Ye Tian-Shi on Vacuity Detriment

A Model for a Mode of Inquiry in Chinese Medicine

By: Bob Damone

According to Wiseman and Feng (1998), Vacuity Detriment (xū sǔn虚损) is “any form of severe chronic insufficiency of yīn-yáng, qì-blood, and bowels and viscera arising through internal damage by the seven affects, taxation fatigue, diet, excesses of drink and sex, or enduring illness.” (p.646) I have found this Chinese disease category helpful in evaluating and formulating treatment strategies for patients with enduring diseases such as Chronic Fatigue Syndrome, Depression, and Fibromyalgia.[1] These patients invariably have many concurrent, complicated, and apparently contradictory symptoms, and always present a formidable challenge to the clinician. Vacuity Detriment is a useful conceptual template in such circumstances precisely because it provides the Chinese medical context in which to understand not only the complexities of serious and multiple vacuities but also their complications. As such, it gives clinicians insight into available conceptual models and treatment strategies for deeply vacuous patients. And when treating patients with complex diseases such as Vacuity Detriment, strategy often emerges as the decisive factor for attaining good clinical results.

Yè Tiān-Shì (叶天士), the preeminent Qīng dynasty physician, who is perhaps best known in the West for his contributions to the Warm Disease School (温病学派 wēn bìng xué pài), also influenced many other aspects of Chinese medicine. One of the most famous works recording his case studies and teachings on various medical topics—”A Clinical Guide with Case Histories” (临证指南医案 lín zhèng zhǐ nán yī àn)—was published in 1766. This text is organized by Chinese disease category[2] and each chapter typically contains many case studies followed by a summary essay in which Doctor Yè or one of his students eloquently transmits clinical guidance for treating that disease. Although I find the case studies themselves fascinating and instructive, I am especially intrigued by these challenging essays.

I have translated the short summary essay on Vacuity Detriment contained in “A Clinical Guide with Case Histories” and offer it here. Although any translation is fundamentally flawed, and as the classical Chinese used in the text is somewhat difficult to penetrate, I may have erroneously translated some of the text. However, I have done my best to faithfully render its intended meaning as I understand it. Additionally and admittedly somewhat boldly, I have taken the liberty of offering my own comments on the text itself (which follow the essay in the “notes” section; the bracketed numbers in the text correspond to the number of the note).[3] Lastly, I offer some of my own opinions and conclusions from observing the mode of inquiry revealed in the text.

[On the subject of] vacuity taxation, the classics are quite detailed, [though within them] this condition [does] have more than one name. When investigating the Inner Canon,[4] [one finds] discussions of taxations of [each of] the five viscera and [that] there are many different treatments [described] for them. Then, later people were of the opinion that upper [burner] taxation is yáng and lower [burner] taxation is yīn. [Further], they did not treat [this condition] with acupuncture, but regulated it by using sweet medicinals [instead]. The Golden Coffer[5] followed this [principle] and established xiǎo jiàn zhōng tāng (小建中汤 Minor Center-Fortifying Decoction) to rapidly fortify center [burner] qì so as to increase [one’s intake] of food and drink and to [thereby] make fluid and blood effulgent. [1] Thus, abundant blood engenders essence and one recovers from insufficiency of the true origin [indirectly]. [2] When sowing and reaping [in this way, one may] mainly use the sweet flavor; [therefore], it is not necessary to use sour, acrid, salty, and bitter [flavors]. [3] [However, one cannot] build a barn [with this method alone and likewise one must have] other methods with which to treat. So, [one can] treat detriment and insufficiency of the upper burner yáng aspect by banking up the root of the lower burner true yīn. [Thus] relying on doctor [Zhāng Zhòng-Jǐng then, others] derived formulas such as Heaven, Human, and Earth Decoction (sān cài tāng 三才汤), Root-Securing Pill (gǔ běn wán 固本丸), True Heaven Elixir (tiān zhēn dān 天真丹), Great Creation Pill (dà zào wán 大造丸), Cinnamon Twig Plus Dragon Bone and Oyster Shell Decoction (guì zhī jiá lóng gǔ mǔ lì tāng 桂枝加龙骨牡蛎汤),[6] and Pulse-Restorative Decoction (fù mài tāng 复脉汤), as well as various securing and containing formulas, [and those methods] that evenly supplement the three foot yīn [viscera]. [Thus], they treated vacuities of all five viscera simultaneously. [This] greatly relieved the ignorance of later people [who then realized that these other methods] can also be helpful in treating vacuity detriment.

The Golden Coffer also states that [when] a man has a large pulse, he [has] taxation, [and that] extreme vacuity is called taxation. A large pulse [indicates] even greater damage to the qì aspect [than a fine pulse does]. [4] [It shows] thought and preoccupation and depression and binding, heart-spleen construction detriment in the upper and center [burners], and exhaustion of the construction aspect. It must be treated by formulas such as guī pí tāng (归脾汤 Spleen-Returning Decoction), xiǎo jiàn zhōng tāng (小建中汤 Minor Center-Fortifying Decoction), rén shén yǎng yíng tāng (人参养营汤 Ginseng Nutritive-Nourishing Decoction),[7] sì jūn zǐ tāng (四君子汤 Four Gentlemen Decoction), schisandra (五味子 wǔ wèi zǐ, Schisandrae Fructus),[8] and yì gōng sǎn (异功散 Special Achievement Powder). [If] the pulse is extremely vacuous, the condition is also called taxation. It is interior essence-blood despoliation and liver and kidney failing to naturally construct [each other]. [5] It must be treated by formulas such as liù wèi dì huáng wán (六味地黄丸 Six-Ingredient Rehmannia Pill), bā wèi dì huáng wán (八味地黄丸 Eight-Ingredient Rehmannia Pill), True Heaven Elixir (tiān zhēn dān 天真丹), dà zào wán (大造丸 Great Creation Pill), Heaven, Human, and Earth Decoction (sān cài tāng 三才汤), gù běn wán (固本丸 Root-Securing Pill), fù mài tāng (复脉汤 Pulse-Restorative Decoction), by methods that evenly supplement the three foot yīn [viscera], and by various securing and containing methods.

So, after Zhòng-Jǐng, heroes and virtuous [people] came forth in large numbers; [however], how could they not expound on [he whose teachings] lay hidden behind [their own]? Moreover, how could so many doctors not study the teachings of their ancestors well? Thus, they wished to abandon doctor Zhòng-Jǐng’s methods, and [they believed] they were capable of treating every person who has vacuity taxation [by employing] many different ideas. [These included] Dōng-Yuán and Dān-Xǐ,[9] [who were] famous doctors from earlier dynasties who disagreed with [past treatments for] detriment and [instead] mainly used ginseng (人参 rén shēn, Ginseng Radix) and white atractylodes (白朮 bái zhú, Atractylodis Macrocephalae Rhizoma), and they used many jīn[10] of each. The gist of their approach seems to be that since that which has form—essence and blood—is difficult to restore, they urgently supported the formless qì [instead]. [6] [Thus], they expanded on Zhòng-Jǐng’s various Center-Fortifying Decoctions.

Later, there was Zhāng Jǐng-Yuè, who considered life gate yīn aspect insufficiency as vacuous yīn within yīn, and who mainly used zuǒ guī yǐn (左归饮 Left-Restoring [Kidney Yīn] Beverage) and zuǒ guī wán (左归丸 Left-Restoring [Kidney Yīn] Pill); [moreover, he considered] life gate yáng aspect insufficiency to be yáng vacuity within yīn and mainly used yòu guī yǐn (右归饮 Right-Restoring [Life Gate] Beverage) and yòu guī wán (右归丸 Right-Restoring [Life Gate] Pill). He did not deviate from formulas used by other doctors such as gù běn wán (固本丸 Root-Securing Pill), True Heaven Elixir (tiān zhēn dān 天真丹), and dà zào wán (大造丸 Great Creation Pill), or from even supplementation of the foot three yīn, or from various securing and containing methods.

[In light of the above], subsequent people praised doctor Zhòng-Jǐng for being good at treating vacuity taxation; [one] should [aspire to understand] his intentions.

Enduring vacuity without recovery is called detriment, and extreme detriment without recovery is called taxation. These three—vacuity, taxation, and detriment—occur in succession. In reference to the causes [of this condition], there is not only one origin; even after it comes about, it is difficult to make a detailed analysis [of its causes]. In most cases, the cause is vexation and taxation damaging qì. Doctor [Zhòng-Jǐng] treated the upper [burner], and the center [burner], and therefore used sweet cool lung-stomach supplementation for clearing and moistening or emolliating formulas to nourish the construction-fluid of the heart and spleen. [7] Or, [he used] sweet flavors with warm qì to construct the center palace without causing the two qì to become inclined to one side by day, meaning that construction and defense should follow [their normal cycles]. And for those [cases] which are caused by sexual overindulgence damaging essence, [one] should treat the lower [burner] and simultaneously treat the eight [extraordinary] vessels [as well]. Also, one should know that to replenish and supplement essence-blood, [one should supplement] the essential qì aspect, boost fire, and enrich yīn. Or, quiet and contain the controlling [channel]-yīn,[11] and warm and rectify the mysterious place’s[12] extraordinary yáng. If this is the cause, the condition will be defeated. For those with mixed and widespread [disease, one] should recognize all the details, follow the dynamics and circumstances and regulate. Following the intentions of the master, differentiate the constitution in terms of yīn and yáng in order to [ascertain] the main points—upper, center, and lower—and take them [all] into consideration. [Understanding] the shift, passage, and transmutations of early and later heaven is decisively the key to life and death. If [one] pursues these details and inquires into them, one by one the roots can be considered and [one can] avoid merely [haphazardly] floating downstream and putting together a few supplementing medicinals randomly [in an attempt to treat this condition]. [8]

1. This strategy emphasizes that if the spleen and stomach are strong, then their functions—decomposition of water and grain as well as movement and transformation of water and grain essence—will be more effective. The lung governs qì and is the place where ancestral qì is formed from a combination of water and grain essence (grain qì) and clear qì inhaled from outside the body. The heart governs blood. This function includes not only its action on movement of blood but also points to its role in engendering blood, which is described in chapter 5 of the Sū Wèn (Plain Questions). Moreover, as the spleen is “the origin of fluids,” it plays a vital role in the initial creation of fluids. Thus, as the spleen bears this water and grain essence upward to the lung and heart more efficiently, more qì, blood, and fluid can be engendered through their mutual actions and cooperation.
2. I believe this alludes to the transformation of surplus blood to essence through the mutual actions of the liver and kidney, and to the storage of that essence in the kidney. In this way, later heaven essence can bank up early heaven essence.
3. I find this a very interesting choice of words. My hypothesis is that the use of the agricultural imagery in this sentence is meant to draw analogy between supporting the center burner-earth and farming.
4. This is a direct allusion to chapter 6 of The Golden Coffer. It is imperative that we not misinterpret a large pulse that lacks force as a repletion pulse. At times, an inexperienced student or even a practitioner may misconstrue the largeness of an otherwise forceless pulse as an indicator of force, when in fact it indicates significant interior vacuity.
5. Here again there is a reference to the interrelationship between the liver and kidney summarized in the axiom: “The liver and kidney share the same origin.” In normal circumstances, there is some surplus blood stored in the liver which can be transformed into essence by the liver and kidney, and can then be stored in the kidney to supplement early heaven essence. Conversely, when kidney essence is being depleted, stored essence is then transformed into blood to nourish the viscera-bowels, channels and network vessels, and the rest of the bodily form.
6. Supplementing formless qì to engender that which has form, namely essence-blood, is an important treatment principle to keep in mind for patients who have substance vacuity (i.e., essence and blood vacuity) but who also have vacuity-weakness of the center burner; indeed, their essence-blood vacuity may be a direct result of their spleen-stomach vacuity. Although such patients require substantial nourishment—including medicinals with an affinity to flesh and blood (i.e., animal products)—they sometimes cannot tolerate them unless they are not either given with center fortifying medicinals, or given after a course of center fortifying treatment has been completed. I find that this dilemma is quite the rule in Vacuity Detriment conditions. This treatment principle also reveals that Yè—as well as Dān-Xǐ and Dōng-Yuán—understood the human body as an integrated whole; thus, intervening at the formless qì aspect can eventually result in an increase in the substantial essence-blood aspect.
7. This appears to be alluding to mài mén dōng tāng (麦门冬汤 Ophiopogon Decoction) and gān mài dà zǎo tāng (甘麦大枣汤 Licorice, Wheat, and Jujube Decoction).
8. At the risk of reading too far into this last section, I sense Yè is reiterating the Inner Canon’s advice to treat the root of disease. Although there are a number of strategies used to treat patients with several concomitant patterns, and I have seen results from more than one of them, there is something to be said for seeking the root and focusing one’s treatment on it, rather than being distracted by the tip. For example, I have seen some complicated patients with Vacuity Detriment or Vacuity Taxation (some of whom had even suffered from qì vacuity heat effusion or yáng vacuity heat effusion) and a history of digestive side effects from failed attempts at conventional and cloying supplementation. Many of these patients respond well to variations of the yīn-yáng harmonizing formula xiǎo jiàn zhōng tāng (小建中汤 Minor Center-Fortifying Decoction). In other words, for such cases, trying to nourish essence-blood directly with a complicated and multi-faceted formula is sometimes not as effective as doing so indirectly by first fortifying the center burner. When we understand the interrelationships among the viscera and bowels, we see that the center burner is the source of later heaven essence which can be used to bank up early heaven essence.

A careful reading of essays like this bears witness to the literate Chinese medical mind of Yè Tiān-Shì as he grapples with the problems of human illness. From the fact that he searches the writings of his predecessors for solutions to these problems we may conclude that to Yè—and presumably to other physician literati of his era—doctoring was partially viewed as a scholarly pursuit which bound literate Chinese doctors to the mastery of a specific medical corpus (even as they retained a certain critical yet respectful stance toward it).[13] This is the only explanation for his frequent reference to certain classic texts and his allusions to the clinical and theoretical perspectives recorded there by his predecessors. His essays do not emit, however, a sense of blind allegiance to scripture-like dogma, but rather reveal a two step process of: 1) exploration of the extant writings on a particular disease as recorded in the medical corpus of Chinese medicine and 2) the generation of coherent arguments for new approaches when these existing ones are found to be inadequate.

In my assessment, this process has not fully matured in East Asian medicine circles in the West. Because we have been unable to access the lion’s share of the medical corpus and have in effect skipped the first step, we have often erroneously concluded that existing perspectives are inadequate. And as a result, we have created entirely new models which we represent as authentic “Oriental medicine” but which may fail to resemble the host tradition in any significant way. On the other hand, once we do discover an authentic[14] pre-modern perspective on a given topic, we naively regard it as dogma which must be adhered to at all cost, rather than seeing it more clearly as one historically-based approach among many. Further, it seems that broad acceptance of a new perspective should be established through clinical experience and peer review, rather than relying on the success of a marketable seminar series for validation.

As compared to the heterogeneous written record accessible to literate Chinese doctors throughout history—both pre-modern and modern—we suffer from a comparative lack of seminal information. Thus we lack ways to improve on our rudimentary understanding of Chinese medicine. This vacuum has yielded to an “anything goes” ethic in the profession which neither adheres to any specific textual standard or historical precedent (indeed it is often guilty of misrepresenting it) nor is subject to any meaningful large-scale scrutiny by the profession-at-large. This stands in stark contrast to Yè Tian-Shì’s respectful and scientific exploration of extant literature on Vacuity Detriment as it is revealed here, and to his re-interpretation of these opinions according to his own experience. He could only engage in this process because he did not suffer from the lack of access to the formative texts which unfortunately characterizes our own dilemma.

I do not argue for squelching our creativity or intuition in our application of what we perceive to be East Asian medicine. I do suggest, however, that we learn to temper and discipline it by first exploring the written intuitions of our predecessors. If we allow them to, these writings can shape our practice in many new and interesting ways. I do not submit that we should blindly adhere to classical literature or opinion, but only that we take the time to plumb its depths before discarding it or ignoring it out of hand. There is 2,000 years of professional literature extant, which is teeming with clinically valid and educationally useful information, do we not have an ethical responsibility to access it? In my opinion, as we physicians and teachers of East Asian medicine in the West consider the future direction of our profession, and as our colleges make choices about the content of their curricula, we should carefully reflect on this. Thus, we should weigh our mode of inquiry against that of our predecessors including people like Doctor Yè Tiān-Shì, and should then take steps to rectify our shortcomings.

Bensky, D. and Scheid, V. (date unknown). “UMedicine is Signification: Moving Towards Healing Power in the Chinese Medical Tradition.U” Reprinted from the European Journal of Oriental Medicine. SIOM Resources [On-line]. www.siom.edu.

Damone (2003) “From Symptoms to Treatment in Four Easy Steps.” Blue Poppy Seminars. Audio distance learning CEU seminar. Boulder: CO.

Flaws, B. (2004) (Trans.). UTreatise on the Spleen and Stomach.U Blue Poppy Press. Boulder: CO.

Scheid, V. (2003). “Ye Tian Shi’s Strategies for the Treatment of Bloody Stools.” Journal of Chinese Medicine, Volume 71 #41. United Kingdom.

Wiseman and Feng (1998). UA Practical Dictionary of Chinese MedicineU. Paradigm Publications: Brookline, MA.

[1] I do not suggest, however, that this is the only effective approach. Certainly the work of Lǐ Dōng-Yuán and Zhū Dān-Xǐ, as Bob Flaws has pointed out, also has merit here. See Flaws (2004).

[2] I intentionally use the term “disease (bìng)” here to distinguish from “pattern (zhèng)” or “disease pattern (bìng zhèng).” Although pattern discrimination is an essential component of Chinese medicine, we should not overlook the importance of disease discrimination, which I argue provides the focal point for our treatment. (Damone, 2003)

[3] I acknowledge that these comments are my own and also that as revealed in the excellent article by Sheid (2003), there is a body of traditional commentary available for Yè’s writings. I have not consulted these in the preparation of this article.

[4] 黄帝内经 {huáng dì nèi jīng}, The Yellow Emperor’s Inner Canon (1st century C.E).

[5] 金匮要略方论 {jīn guì yào lǜe fāng lùn}, 书名 On the Essential Prescriptions of the Golden Coffer (Eastern Hàn, {Zhāng Jī 张机 [Zhòng-Jǐng 仲景]).

[6] This is a bit puzzling as this formula is attributed to Zhāng himself.

[7] The text only says yǎng yíng (养营). It seems reasonable to suggest it is shorthand for this formula, as the rest of the formula names in this sentence are also written in shorthand.

[8] The text states wǔ wèi (五味). Although it does seem odd that schisandra (五味子 wǔ wèi zǐ, Schisandrae Fructus) would be the only individual medicinal referred to within this longer list of formulas, I am unable to find a supplementing formula it be serving as shorthand for.

[9] The reference here is to Lǐ Dōng-Yuán and Zhù Dān-Xǐ, who were arguably the two most influential doctors among the four great physicians of the Jīn and Yuán period (金元四大家 {jīn yuán sì dà jiā}.

[10] A jīn (斤) is a traditional Chinese measurement equivalent to ½ a kilogram.

[11]任脉 (rèn mài) controlling vessel

[12] 奇阳之妙处 (qí yáng zhī miào chù) This is an allusion to the interstices and is most often found in older texts

[13] See Bensky, D. and Scheid, V. in which Yè Tiān-Shì is quoted as saying: “that which is referred to as reading the ancient [classics] but not getting bogged down by them, adopting their methods [or prescriptions] without being controlled by them, this marvel of transformative judgment, [unfortunately] is something of which people are capable only with difficulty.”

[14] I struggle to define what I mean by “authentic” here and therefore acknowledge that my definition requires further development. I presently consider authenticity in East Asian medicine to be measured by the degree to which a practice or theory is actually rooted in and imbued with the core concepts of the pre-modern formative texts of Chinese medicine. Among these texts are the Inner Canon, the Classic of Difficult Issues, On Cold Damage, The Golden Coffer, etc.