During one of my recent Pearls 2015 Beijing Study Tour in November 2015, I was very inspired by Professor Zhao Jin Xi’s application of Sheng Xian Tang for treatment of Diabetes and Chronic nephritis based on the patients’ presentation of shortness of breath, fatigue, heart palpitations etc. and the rationale behind this can be attributed to the “Sinking of the Big or ancestral qi”, a theory advocated by the famous early republic practitioner Zhang Xi Chun 张锡纯. Professor Zhao Jin Xi is a specialist in treating diabetes and chronic diabetic nephropathy at the Dongzhimen Hospital in Beijing. Clinically , a pattern characterised by shortness of breath, rapid breathing, heart palpitations, Zhang Xi Chun’s Sheng Xian Tang is indicated. Conversely, Li Dong Yuan’s Bu Zhong Yi Qi Tang is indicated for the sinking of the middle qi (spleen and stomach qi) due to damage to the middle qi. Li Dong Yuan’s theory was inspired by the statement in Nei Jing,” If there is stomach qi, one lives and the absence of stomach qi one dies. ” Therefore both the Sheng Xian Tang and Bu Zhong Yi Qi Tang are targeting the sinking of qi with the function of lifting the yang, however the exact indications, herbal ingredients and dosage differ
Zhang Xi Chun 张锡纯 （1860~1933）
The renowned Qing dynasty practitioner Zhang Xi Chun based his theory on Da Qi by detailed research of Nei Jing, Yi Men Fa Lu coupled with his clinical experience compiled the book “Yi Xue Zhong Zhong Can Xi Lu” put forward his theory of “Da Qi Lun” . In his book Zhang explained the concept of Da Qi and its physiological function, the aetiology and pathogenesis of “Da Qi Sinking” disorder and a series of formulas to address the treatment of Da Qi Sinking. Zhang Xi Chun said that the basic pathology of Da Qi Sinking is qi deficiency irrespective of the cause. The effect of Da Qi is to lift the heart and lung qi as well as managing the qi and blood.
1. Herbal dosage: The dosage of Sheng Xian Tang is large and the effect is instantaneous while the dosage of Bu Zhong Yi Qi Tang s relatively small and the effect is slow but sustaining. Sheng Xian Tang is indicated for the sinking of the ancestral qi with absence of symptoms associated with weak and deficient spleen and stomach. The heavy dosage of Huang Qi (six qian ~ several liang) combined with Sheng Ma, Chai Hu, Jie Geng to to enforce the ability of lifting; while Bu Zhong Yi Qi Tang is indicated for chronic and deficient spleen and stomach characterised by no appetite, wilting complexion, abdominal distension after ingestion of food and sloppy stool etc. The dosage of the herbs is small aiming at restoring the movement of spleen and stomach qi hence the dosage of Huang Qi is 5 fen; Ren Shen 3 fen with the total dosage of the formula not exceeding 2 qian and 4 fen.
2. Herbal property: Sheng Xian Tang is acrid, sweet and moistening while Bu Zhong Yi Qi Tang is acrid, sweet and warm. Sheng Xian Tang is targeting the sinking of the chest qi or ancestral qi with the chest incorporating the heart and the lung. Huang Qi is warm and hot but Zhi Mu is cold and moistening to negate the warm property of Huang Qi; therefore the overall effect of Sheng Xian Tang is acrid, neutral, sweet and moistening. This is in keeping with the theory in Nei Jing, quote: “Vigorous fire will exhaust qi”. Bu Zhong Yi Qi Tang is for treatment of chronic and deficient disorders in the middle jiao by using Huang Qi, Ren Shen, Bai Zhu to warm and tonify supplemented by a small amount of yang lifting herbs as cold and cool herbs may damage the spleen and stomach yang.
3. Historical Background on the Theory of “Da Qi or ancestral Qi” : The concept of “Da Qi” originated from “Lingshu: Wu Wei Lun” chapter 63 which said: ”The ancestral qi is not moving instead it is accumulated in the chest, it is known as Qi Hai; it emanates from the lung, circumvents the throat and governs breathing. Therefore “Da Qi” is referring to the ancestral qi in the chest and lung. During the Qing Dynasty, Yu Jia Yan in his book : “Yi Men Fa Lu Rules for Physicians ” clearly stated the significance of Da Qi and its association with the ascending and descending of qi dynamic. Zhang Xi Chun remarked in his book “Yi Xue Zhong Zhong Can Xi Lu” said: “The accumulation of Da Qi in the chest serves as the support for the whole body.”
4. Pathology of the sinking of Da Qi: Zhang Xi Chun regarded the health of the “Da Qi” hinges on the water and essence of grain to nourish and maintain the health and normal function of the Da Qi; if there is any lack of nourishment by the water and grain qi will result in the sinking of the Da Qi. The basic pathology of sinking Da Qi is qi deficiency irrespective of whatever the causes for the Da Qi to sink. The main function of Da Qi is to lift the qi of the heart and lung with ensuing circulation of qi and blood. A mild condition of Da Qi sinking will affect the heart and lung’s normal function while a more serious condition will cause sudden death.
5. Aetiology and Pathogenesis of Da Qi Sinking: Zhang Xi Chun in his book said that there are many causes leading to the sinking of Da Qi such as over taxation, poor convalescence of chronic illness, or chronic diarrhoea or ingesting excessive herbs to break the qi or deficiency of qi aspect with spontaneous qi sinking. From his case studies it incorporates internal injury, chronic illness, over taxation, incorrect treatment, qi constraint due to anger, and post-partum deficiency etc. He also pointed out the danger of incorrect treatment with detailed analysis of the outcome. For example, inhibited respiration with subjective feeling of chest fullness which was mistaken to be qi constraint with formula to relieve the constraint; difficulty of breathing verging on cessation of breathing mistaken to be qi counterflow and wheezing and prescribe formula to downbear qi causing the further sinking of Da Qi.
6. Scope of contemporary diseases associated with sinking Da Qi: With reference to all the modern medical journals and text books, diseases such as coronary heart diseases, viral myocarditis, hypotension, wheezing, cough, myasthenia gravis, prolapse of the uterus and anus; spotting and excessive menstruation etc.can be regarded as a Da Qi Sinking disorder. Clinical presentations are difficulty in breathing, shortness of breath, heart throbbing and palpitations; copious sweating; delirium and forgetfulness accompanied by alternating fever and chill, chest oppression, parched throat with thirst, frequent yawning; wilting and atrophy of the four limbs and incontinence. There was a total recordings of 28 case studies on Da Qi sinking disorders in Zhang Xi Chun’s book “Yi Xue Zhong Zhong Can Xi Lu 医学衷中参西录”. In addition Zhang Xi Chun gave a general description of the Da Qi sinking pulse sign as submerged, slow and slightly weak particularly before the Guan position.
7. Differentiation between wheezing of Da Qi sinking versus cold rheum chest bind: Clinically, both Da Qi sinking and cold rheum chest bind are characterised by abnormal breathing and Zhang Xi Chun suggested that one needs to be discerning on this presentation. Da Qi sinking due to qi deficiency is characterised by difficulty in breathing while pulmonary disease with wheezing is characterised by severe shortness of breath with rapid breathing accompanied by breathing through the mouth and lifting of the shoulders during breathing while Da Qi sinking disorder patients suffer from difficulty in breathing with absence of shoulder lifting and opening of the mouth during breathing episodes. Zhang Xi Chun emphasized the key difference between the two is “aversion to cold and no aversion to cold”. The cold rheum chest bind disorder is characterised by aversion to cold on account of the cold water rheum obstruction in the chest with ensuing shortness of breath while the shortness of breath with Da Qi sinking disorder can be attributed to the non-communication of qi between the upper and lower jiao. Da Qi sinking is a deficient pattern while the cold rheum chest bind is an excess pattern.
8. Treatment Strategy of “Da Qi Sinking” pattern: Theory on the Da Qi was first discussed in Nei Jing but there was not a lot of discussion on the characteristic of Da Qi. Zhang Xi Chun remarked: “It is a pity that there are so many incorrect treatments of Da Qi sinking …” and over the years Zhang put forth the core aetiology and pathogenesis of the sinking of the Da Qi and created the formula Sheng Xian Tang to treat this disorder which was not discussed in the Nei Jing and Shang Han Lun nor is there a dedicated formula to address diseases associated with the sinking of the Da Qi disorder.
9. Sheng Xian Tang:
Sheng Huang Qi 18g; Zhi Mu 9g; Chai Hu 4.5g; Jie Geng 4.5g; Sheng Ma 3g
Function: Augment qi and Lift the sinking qi.
The large dosage of Huang Qi tonifies qi and lifts the sinking qi; the warm property of Huang Qi is negated by Zhi Mu which is cool and moistening to prevent the damage to the yin fluid; Chai Hu is a Shao Yang herb to guide the Da Qi to rise from the left; Sheng Ma is a Yang Ming herb to guide the da qi to rise from the right; Jie Geng serves as a carrier to guide the herbs upwards to the chest. The combined effect of the formula can facilitate the sinking qi to return to the chest in order to elicit the effect of governing respiration and manage the qi transformation of the triple jiao.
Modifications: Ren Shen can be added to enhance the tonification of source qi to prevent the rising of Da Qi from dissipating; Shan Yu Rou can be added to astringe; for the sagging pain of the lessor abdomen, increase the dosage of Sheng Ma.
Case Study 1: Diabetic Nephropathy
Li x, female 62 year-old
First consultation: 18th November 1996
S/S: Thirst, fatigue for ten years with recent exacerbation of her condition accompanied by nausea and vomiting for one year.
History: The patient suffered from diabetes for ten years and recently her condition deteriorated to be diabetic nephropathy with impaired renal function.
Currently she suffered from nausea, vomiting, heart palpitations, chest oppression, shortness of breath with acute difficult breathing; skin itch, edema in the lower limbs and inhibited urination. Her insulin dosage was 59U daily but in spite of her medication, her blood sugar was not satisfactory. She consulted Professor Zhao Jin Xi.
Examination: Wilting complexion, generalised encrusted skin with scratch marks; pale nails, dull and pale tongue with greasy tongue coat and a submerged and thready pulse.
Blood test: Serum creatinine 344.8µmmol/L. urea nitrogen 18.6mmol/L; haemoglobin 72g/L
Diagnosis: Deficiency of the source kidney with turbid toxin in the interior and disharmony of the stomach.
Treatment: Tonify and lift the sinking qi, drain turbidity and harmonise the stomach plus invigorate blood and transform dampness.
Prescription: Sheng Huang Qi 18g;Zhi Mu 12g; Sheng Ma 5g; Chai Hu 5g; Qing Ban Xia 9g; Dan Shen 15g; Chao Ting Li Zi 15g; Tu Fu Ling 30g; Shi Wei 30g; Di Fu Zi 24g; Ku Shen 9g. 30g Seven packs.
18th December 1996
After taking 15 packs of medication, her shortness of breath and heart palpitations were reduced and after completion of 30 packs the heart palpitations and shortness of breath and skin itch were gone but the nausea and vomiting persisted. Use Dang Gui Bu Xue Tang + Er Chen Tang modified.
(Ref: Case study extracted from Professor Zhao Jin Xi Guo Jia Zhong Qing Nian Ming Zhong Yi)
Case Study 2: Viral Myocarditis
Jiang x Female 11 year-old
First consultation: 16th March 2009
Chief complaints: Heart palpitations, shortness of breath and fatigue for more than three months.
History: Three months ago the patient contracted a cold and immediately after the cold she suffered from heart palpitations, shortness of breath and subsequent ECG confirmed that there was ST-T depression and diagnosed as myocarditis.
She was prescribed RYTHMOL and CQ10 for her condition but it was not effective.
Chinese medicine diagnosis: Heart palpitations due to insufficiency of heart qi with mal-nourishment of the heart.
Sheng Xian Tang modified: Huang Qi 18g; Zhi Mu 9g; Jie Geng 4.5g; Chai Hu 4.5g; Sheng Ma 3g; Sha Shen 10g; Shan Yu Rou 10g; Dan Shen 10g. Seven packs.
After seven packs of medication, there was improvement of her condition and ECG confirmed ectopic beats. Stick with the original formula, omit Sha Shen, add Tai Zi Shen 10g; Mai Dong 10g; Wu Wei Zi 10g; 15 packs. Consolidate with a further 2 months of medication. She recovered.
Discussion: Myocarditis is most often due to infection by common viruses generally affecting young children or young adolescence. During convalescent period, the sufferer often presented with shortness of breath, chest oppression, heart palpitations often accompanied by premature heart beats. Treatment for chronic convalescent patients attributed to heart qi deficiency, Sheng Xian Tang is generally indicated. Huang Qi apart from augmenting qi can enhance the lifting of qi is used to increase the body’s immune system and is also an anti-viral herb to prevent further contraction of cold. For patient suffering from premature heart beat, add Sheng Mai Yin; and for recurrent contraction of cold, use Yu Ping Feng San; for sore throat, add Niu Bang Zi to clear heat and disinhibit the throat; for copious sweating, add Shan Yu Rou; for chest oppression, add Gua Lou, Xie Bai and Dan Shen.
Case Study 3: Hemoptysis
A female patient of 40 + year-old suffered from haemoptysis two to three times daily for the past four year with her condition worsening over the years. She also suffered from recurrent cough with phlegm congestion and wheezing on exertion with shortness of breath. Her pulse was submerged, slow and slightly weak particularly in the right pulse.
Diagnosis: Sinking of Da Qi and prescribed with Sheng Xian Tang + Long Gu and Mu Li 6 qian; Sheng Di Huang 6 qian; and change the dosage of Zhi Mu to 5 qian. Three packs. She recovered and omit Sheng Ma for several packs to consolidate.
Discussion: Haemoptysis can be due to counterflow qi with the blood anchoring on to qi. This is a Da Qi sinking pattern and the patient should suffer from blood in the stool and haematuria, why only haemoptysis? Answer: This is due to the Da Qi sinking with mal nourishment of the lung and cough with haemoptysis. A more serious condition may cause the Da Qi in the chest to downbear resulting in blood in the stool. Long Gu and Mu Li were astringent and should not be used with lifting herbs. The incorporation of astringent herb may affect the lifting a qi. Answer: Long Gu and Mu Li can astringe the source of blood; however by using the lifting herbs alone may cause the haemoptysis to worsen. It was known that Sheng Ma is contraindicated for haemoptysis, however the addition of Long Gu and Mu Li can negate the excessive lifting. (Case study of Zhang Xi Chun)
Zhang Xi Chun provides a detailed discussion on the Da Qi Sinking theory which was substantiated with many case studies. What is more Zhang pointed out the significance and role of the Da Qi in maintaining the daily activities of our life. He said that the lung governs respiration which in turn is subject to the health of the Da Qi of which apart from governing respiration, it supports the qi of the whole body and provides vitality for our intellect and thoughts. This theory continues to guide practitioners in the management of many cardiac cerebral and respiratory diseases indicating the sinking of Da Qi. Besides Sheng Xian Tang, Zhang Xi Chun created Hui Yang Sheng Xian Tang, Li Yu Sheng Xian Tang and Xing Pi Sheng Xian Tang to address the sinking of the Da Qi.
Yi Xue Zhong Zhong Can Xi Lu Medical Records of Integrated Western and Chinese Medicine Published by He Bei Ke Ji Publishing 1974
Zhao Jin Xi Guo Jia Zhong Qing Nian Ming Zhong Yi Zhong Yuan Nong Min Chu Ban She 2015