八綱 Bā Gāng: The Eight Guiding Principles – Once the key links are grasped, everything falls into place

This is a comic which tells of the importance of the Eight Guiding Prinicples.  The fisherman is exclaiming “Once the key links are grasped, everything falls into place”.

When Dr. Fu Yan-Ling was here two weeks ago, one thing he said that stood out for me was

“Dr. Liu Du-Zhou felt that the bā gāng, Eight Guiding Principles were extremely important”.

Indeed, Dr. Fu, as an official successor of Dr. Liu, consistently steadied us throughout his teaching with these eight guiding principles.

Somehow, over the years that I have been practicing and being involved in the world of Chinese medicine, the bā gāng have had a bad name.  This began with the split between what was called the “8 principle practitioners” and the Worsely style 5 element practitioners.  Having been good friends and colleagues with quite a number of these 5 element practitioners, it was clear from our discussions that they had been explicitly taught to look down on the 8 principle practitioners as practicing a symptomatic medicine that did not take spirit into account.  The term “8 principles” was synonymous with this gross practice of TCM as opposed to the refined and profound 5 element practice.

Later, with the rise of interest in classic formulas of the Shang Han Lun, the bā gāng were set in opposition to and were still associated with, if not synonymous with, TCM.  I heard many put downs of TCM and the bā gāng as a flattened, standardized and destroyed version of Chinese medicine.  Classic formula study, specifically the study of the Shang Han Lun, has been discussed in contrast to this as a living, flexible version of Chinese medicine.

When Dr. Fu Yan-Ling told us of Dr. Liu’s appreciation of the bā gāng, I sat up a bit straighter.  I had always considered the 8 guiding principles to be important and misunderstood.  It seemed that they had been scapegoated as the culprit of the problems with modern renditions of Chinese medical theory without really giving them the credit they deserve.  In fact the understanding of the bā gāng is essential as a foundation in the understanding of the Shang Han Lun.  Not only this, the bā gāng is woven inextricably into the Shang Han Lun.

Based on my experience working with and listening to students, I see that many practitioners have a misunderstanding of the bā gāng.  This misunderstanding is due to the way the bā gāng have been discussed in their classes.  When I graduated from school in 1983, I was under the impression that I was to determine if a particular illness was Yin OR Yang, either hot OR cold, either on the exterior Or the interior and either excessive or deficient.  Since most of my patients were complex, I was, in most cases, unable to categorize their issues in such a simple manner.  Because of this, for quite some time, I also thought that the eight guiding principles were not very useful.

However, as I studied, paid attention and improved, I began to see their importance.  If I asked the question regarding hot/cold, outside/inside, excess/deficient and yang/yin in relation to the disease or the pathogen, the principles were very mildly useful.  However, if I saw the whole picture, including the constitution and condition of the patient, the nature and location of each sign and symptom and their relationship to each other, the bā gāng became a foundational way to see.

An analogy I think of is knitting. The basic stitches of all knitted projects are knitting and purling.  Then there is increasing/decreasing, dark and light colors and small and large needles and yarn.  All knitted pieces are put together and can be analyzed with these basic parameters.  And yet, look at the profound complexity of objects that can be made using these basic parameters!  In fact, take a look at these two completely different projects that were being worked on during Dr. Fu Yan-Ling’s class (one by me and one by Jennifer Tongren)

All the basics right there but, like our patients, so different!  My point is that most times we can’t say that a piece we knit is knit OR purl, dark OR light etc…what we can say is where there is knit and where there is purl, where I increased or decreased, where there is dark and where there is light and what the synthesized effect of all this this is.   If we only could use knit OR purl, dark OR light….we would not be able to make sweaters or socks or lacy shawls…..

Bringing this back to Chinese medicine, we also can’t say whether an illness or a person is Yin OR Yang, excess OR deficient, hot OR cold or if the illness is external OR internal.  Instead, we describe what is happening internally and externally, where there is heat and where there is cold, what is excess and what is deficient and then, how all of this relates to the relationship between all of these and the relationship between Yin and Yang.  These terms are the building blocks of our ability to perceive and diagnose our patients.  We may say there is dampness in the interior while there is dryness in the exterior, heat above and cold below or heat in the muscles due to wind cold fettering the exterior with an internal deficiency of Kidney Yang….etc.  Any discussion we have requires us to use the language of the eight guiding principles and to use our articulation of these principles to see what is happening in our patients in a complete and integrated way.

The either/or way of using the bā gāng can leave us confused.  How can my patient have a red mean rash and have a pale tongue body?  Is this hot or cold?  Is it Yin or Yang?  Is it excess or deficient.  It is very possible to have a heat excess on the exterior and a deficiency of Yang on the interior.  Our bā gāng building blocks help us locate and evaluate what is happening.  When we start with these basic building blocks we can even start to see how the internal Yang deficiency is related to the heat excess on the exterior! I’ll put a case study I recently translated at the end of this entry to illustrate this.

As much as bā gāng is essential and explicit in the Shang Han Lun, Zang Fu theory is as well.  Zang Fu diagnosis is also something that has been poopoo-ed in recent years by “classic formula” proponents, as if it is something separate from classic formula theory.  Perhaps if all we have is Zang Fu diagnosis we will be limited, however, I have not yet found a Shang Han Lun presentation that cannot be described in terms of and the understanding of the presentation enhanced by Zang Fu theory.  Perhaps Dr. Liu Du-Zhou is one of the great proponents of the type of integration I am talking about here. Let us not, in our quest to find and be associated with the most superior form of our medicine, throw the baby out with the bath water!

And back to our course with Dr. Fu Yan-Ling – which was so useful and clear – I loved that Dr. Fu integrated these theories in his teaching so that we could deeply understand the mechanisms of the formulas and why they address what they do.  He did not stop at a simple lock and key, presentation and formula conceptualization.  We all left with a sense of how the ingredients of the formulas presented work together, where they go, what they do and how a patient presents who needs them.  He fluidly moved between the presentation, the constitution of the patient, the Zang Fu diagnosis and the bā gāng – utilizing all of these to help us obtain a clear view of the patient and of the appropriate classic formula.

Here is the promised case.  Enjoy!

Gui Zhi Tang for Lack of sweat

This is a case of Dr. Luo Bai-Shan.  It was gathered as part of a collection by Liu Du-Zhou in his 伤寒名医临案精选 Shāng Hán Míng Yī Lín Aǹ Jīng Xǔan (Hand Picked Shang Han Case Studies from Famous Doctors)

This patient is named Lu and he was 9 years old.  He came for a visit on July 5, 1985.  His mother reported that since childhood every summer, when he needed to sweat, instead he broke out in a red skin rash over his whole body.  It was dry and itchy so he scratched it often to such an extent that there were bloody scabs.  He suffered greatly and it was difficult to endure.  He had visited the local hospital where he was diagnosed with an autonomic nerve dysfunction and given Oryzanol.    This was not effective.

Diagnosis:  His whole body was red and dry.  There were stripes of bloody scab lines on his limbs, chest and abdomen.  His respiration was rough and he was agitated.  His mouth and nose were dry.  His tongue was pale red with a thin white moss and his pulse was floating and rapid.  Although this appeared as heat, the determination of etiology was not internal excess heat.  Rather, this was lack of regulation of the Ying and Wei.  Sweating did not function to drain and so the pores needed to be opened.  For this I used Gui Zhi Tang:

I summarize the results after this boy took the herbs below:  The boy sweat and compared to before, his skin felt comfortable and softer.  Because drinking the decoction was difficult for children, I switched to giving him the formula in powder form.  I ground up the Gui Zhi, Bai Shao and Gan Cao into powder and put them in gelatin capsules. He took 10 grams, twice a day.  He drank this down with a liquid made from decocted Sheng Jiang and Da Zao.  He took this for 20 days.  His whole body was able to issue sweat and the pathology was all dispersed.  He was like a normal person.  A follow up 3 months later showed no relapse.

Discussion:  In this case, the lack of sweating had occurred since childhood and yet there is no history of externally contracted wind cold or floating tight pulse.  So we knew that this was not stagnation of the Ying and Wei on the exterior wind cold excess pattern.  Rather, this was a “Moistness weak, Protective strong” Gui Zhi Tang presentation.  The Ying Qi was internally weak and was not able to aide the Protective Yang.  This caused the protective Yang to lack Ying and consequently stagnate in the sweat pores.  This “externally strong” protective qi constrained in the pores gave rise to the red itchy skin that even went so far as to leave bloody scabs, cause agitation and a floating rapid pulse.  All of these symptoms appear as heat.  However, this was not the same as a patient with vexation thirst with a desire to drink, red urine or knotted bowel in which you would use bitter cold herbs.  This was a decline of the Ying/Wei.  One must avoid using Ma Huang Tang to open the pores because it will damage the Ying and Wei.  Gui Zhi Tang is the only thing that is suitable to promote sweating and resolve the flesh.  It will benefit the Ying and free the Wei, mutually benefiting both the Ying and Wei so that they can perform their functions.  When sweating issues, the flesh is disinhibited and the vexatious heat is spontaneously dispelled. In truth, Gui Zhi Tang’s function of inducing sweat resides in its ability to resolve the flesh and regulate and harmonize the Ying and Wei.

Sharon’s discussion: I present this case as an example of internal Yang deficiency with heat on the exterior.  Gui Zhi Tang produces and disseminate harmonized Ying and Wei from the stomach.  Gui Zhi and Sheng Jiang both enter and warm the stomach, and when combined with Bai Shao and Da Zao as moistening agents, it starts the steaming process that brings the harmonized Ying and Wei to the surface.  The Wei now being inside the Ying, can push out the surface as sweat and allow the trapped Yang (excess heat on the exterior) to exit.  It was heat but not internal heat.  The pale tongue helped explain why the sweating was not harmonized.