of these medicinals fulfills the first three treatment principles of a typical Li Dong-yuan yin fire protocol.

To this base are added a number of other medicinals. Pueraria, Ophiopogon, Schisandra, and Dang Gui all engender fluids and enrich yin. In addition, Pueraria upbears yang and effuses heat, while Ophiopogon clears heat from the heart and lungs and transforms phlegm. The heat of damp heat in the lower burner will A) ascend to harass above (i.e., the heart, lungs, head, and face), while B) it will damage and consume yin fluids. On the other hand, medicinals which are windy and dry in nature (qi-rectifiers, exterior-resolvers, and dampness-driers, e.g. the two Atractylodes) can also damage yin fluids. Therefore, the inclusion of these fluid-engendering, yin-enriching ingredients treats both the heat wafting upward as well as prevents any side effects from dampness-drying medicinals in the formula.

The Alisma in this formula both seeps the damp component of summerheat, i.e., damp heat, while it also leads yang back down to its lower source. (In fact, Li says Phellodendron also leads yang qi back down to its lower source.) If the spleen is vacuous and weak and further encumbered by dampness due to damage by externally invading summerheat, then the spleen's control over movement and transformation will, in all probability, lose its command or duty. Therefore, spleen vacuity and damp encumbrance are often complicated by an element of food stagnation. The clear is not upborne and the turbid is not downborne. Therefore, Massa Medica Fermentata is included as a "grace note" in this formula.

If one goes through the Pi Wei Lun or Li's other major work, the Lan Shi MiCang (The Secret Treasury of the Orchid Chamber), one will see that the great majority of Li's formulas follow this same basic outline. In structure, such formulas are also what I had come to on my own for all my patients with PSCC, allergies, autoimmune, and immune deficiency conditions. However, once I discovered Li's Pi Wei Lun is was able to write even better, more clinically effective formulas. As an extension of this, when I then went on to work on Zhu Dan-xi's The Heart & Essence of Dan-xi's Methods of Treatment, I learned how Zhu refined and extended Li's prescriptions even further. At this writing, 90% of all my patients with chronic, enduring, difficult to treat diseases are taking Chinese herbal formulas which can easily be recognized as derivative of Li and Zhu.

When this kind of formula is combined with a clear, bland diet as described by Li and other Chinese doctors, then their effects on PSCC, allergies, autoimmune, and immune deficiency problems are profound. A clear bland diet here means a rice-based diet high in vegetables and some animal protein. It avoids sugars and sweets, including citrus fruits and all fruit juices, foods which are both sour and sweet, i.e., acidic, such as tomatoes, wheat products, especially yeasted wheat products, cheeses, vinegar, alcohol, or anything else made through yeast-based fermentation, any foods which mold easily, such as strawberries and peaches, but not apples or pears, and anything which is spicy, hot or greasy and fatty. If one understands all the above categories and examples of foods, they are all either damaging to the spleen, engender more fluids in a body already encumbered by dampness, damage the liver and, therefore, cause or aggravate liver depression qi stagnation, thus inhibiting the qi mechanism, or directly or indirectly cause depressive and/or damp heat.

In my experience, if one tries to use Li Dong-yuan yin fire type formulas and medicinals but does not also combine this with a hypoallergenic, yeast-free, clear, bland diet, then the treatment will not be very effective. Patients typically need to adhere to such a clear, bland for at least three months and better for six months before trying to add back into their diet allergenic or yeast-contaminated foods or even a little bit of sugar and sweets.

Along the same lines, Heiner Fruehauf, a Chinese-reading teacher of Chinese medicine at the Northwest Naturopathic College in Portland, OR, has done some interesting research on historical or premodern Chinese schools of medicine addressing themselves to gu zheng. According to Fruehauf, gu are a type of chong or parasites which cause complicated, multifaceted complaints which, when analyzed, seem to correspond to such modern disorders as PSCC, chronic fatigue immune deficiency syndrome, intestinal parasitosis, leaky gut syndrome, etc.

In his essay on this subject, Fruehauf lists five categories of medicinals typically found in a gu zheng formula. These five categories of medicinals are similar to Li's three categories of treatment principles in the treatment of yin fire conditions. The first of these are san du, scattering toxin medicinals. These should not be confused with heat-clearing, toxin-resolving medicinals (qing re jie du yao). Scattering toxins medicinals are exterior-relievers. They include: Folium Perillae Frutescentis (Zi Su), Herba Menthae Haplocalycis (Bo He), Radix Angelicae Dahuricae (Bai Zhi), Radix Et Rhizoma Ligustici Chinensis (Gao Ben, a.k.a. Hao Ben), and Rhizoma Cimicifugae (Sheng Ma).

The second of these categories of medicinals (or treatment principles) is sha chong medicinals. Sha chong means to kills worms or parasites. This was a treatment principle I argued for including in cases with PSCC in Scatology. The medicinals Fruehauf lists in this category are: Tuber Curcumae (Yu Jin), Radix Sophorae Falvescentis (Ku Shen), Fructus Cnidii Monnieri (She Chuang Zi), Rhizoma Acori Graminei (Shi Chang Pu), Flos Lonicerae Japonicae (Jin Yin Hua), Fructus Terminaliae Chebulae (He Zi), and Fructificatio Omphaliae (Lei Wan). Of these, only Omphalia is nowadays categorized as worm-killing or expelling medicinal. Sophora and Fructus Cnidii both clear and eliminate damp heat and have a very strong fungicidal effect. Terminalia is nowadays thought of as an astringent which treats diarrhea. However, in Tibetan medicine, it treats constipation or diarrhea and is a very important medicinal for regulating what in Chinese medicine would be thought of as the lower source. Curcuma rectifies the qi but is especially useful when there is liver depression qi stagnation complicated by damp heat in the liver-gallbladder.

The third category of medicinals are qu gui, expelling ghost medicinals. These include Herba Artemisiae Apiaceae (Qing Hao), garlic (Da Suan), and Squama Manitis Pentadactylis (Chuan Shan Jia). Artemisia Apiacea clears vacuity heat. However, it is very useful in my experience when there is vacuity heat above due to damp heat brewing and steaming below. Anteater Scales are a blood-quickening medicinal which break the blood in the treatment of concretions and conglomerations. Such blood stasis concretions are often associated with damp heat stasis and stagnation. Because static blood is dead blood, it prevents the engenderment of fresh or new blood. Therefore, the heart spirit does not receive its nourishment and may become restless. Garlic is a well-known anti-fungal medicinal with a strong effect on the intestinal fauna and flora.

The fourth category of medicinals are spirit-calmers (an shen). Fruehauf notes that patients with gu zheng typically also complain of various psychoemotional disturbances. The medicinals in this category are: Rhizoma Polygonati (Huang Jing), Bulbus Lilii (Bai He), Radix Glehniae Littoralis (Sha Shen), and Sclerotium Pararadicis Poriae Cocos (Fu Shen). The first three of these are all yin-enriching, fluid-engendering medicinals which engender fluids in the stomach which are then upborne to nourish the lungs and heart yin and blood. As we have seen above, if there is damp heat brewing and steaming below, heat will waft up and damage and consume yin fluids in the lungs and heart. In that case, the heart spirit will be restless and disquieted. Spirit of Poria is a spirit-calming medicinal by towards TCM standards of care. It quiets the spirit by nourishing the heart as well as seeping dampness. Seeping dampness leads ministerial fire back down to its lower source.

The fifth category of medicinals are qi and blood supplements. Those listed by Fruehauf as being supplements with anti-gu natures are: Radix Angelicae Sinensis (Dang Gui), Radix Albus Paeoniae Lactiflorae (Bai Shao), Radix Polygoni Multiflori (He Shou Wu), Radix Glycyrrhizae (Gan Cao), and Radix Astragali Membranacei (Huang Qi). We have already seen that Li almost always used Astragalus and Licorice in his formulas based on principle number one, fortify the spleen and boost the qi. Li also almost always included Dang Gui in his formulas and often used White Peony. This is based on the relationship between supplementing the qi and supplementing the blood and the relationship between nourishing the liver and rectifying the qi. The only real difference in thinking here between Li and the school of treating gu zheng is that Fruehauf says people with gu zheng react negatively to Ginseng. Since these days Radix Codonopsitis Pilosulae is routinely substituted for Ginseng, this may not be an issue.

As an example of a prototypical gu zheng formula, Fruehauf gives Jia Jian Su He Tang (Modified Perilla & Mentha Decoction):

Folium Perillae Frutescentis (Zi Su)
Herba Menthae Haplocalycis (Bo He)
Radix Angelicae Dahuricae (Bai Zhi)
Radix Angelicae Sinensis (Dang Gui)
Radix Ligustici Wallichii (Chuan Xiong)
Radix Glycyrrhizae (Gan Cao)
Radix Astragali Membranacei (Huang Qi)
Radix Polygoni Multiflori (He Shou Wu)
Bulbus Lilii (Bai He)
Cortex Radicis Acanthopanacis Gracilistyli (Wu Jia Pi)
Herba Lycopi Lucidi (Ze Lan)
Rhizoma Curcumae Zedoariae (E Zhu)
Rhizoma Sparganii (San Leng)
Pericarpium Citri Reticulatae (Chen Pi)
Radix Auklandiae Lappae (Mu Xiang)
Flos Caryophylli (Ding Xiang)

If one compares the categories, flavors, and natures of the ingredients in the above formula, one can see that the structure of this formula parallels a Li Dong-yuan yin fire formula except that it does not clear heat much. It includes sweet, warm spleen-supplements and acrid qi-rectifiers. It does not contain much in the way of bitter, cold, heat-clearing medicinals, except that Mentha is cool and does clear heat. However, effusing heat with qi-rectifiers and exterior-resolvers is another legitimate way of dealing with internal heat. Obviously, from the inclusion of the strongly blood-breaking medicinals, such as Zedoaria and Sparganium, this formula is meant to treat someone with concretions and conglomerations as well as intestinal dysbiosis. Since this formula would be modified by the inclusion of heat-clearing medicinals if the signs and symptoms of internal heat were more, this formula could be very easily modified to fit Li's treatment principles for a yin fire scenario.

For me, the above gu zheng theories and therapies add further credence to Li's theories about and therapies for chronic, enduring, difficult to treat diseases associated with spleen vacuity, and inhibited qi mechanism, and the presence of damp heat associated with PSCC, leaky gut syndrome, food allergies, and intestinal dysbiosis and parasitosis. By adding some of the insights of gu zheng theory to Li's, I believe that one can achieve even better clinical results. Fruehauf states, "During the last three years, I have prescribed variations of Modified Perilla and Mentha Decoction to approximately one hundred patients who have been diagnosed with chronic conditions of entamoeba histolitica, giardia, blastocystis hominis, candida albicans, and other parasitic organisms, or to patients who simply suffered from a multiplicity of mental and physical symptoms that could not be explained by standard parameters. I can say without hestitation that the clinical results obtained in these cases are promising."

In presenting Li Dong-yuan's approaches and those of gu zheng therapy to the treatment of such "knotty, difficult to treat diseases" above, I do not mean to suggest that one should routinely prescribe this kind of formula to every Western patient who comes in the door. Rather, it is my suggestion that, when faced with complex patients with difficult to treat diseases and a history of intestinal dysbiosis, allergies, or immune system dysfunctions, one look for A) spleen vacuity, B) inhibition of the qi mechanism (read liver depression qi stagnation), and C) heat, either depressive or damp heat. If one finds a combination of these three things, then look for 1) concomitant blood, yin, and/or fluid vacuities, 2) heat disturbing the lungs or heart above, and 3) even possible kidney yang vacuity below. In that case, there will be symptoms of hot and cold, dampness and dryness, vacuity and repletion all at the same time. Then, on top of all this, there may be other disease mechanisms associated with concretions and conglomerations (as in endometriosis), wilting (as in multiple sclerosis), or impediment (as in rheumatoid arthritis and systemic lupus erythmatosus). In such cases, one must write complex formulas which treat all the disease mechanisms at the same time, not one after the other. Li Dong-yuan shows how one can do this. In addition, eating the proper clear, bland, hypoallergenic, yeast-free diet is a sine qua non of a successful outcome.

As I think the above discussion shows, when it comes to the TCM treatment of PSCC, allergies, immune disorders, etc., one does not need to bail out and use Western naturopathic theories and therapies. Chinese medicine does have theories which adequately describe the causes of these conditions and therapies which effectively treat them. However, this requires going more deeply into the Chinese medical literature than books meant for beginning practitioners. That in turn requires being able to read the Chinese medical literature in Chinese. But that is the subject for another discussion.

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