As promised, here is the first installment of a short series of entries on Kampo.  These next three entries are all taken from a written conversation between Nigel and myself, in the form of questions and answers.  I hope you all find this as interesting and useful as I do!

In a deficient person with a tight abdomen and pulsations – how would you differentiate whether to use Gui Zhi Jia Long Gu Mu Li Tang vs. Zhi Gan Cao Tang?

Firstly on the abdomen the location of the pulsations will be different for each formula. Gui Zhi Jia Long Gu Mu Li Tang will often have pulsations along the midline in the upper portion of the abdomen especially around Ren 12/13/14 (though they can also occur lower down at the navel area). In the case of Zhi Gan Cao Tang the pulsations are always around and below the navel and less commonly higher up. What is more helpful in differentiating these two abdomens though is the other findings that tend to occur along with the pulsations. Gui Zhi Jia Long Gu Mu Li Tang is a Qi formula and the abdomen, especially the rectus, will generally be thin, tight with a tendency for Shin Ka Hi Ko (Epigastric subjective and objective tightness). This kind of abdominal presentation is generally referred to constitutionally as the Gui Zhi Tang abdomen and is seen as related to the Chu Ki Kyo (Zhong Qi Xu) dry type as opposed to the Deficient Middle Qi Wet type for whom the Si Jun Zi Tang family is usually prescribed. Sometimes the abdomen will be cool and clammy, which is a Qi deficiency sign.  On the other hand,  Zhi Gan Cao Tang is a Blood formula and so, the abdomen will show Oketsu (blood stasis) findings, typically clustered around the navel (the Terasawa Oketsu points) and often Sho Fuku Fu Jin (lax and powerless lower abdomen). Ri kyu (rectus tightness) may also be found in relation to Zhi Gan Cao Tang. The skin will be dry and rough, which is a blood deficient sign. With an overly deep palpation technique, Ri kyu in the lower abdomen area is sometimes mistaken for Oketsu. Thus in the first formula, the pulsations arise from Qi nobose (flushing upward) reflecting in symptoms such as anxiety and sleep disorders and sometimes sexual dysfunction whereas in the second, Zhi Gan Cao Tang, they arise from the obstructive influence of Oketsu due to blood dryness in the lower abdomen.

In an excess person with abdominal fullness and pulsations – how would you differentiate Da Chai Hu Tang from Chai Hu Jia Long Gu Mu Li Tang?

This is more straightforward since the constitutional typing is quite different. Both are Strong Constitution Qi types with well-developed / toned musculature, however they nonetheless differ in body mass. The Da Chai Hu Tang abdomen is ample, broader and more inflated and full (with gas etc) than the Chai Hu Jia Long Gu Mu Li Tang abdomen which is thinner, more wiry and less distended, with a tendency for the abdominal wall to be thinner and the surface muscles such as rectus abdominis to be tighter. In addition the Da Chai Hu Tang type is relatively more wet and the Chai Hu Jia Long Gu Mu Li Tang type more dry.  This means that the Da Chai Hu Tang type is more prone to damp accumulation when there is Qi stasis. The Chai Hu Jia Long Gu Mu Li Tang abdomen does not reflect this fullness in terms of mass and, in the presence of this dryness, excess Yang Qi will of course rise more quickly and more dramatically.  This gives rise to all the characteristic psycho-emotional and sleep disturbances of that formula SHO (Presentation).  This is compared to the abject fullness and accumulation in the middle and lower jiao which characterize Da Chai Hu Tang. Pulsations will occur on both abdomens but the intensity of the Chai Hu Jia Long Gu Mu Li Tang ones will be especially dynamic and often very visible on the surface of the abdomen. This is due to the absence of any Yin factor (Eg: water/damp) to check them. Conversely,the Da Chai Hu Tang pulsations will be more subdued, subsumed as it were by the engorged fullness of the abdomen as a whole. Da Chai Hu Tang is also Fuku Man (abdominal fullness) where Chai Hu Jia Long Gu Mu Li Tang is not.

Perhaps a quick clinical profile might serve to highlight some differences between these two closely related formulas:

A hypertensive patient with the Chai Hu Jia Long Gu Mu Li Tang Sho will tend to be a thin, wiry, hyperactive and anxious type whose blood pressure can be very labile and is always elevated by anxiety-provoking situations and experiences. Typically they do NOT fit the profile of obese, more sedentary types with high cholesterol and sclerotic changes in the vascular system typical of the congested Da Chai Hu Tang type who is damp, hot and full. The hypertensive state of the latter is likely to be constant and worsened by poor eating habits and lack of exercise. The former will do well with learning how best to manage stress in their lives and maintain relative emotional stability whilst the latter will undoubtedly need to make major dietary and exercise routine changes in order to improve the condition.

In other words, how do you determine when to use the Shells and Bones?  Is there a key symptom or sign that tells you to use shells?

As we know these substances descend and anchor Qi and tend to be very cooling. As such they appear in formulas treating either deficient or excess types but who, in both cases, have a dry constitution. The drier the type the more unstable the Qi.  The tendency for Qi to rise increases and with the Qi,  heat may flare as well. Chai Hu Jia Long Gu Mu Li Tang patients often have night sweats and feel hot at night when they experience palpitations, insomnia and nightmares. Gui Zhi Jia Long Gu Mu Li Tang patients, though KYO (deficient) and often HYO SHO (cold constitution), nevertheless, they can experience mild sweating at night with insomnia and palpitations as the Yang Qi, after the day’s activities, is without an anchor.  The Yang Qi instead remains at the surface and cannot be contained. What distinguishes the pulsations in these cases is the intensity with which both the patient and the practitioner experiences them. This is due to the thinness and tightness of the abdominal wall in these dry types.

The pulsations in Da Chai Hu Tang are less due to the upward surge of Qi itself. They are rather more due to the accumulation of Qi in the abdomen thus the formula concentrates strongly on dispersing and draining rather than descending, cooling and anchoring. In the case of Zhi Gan Cao Tang the pulsations are due to blood stasis caused by blood dryness and so blood moistening and invigorating is called for.