7　Bold Application of TCM Theories to Practice

Question： "Differentiation"and"unity"are unique concepts only in TCM.Could you talk about some typical cases？

Answer： TCM indeed has unique advantages to some cases that can't be solved by Western medicine.For instance，I treated a 5-year-old girl(No.82091)in 1983 who was admitted because of severe burns(total burnt surface 27%，II degree 7%，III degree 20%)complicated by shock.We rescued shock by Western medicine.But severe infection of burns caused septicemia and then the temperaturewas below 37℃accompanied with mental confusion，convulsion of limbs and elevation of blood pressure.There was a severe dyspnea and temperature was below 35℃after one week.So she was given a tracheotomy and oxygen supply provided by breathingmachine due to stopping of spontaneous respiration after operation.She was diagnosed with hypothermia septicemia and toxic encephalopathy at Burn Department.Most of the embedded skin didn't survive because of severe inflection of the burned wounds，white blood cell20.4×109/L，neutrophils 0.74，and lymphocyte 0.26，toxic granule cell 10%.There was no improvement after anti-infective treatmentwith Westernmedicine，so an emergent TCM consultation was arranged on March 17，1983.

During consultation，the patient had abated temperature，elevated blood pressure(160/120mmHg)，cold of hands and feet，mental confusion，polypnea，gurgling with phlegm in the throat，scanty dark urine(catheterization)，little and dark feces，dark red lips and tongue，slimy coating and a deep，thready and rapid pulse.So the syndrome pertained to fire toxin invading heart and blood，which obstructed pericardium，led to internal stirring of liver wind and raised phlegm with wind-fire.The therapy is to purge fire，cool blood，remove toxin，eliminate phlegm，open orifices and extinguish wind.So Icombined Xie Xin Tangwith An Gong Niu Huang San(modified):Huang Lian 10g，Huang Qin 10g，Da Huang 10g(to be decocted later)，An Gong Niu Huang San 1 piece(to be taken infused for two times)，Sheng Zhi Zi10g，Sheng Di Huang 15g，Chi Shao 15g，Mu Dan Pi 10g，Zi Cao 10g，Jin Ying Hua15g，Lian Qiao 15g，ShiChang Pu 15g，Yu Jin 10g.Two doses per day，nasal feeding，once every six hourswith 100ml each time.

Second visit(on the fourth day):the stool frequency increased(9 times daily for themost)with about100g each time and of the brown colour.There wasmore than 2，000ml urine each day，temperature was 37.4℃and blood pressure was 100-116/60-70mmHg.Convulsion stopped and the situation improved greatly.Taking the original formular for another three days but one dose per day.

Third visit(on the seventh day):her temperature and blood pressure became normal and her spontaneous breathing recovered well，stopping the use of breathingmachine.She was in agrypnocoma with blink and blunt senses of pain and touch.Therewas still gurgling phlegm in the throat，yellow stools for 3-5 times per day，a red tongue with thin and white coating and a thready and rapid pulse.White blood cell was 8.5×109/L，neutrophils 0.74，and toxic granule cell6%，indicating the situation was remarkably improved.The modification of the above formulawas prescribed to strengthen the effects of eliminating phlegm and opening orifices so as to regain consciousness.

Prescription was as follows:Huang Lian 6g，Huang Qin 10g，Da Huang 10g(to be decocted later)，An Gong Niu Huang San 1 piece(to be taken infused for two times)，Sheng Zhi Zi10g，Tian Zhu Huang 10g，Dan Nan Xing 6g，Jiang Can 10g，Yuan Zhi6g，Shi Chang Pu 15g，Yu Jin 15g.Taking the prescription formore than 10 doses accompanied with Western medicine and support therapymade the patient totally consciouswith normal breath，temperature and blood pressure，hemogram.The examination showed no bacteria in blood culture and no toxic granule cell.Then with another skin-grafting operation，the patient recovered well and was discharged from hospital.

According to doctors of Burn Department，there was no satisfactory curative effect for the similar cases of this severity in the former time.While in this case TCM diagnosis and treatmentworked well to save the patient for the high consistency between prescription and syndrome，fully indicating the unique advantages of TCM in treating emergency disease.

Question： What you have said is of enlightening significance.Could you talk about the TCM methods of"elimination"and"tonification"in deficiency and excess syndroms？

Answer： Elimination and tonification should be decided by the relationship between exuberance and debilitation of pathogenic qior healthy qiaswell as deficiency and excess of the disease.Generally speaking，weak constitution and long illness pertains to deficiency syndrome and for which tonification is suitable；whereas strong constitution and early illness pertains to excess syndrome and forwhich elimination is suitable.This is themost basic therapeutic principle between deficiency and excess and it is obvious that treating deficiency without purgation and excess without tonification.But for some cases with weak constitution，accumulative stagnation and excess pathogen，or some caseswith strong constitution but weakened by pathogens and improper treatment，resulting in excess pathogenic qi and weak healthy qi.In such condition，if the treatment is simply to reinforce healthy qi，the resultwill go opposite with pathogenic qi reinforced instead of healthy qi，definitely worsening the illness.And if the treatment is simply to eliminate pathogen，then both healthy qi and pathogenic qi would probably become exhausted，leading to dangerous collapse.So for the cases not suitable for elimination going before tonification or vice versa，the therapy should combine elimination with tonification.For instance，Bai Hu Jia Ren Shen Tang，Tao Shi Huang Long Tang and Zeng Ye Cheng Qi Tang，they all pertain to this therapy.

Moreover，it should not be considered as a whole that whether enduring illnessmustbe tonified or acute illnessmustbe eliminated.Take enduring abdominalmass for instance，pure tonification makes it firmer，so it should be treated by gradual elimination or simultaneous application of tonification and elimination whereas sudden deficiency of healthy qi needs immediate tonification instead of elimination.

Although the relationships between deficiency and excess aswell as pathogenic qi and healthy qi are still within the framework of"treating deficiency syndrome with tonification and excess syndrome with purgation"，they should be based on exuberance and debilitation of pathogenic qi and healthy qi.So only by understanding the relationships between"branch"and"root"，"mildness"and"acuteness"and making careful syndrome differentiation and flexible application can we have a comprehensive understanding about deficiency，excess，tonification and purgation so as to avoid the therapeutic mistake of"reducing deficiency and tonifying excess".

Generally speaking，the theory of exuberance and debilitation of pathogenic qi and healthy qi and deficiency-excess transformation is a unique TCM reflection about the occurrence，developmentandmechanism of disease.Although all diseases are related with pathogen，"deficiency"and"excess"are based on the patient's resistance to disease and ability to recover.Clinically，based on different symptoms of exuberance and debilitation of pathogenic qi and healthy qi during the development of disease，there is therapeutic principle of"eliminating pathogen to reinforce healthy qi"and"reinforcing healthy qi to eliminate pathogen".This indispensable guiding principle originates from"exuberance of pathogen causing excess syndrome，lack of essential qi causing deficiency syndrome"and"treating deficiency syndrome with tonification and excess syndrome with purgation"in Huang Di Nei Jing .

Here is the application of purgation，one of the important TCM therapeutic methods，which uses purgative medicinal to strengthen defecation of the body so as to cure the disease and is clinically grouped into cold purgation，warm purgation and moist purgation.According to medicinal property，most purgativemedicines pertain to cold-cool nature except some oneswith warm nature，such as Ba Dou，Xu Sui Zi and Yuan Hua.My clinical experiences proved that cold purgation is themost frequently and widely used method.A-mong internal diseases，cold purgation ismainly used to treat acute infection disease.Although the causes of acute infection disease are different，excess heat syndrome is the common feature.Due to the seriousness，quick development and various change of acute infection disease，the critical treatment is to reverse and stop the trend at the acute stage.

By relaxing bowels and discharging heat，cold purgation canmake general toxemic reaction alleviated or disappeared to control the disease development.As themain medicine in cold purgation，Da Huang with actions such as purging，discharging heatand fire，removing toxin，dispelling stasis aswell as antisepsis and anti-inflammation is the most frequently applied medicine in treating internal acute infection.It can be applied at the early stage of acute infection even if the patient's stool is normal.However，it is usually inadvisable to use large dosage and slight purgation is appropriate.For cases with severe interior excess heat syndrome，large dosage of Da Huang is proposed to promote a quick defecation and should be stopped until the patient feels comfortable after defecation so as not to damage yin at the same time.

Clinically，I often combine Da Huang with Yu Li Ren and apply cold purgation when treating infection of respiratory system.For instance，acute respiratory distress syndrome，a clinical serious complication of various acute and severe diseases，is often caused by acute and severe infectious diseases in internal diseases.Therefore，it is critical to control infection strictly so as to early preventand treatacute respiratory distress syndrome.Inmy opinion，attention should be paid to relax bowels during the early treatment，for shock and hypoxiawill easily cause enteroplegia.Moreover，stagnation and obstruction of heat toxin，disturbance of qimovement and obstruction of blood circulation will easily cause obstruction of fu-organs qi，and then worsen enteroplegia.So relaxing bowels and discharging heat is necessary to ease abdominal distention，lower diaphragm and remove lung expansion，thus improve qi movement.My experienced medication is Sheng Da Huang，Hou Po，Zhi Shi，Hu Zhang and Ting Li Zi，etc.

Take another example，acute pneumonia at its excess heat stage often pertains to syndrome of pathogenic heat congesting lung，with excess symptoms such as high fever，cough，expectoration of phlegm，constipation，red tongue with yellow and slimy coating and slippery and rapid pulse.And there will be no effect if it is treated with routine formula such as Ma Xing Shi Gan Tang，Qing Jin Hua Tan Tang and Xie Bai San.According to the experience of"treating lung excess syndrome by purging the large intestine"，I created"Xie Fei Tong Fu Tang"to treat pneumoniawith excess heat syndrome，a formula which can stop disease development and speed inflammatory absorption by"suddenly discharging heat".The formula includes Sheng Da Huang，Ting Li Zi，Sang Bai Pi，Huang Qin and Qi Ye Yi ZhiHua，etc.It is also suitable for infantile pneumonia and can quickly bring down the temperature and shorten acute period.

The third example is asthma at its acute stage.If it pertains to lung excess syndromewithmanifestations such as phlegmatic dyspnea，qi congestion，stagnation and stasis，Istress the use of Da Huang based on syndrome differentiation and treatment，usually with the satisfied effect that one dose works and two doses cure the illness.This is because of the interior-exterior relationship between lung and large intestine.Aftermedication，the patient's fuorgan qi and lung qi descent，thus，relieves asthma immediately.

Many senior practioners have deep insights that it's not strange to apply purgativemethod to pure interior syndrome of excess heat and only those who flexibly and effectively apply the method to various deficiency syndromes or concurrent interior syndrome of excess heat can be regarded as masterhands.Clinically，purgative method is applied to treat deficiency syndrome mingling with excess syndrome with manifestations such as constipation，loose stool，abdominal distension，much phlegm and disturbance of qimovement，stuffy chest and quick breath，rapid pulse and yellow，slimy and turbid coating，etc.

According to clinical experience，thick and slimy coating or turbid and slimy coating is themain evidence of purgativemethod.In these cases，tonification and purgation should be applied simutanously，even for severe case，with pathogenic factor reduced and healthy qi recovered itself.Just as Xu Dachun(徐大椿)stated in Yi Xue Yuan Liu (《医学源流》， Origin and Development ofMedicine )that"when Da Huang is combined with Ren Shen，the former expels hardness and accumulation without damaging healthy qi；while the latter replenishes healthy qi without tonifying pathogenic qi."This indicates that Da Huang can often be combined with tonifying medicinal in treating deficiency syndromeminglingwith excess syndrome.My clinic experience proved that Da Huang can be applied to treatmany diseases with the good effect of"tonification by purgation"，such as bronchial asthma，chronic bronchitis，obstructive emphysema，and pulmonary heart disease，etc.

As to purgativemethod，physicians of past generations have put forward many contraindications and strict indications.According to clinical experiences，I think thatas long as there ismanifestation of interior syndrome of excess heat，whether it's pure excess syndrome or deficiency-excess in complexity，purgativemethod should be quickly applied to relieve the seriousness of the disease without over-emphasizing the accordance between pulse and syndrome，otherwise the best time will be missed and therapeutic effect will be affected.Besides，when Da Huang，the main medicinal in purgation，is not combined with Mang Xiao，itwill never lead to reactions of"uncontrollable purgation"and"toomuch purgation damaging yin".A chronic persistent hepatitis patient once took more than 1，500g Sheng Da Huang totally but without any reaction mentioned above，and even got his chronic colitis being cured.

Da Huang discharges heat with bitter-cold nature and enlivens spleen and promotes appetite with its fragrance.Many patientswho took Dahuang for severalmonths had good effects such as refreshment，stomach-intestine harmony and increased appetite without spoiled appetite by its bitter-cold nature.Just like the late renowned physician of Jiangxi Province Xiao Junyi(肖俊逸)stated，Da Huang is a wonderful disease-dispelling and life-prolongingmedicinalwith actions of clearing intestines and removing toxin，discharging water and foodstuff，regulating middle and harmonizing five zang-organs，etc，achieving the effect of tonifying by unblocking.Xiao was good at applying Da Huang，therefore，he was nicknamed as Xiao Dahuang(肖大黄).

Ihave learned from practice that when it is being over-decocted Da Huang's purging action will be lessened while its astringing action increases.Therefore，it is reasonable that the ancient people regarded Sheng Da Huang being drastic while Shu Da Huang beingmild.Clinically，when Da Huang is used to purge，itwill be noted to be decocted later.

It needs to pointout that purgativemethod is neither themere application nor the simple combination of purgative medicinal；rather it should be combined flexibly with other treatment according to different situations.Only by doing so can we get better therapeutic effects.

Question： Since upper gastrointestinal bleeding is mainly due to ulcer and you have achieved great accomplishments in applying Da Huang to treat it，could you share some experienceswith us？

Answer： TCM holds that Da Huang with bitter and cold nature has the actions of"discharging pathogenic heat"，"removing stasis downwards"，"harmonizing stomach and descending qi".And its action of stopping bleeding is in accordance with the theories of"dispelling stasis to stop bleeding"，"clearing heat to stop bleeding"and"descending qi to stop bleeding".Therefore，it is an idealmedicinal of blood-activating and stasis-dispelling as well as purging fire and stopping bleeding.Moreover，modern pharmacological experiments also indicate that it can shorten blood coagulation time，help bonemarrow to produce blood platelets，make blood capillaries compact and reduce their brittleness，so as to stop bleeding.

Upper gastrointestinal bleeding ismainly due to ulcer，which is clinically characterized by deficiency rootand excess branch，namely，spleen deficiency is the rootand blood stasis is the branch.For digestive tract itself，it is excess syndrome with collateral damage causing bleeding，qi stagnation and blood stasis.As Tang Rongchuan(唐容川)says，blood in stomach also pertains to excess syndrome of stomach which is caused by blood stagnation instead of dry fecesmentioned in Shang Han Lun .Therefore，based on the principle of treating branch in case of emergency，the treatment for upper gastrointestinal bleeding is to dispel stasis first.If blood stasis is not dispelled，blood will fail to circulate in vessels."So，activating blood and resolving stasismakes blood circulate in vessels，realizing the purpose of dispelling stasis and stopping bleeding.Related animal experiments show that blood stasis in stomach can cause directly or induce bleeding，which is consistent with the TCM theory that"when there is bleeding，stasis should be dispelled first rather than stopping bleeding"，and which is the experimental basis for treating upper gastrointestinal bleeding with Da Huang.

There will be much more defecation frequency after taking Da Huang powder，which dispels blood stasis to promote regeneration and stop bleeding".Modern pharmacological experiments indicate that taking Da Huang powderwon't increasemore bleeding because it can promote colonic peristalsis instead of the peristalsis of the stomach and duodenum.Therefore，it's harmless to ulcer of stomach and duodenum.And it containsmuch tannin with actions of local hemostasis and protecting ulcer.On the other hand，Da Huang has dual-direction regulating action because it contains diarrhea-inducing sennoside and constipation-inducing tannin，both ofwhich restrict each other，thus causing no hypercatharsis after taking it.

When Iworked at the first affiliated hospital，I treated many patients of gastrointestinal bleeding among whom the two most impressive ones were admitted in Dec.1982.One was a Mr.Xiong of 37 years old，male，(admission No.108706)who felt burning sensation in epigastrium，thirsty and large intake of drink on Dec.4.Therewas sudden vomitus of about300ml coffeelike liquid at about5 o'clock the nextmorning and he defecated black stool at about8 o'clock.After breakfast there was another vomitus of food and then about400ml coffee-like liquid at about 10 o'clock.He felt dizzy and lassitude，aversion to cold and trembling，sloppy and black stool.So he came to get emergency treatment here.Out-patient examination reported that occult blood(++++)，red blood cell 3.55×1012/L，hemoglobin 67g/L，white blood cell7.8×109/L，blood pressure 120/70mmHg.The diagnosiswas gastrointestinal bleeding and hemorrhagic anemia.The symptomswere sloppy and black stool，lassitude，yellow urine，yellow complexion，light red tonguewith thin and yellow coating，feeble and rapid pulse.

Then he took Sheng Da Huang powder 3g，3 times per day.The next day，his stool became yellow and there was slight distending pain in hypogastrium.On the third day occult blood turned to negative.He was given the modified Gui Pi Decoction for a week and then discharged from the hospital.

Stomachoscopy diagnosed as ulcer of the former part of pylorus，superficial gastritis(antrum of stomach)

Another case was a Mr.Li of 41 years old，male，(admission No.926845)on Nov.27，1982.

The symptomswere repeated stomachache formore than 8 years，gastrorrhagia in 1976.Hewas once diagnosed as gastric duodenal bulb ulcer.Stomachache attacked when the stomach was empty and therewas improvementand sour regurgitation after eating.He caught cold on Nov.19 and stomach attacked again.Itwas paroxysmal and accompanied with nausea and sour regurgitation.There was slightly black stool with distending pain in abdomen that can be relieved after defecation.And there was asphalt-like stool for five to seven times per day on Nov.26 and 27.Examination reported that therewere occult blood(+++)，dull stomachache，bittermouth，dizzy and lassitude，yellow urine，dark red tongue with yellow，thick and slimy coating，wiry pulse.He was admitted at noon on 27 but dined out for a bowl of noodles without the doctor's permission.He had a 300ml sudden hematemesis of coffee-like color and pale complexion and the blood pressure was 100/80mmHg.Then the patient took 3g Sheng Da Huang powder immediately and had transfusion simultaneously.Another3g Sheng Da huang powderwas taken after transfusion and his stool on themorning of28 was occult blood(+).On 29，the occult blood became(±).There was no bleeding and hematemesis and occult blood became negative.Then，he took medicines of tonifying spleen，replenishing qiand nourishing blood.And hewas discharged from the hospital after onemonth.

The last stomachoscopy diagnosed as duodenal bulb ulcer(active stage)and mixed gastritis.

Pathological report showed chronic，superficial gastritis in antrum，angulus and the lesser and greater curvature of the stomach；moderate and partial emergent activity.

Both the two cases pertain to stasis and heat in stomach and intestines with meridians and collaterals being damaged and bleeding ourwards.The therapeutic methods focused on discharging heat and resolving stasis to stop bleeding.The bleeding was quickly controlled by using only Sheng Da Huang powder with satisfied effect of"one dose worked and two doses cured the disease."The whole treatment was in accordance with Tang Rongchuan's four therapeutic principles for treating bleeding syndrome:"stopping bleeding"，"resolving stasis"，"tranquilizing blood"and"tonifying deficiency".