Essential Methods of the Wenbing: The Clinical Strategies of Dr. Song Zuomin
Dr. Song Zuomin, pictured here in 2016 at the age of 91, preparing for his clinic hours. (Photo credit: You Macai)
Theory and Practical Application of the Clinical Strategies of Dr. Song Zuomin
宋祚民老師學術思想的學習與實踐
By Dr. Li Xin
Translated by Bryan McMahon
From the time I was in college until meeting Dr. Song Zuomin, for roughly ten years my clinical approach was based primarily on the methods of Li Dongyuan and Zhang Zhongjing. I used herbs almost exclusively according to the strategies of warming the yang, warming the middle, warming to circulate, and moving the wind qi. For patients with a relatively simple constitution and a straightforward pathology, results were very good; in situations where the patient possessed a sensitive shen and qi, weak and deficient constitution, or where there was internal stasis, constriction of the qi mechanism, or even counter-flow movement of the qi mechanism, these strategies were often initially effective, but failed to produce long term resolution.
I often used Li Dongyuan’s methods of combining wind expelling qi level herbs such as Jingjie, Fangfeng, Chaihu, Qianghuo and Duhuo with Shigao, Huanglian, and Huangbai as corrective assistants in order to facilitate the qi mechanism and dispel and transform damp heat. At times, I felt the nature of the formula was too heavy; when treating patients of a sensitive disposition and delicate qi and blood, I found it difficult to balance the formula to the appropriate corresponding degree. I often wondered how to further refine my use of herbs in order to accommodate these types of patients.
I first met Dr. Song in early 1997 with the opening of the Beijing Yanhuang Chinese Medical Clinic. From 2000 until the end of 2002, I was fortunate to be able to accompany him during clinic hours twice a week, observing his diagnoses and copying his prescriptions. When I asked him for advice on the problem I was contemplating [of finding balance in my formulas], he smiled at me and said, “My young friend, you use herbs as if fighting with a wooden staff. When you hit the mark, the results are spectacular. But when you miss, you cause damage.” When I heard this, it was like waking from a dream. I began to gradually experience the light, soft nourishing effects Dr. Song would create with herbs like Rendongteng, Pipaye, Baimaogen, Sangbaipi, Digupi, Pugongying, Lianqiao, Suye, Sugeng, Peilan, Sheng Guya, Sheng Maiya, Lianzi, Oujie, Roucongrong, Tusizi and so forth.
In 2004 I formally requested Dr. Song to assume the role of guiding teacher, a relationship from which I have benefited to no end. In the following, I would like to share some of the humble insights arrived at through the application of these strategies in clinical practice over the past ten years.
1. Herbs differ in their hard and soft nature and must conform to differences in individual constitution, qi mechanism and pathological process
In The Essentials of Medical Origins for Applied Herbology, Qing dynasty physician Shi Shoutang wrote the following regarding the quality of hard and soft:
The Yi Jing states, “the Dao of the heavens is rooted in yin and yang; the Dao of earth is rooted in soft and hard.” Although subtle, the qi and wei of the grasses and trees can be divided into yin and yang, physical constitution can be distinguished as soft or hard. Within all physical matter is a complete taiji. The ancients often spoke about the natures of herbs according to their qi and wei, while seldom mentioning physical constitution. This is because the hard and soft aspects of earth are the very embodiment of the yin and yang of the heavens; such that, when you refer to yin and yang, hard and soft are included there within.
This highlights the need for congruity between the hard or soft qualities of the individual’s physical constitution and the qi and wei of the constituent herbs when composing a formula. The relative thickness or thinness of the qi and wei of the herb is the key to properly calibrating this degree of hard or soft. Suwen Ch. 5: The Great Treatise on the Correspondences of Yin and Yang states:
That with a thick flavor is yin; that with a thin flavor is yang within yin. That with a thick qi is called yang; that with a thin qi is called yin within yang. A thick flavor sedates; a thin flavor penetrates. A thin qi disperses; a thick qi induces heat. The qi of a raging fire grows weak; the qi of a small fire remains strong. A raging fire consumes qi; qi feeds off a small fire. A raging fire scatters qi; a small fire engenders qi.
When the qi is excessively thick, it induces heat; it is easy for a raging fire to consume qi. When the flavor is excessively thick, it seeks return to physical form and often induces loose bowels. This action of excessive flavor is described by Li Dongyuan as “directly entering into the intestines”. Not only will this damage middle burner qi, it also interferes with the rising and descending actions of the qi mechanism.
Many of the herbs that Dr. Song described as “soft” are used to tonify and regulate the middle and lower burners. The qi of these herbs is generally neutral, slightly cool or slightly warm and the flavor is generally sweet, slightly bitter, or slightly acrid. Their qi is generally even and harmonious; their flavor is generally sweet and moderate. His formulas employ the strategies of neutral tonification, moistening tonification, or cooling tonification in a manner that does not induce dryness or heat, is not cloying or lead to static accumulation. Circulating the qi mechanism is, in fact, a key component of so-called “tonification” strategies. In clinical practice, these methods are commonly used for individuals with middle and lower burner deficient constitutions.
“In the past, a Chinese medical doctor would receive a patient as if he were receiving a member of his own family. Their suffering was your suffering.” (Photo credit: You Macai)
In 2007, I treated a woman in her sixties who originally suffered from moderate symptoms caused by peptic ulcers. Unfortunately, she was mistakenly operated on to remove a third of her stomach. Due to her constitutional deficiency, the adhesions were not healing well, requiring a follow-up gastroscopy once a month. She was already 8 months postoperative when we began treatment, having undergone six follow-up gastroscopic procedures. Each one caused her heightened anxiety when the report would confirm that her stomach was not healing properly. As a result, she sought other treatment options from various doctors. The majority of these doctors followed basic strategies to tonify qi and blood and circulate the middle burner with herbs such as Dangshen, Danggui, Baizhu, Zhiqiao and Banxia in relatively large dosages and a confusing mix of flavors. Not only were they ineffective, these formulas actually made her abdominal pain and anxiety worse. Her constitution, pulse image, and complexion all indicated an extreme level of deficiency to the point where she was surviving on liquid nutrition supplements alone. These strategies are examples of excessively thick qi and wei.
I employed Dr. Song’s strategy of clear tonification of the Spleen and Stomach in order to revitalize the qi mechanism, using herbs like Sheng Maiya, Taizishen, Sheng Gancao, Fuling, Lianzi, Paojiang, and Wuweizi together with a small dosage of Huangqi, and Sharen as supporting assistants. From the first day she took the formula, her stomach pain began to ease; five days later, her appetite began to gradually return. After one month as her Stomach qi began to recover, I added Chao Baizhu, Roucongrong, Bajitian, and Bai Renshen (in a small dosage) in order to facilitate the source of digestive transformation to engender and spread qi. Three months later, she began to put on weight and I added herbs like Danggui and Houpo to move the blood and stimulate the intestines. She then returned for another gastroscopy, which found the adhesions fully healed. This is one example of the effective application of the qualities of hard and soft.
In cases such as this of constitutional deficiency, the system will be unable to transform anything but the softest of herbs; it is the only way to kick-start circulation of the qi mechanism. As soon as the qi mechanism begins to circulate, it will recover natural rising, descending, opening and gathering actions on its own; this facilitates the movement and eventual expulsion of damp heat, static blood, and constrained qi. This method is balanced, neutral, and soft. It differs from the use of dry, warming herbs with a thick qi that raise yang and stimulate fire like Ganjiang, Fuzi, Cangzhu, Baidoukou, Muxiang and Danggui. It also avoids using thick, cloying herbs like Sheng and Shu Dihuang, Guiban, and Ejiao. It will not cause excessive interference with the natural and instinctual healing movements of the body’s qi mechanism. This type of strategy is essential for patients with failure of transformative function due to Spleen and Stomach deficiency and systemic cessation of circulation of the triple burner qi mechanism.
Some examples of soft herbs that Dr. Song frequently used to tonify and regulate the middle and lower burners are:
1. Middle burner soft herbs for the Spleen and Stomach: Sheng Guya, Sheng Maiya, Lianzi, Oujie, Sheng Gancao, Taizishen, Baibiandou, Yiyiren, Shanyao. In clinical practice, when faced with a deficient constitution or weak stomach qi with failure to transform together with constrained fire and accumulation of dampness, Baizhu, Cangzhu, Huangqi, Dangshen will actually intensify the heat and make it difficult for the dampness to transform; these soft herbs are more appropriate.
2. Lower burner soft herbs for the Liver and Kidney: Lianxu, Qianshi, Sangshen, Roucongrong, Tusizi, Sheng Duzhong, Baijitian, Heshouwu, Shanzhuyu. Compared with Sheng Dihuang and Shu Dihuangdo, these herbs will not cause static accumulation; compared with Xianmao or Gouji (cibotium rhizome), they will not induce dryness or heat.
Due to overconsumption of heavy, sweet and spicy foods, frequent use of tobacco and alcohol, lack of exercise, high stress and overthinking, and generally externally oriented lifestyle, we see most modern day people present with damp heat and internally trapped toxicity together with exhaustion of source qi, essence, and blood as well as static deficiency in the middle burner with failure to transform. If you tonify this type of patient using herbs with a thick qi, it will often give rise to dry heat; if you tonify using herbs with a thick flavor, it will cause static accumulation and further handicap the process of transformation. In clinical practice we can use the above listed herbs in place of Bawei Dihuang Wan, Liuwei Dihuang Wan, Zuogui Wan, Yougui Wan, Sheng Dihuang, Shu Dihuang, Gouqizi, Xianmao, Gouji, Guiban, and Lujiaojiao for patients with insufficient ability to transform them.
2. That which is light can overcome excess:
The key to using herbal medicine is in circulating and penetrating
Early in his career, Dr. Song thoroughly researched the methods of the Wenbing movement. He summarized them as, “The key to using herbs according to the Wenbing method is to be light, agile and highly mobile. In this way, that which is light can overcome excess.” This quality of weight is a key principle of herbology. The foreword of The Great Compendium of Materia Medica states:
Xu Zhicai says, “Herbs have the ten qualities of opening and circulating, tonifying and sedating, light and heavy, astringent and slippery, dry and moist. They compose the general outline of an herb.” Li Shizhen says, “What is light can penetrate obstruction.” These correctly follow the principle of the Neijing, which states, “that which is light can disseminate”.
The meaning of light refers not only to the physical aspect of small dosage, but also to the essential qualities of a light qi and a thin wei. The Great Treatise on the Correspondences of Yin and Yang states, “A thin wei will penetrate; a thin qi will disseminate.” This method is generally applied to a situation where the qi mechanism is severely congested. Dr. Song was a pediatric specialist. With relatively weak zang-fu organs and a light and agile qi mechanism, the shen and qi of children are very sensitive. Highly accurate diagnosis is essential to treat them safely and effectively. Equally important is appropriate herb selection and their dosage.
In 2010, I treated a newborn infant not yet two months old. Almost immediately after birth, the baby began to run a fever. The hospital diagnosed him with an upper respiratory infection and used intravenous fluids for over 30 days, with no effect. Other Chinese medical doctors had prescribed formulas to dispel heat and alleviate toxicity, disperse wind and release the exterior, facilitate digestion and harmonize the stomach, all unsuccessfully. At that time, the baby was running a repetitive fever for three to five hours each day that would dissipate with sweat. The tongue was pale with a superficial, thick, slippery coating; complexion was a pale yellow with flushed cheeks and the appearance of subcutaneous edema. His appetite was poor with normal bowel movements. This presentation was largely the result of excessive intravenous fluids, which by now had caused interior fluid stagnation. It actually suggests that the baby’s constitution was rather strong. He would raise a fever for which IV fluids would be administered; the cold damp would then obstruct the qi mechanism and congested qi would produce further heat. The process would repeat as a result of the qi mechanism’s inability to circulate. As soon as vital qi could recover to a sufficient degree, it would raise an immune response, but fail to fully overcome the pathogenic influence.
The hands of the Master checking the Three Gates on a child’s index finger. (Photo credit: You Macai)
The pathogenesis was clearly one of damp heat resulting from obstructed yang qi. Previous doctors had used acrid, sweet and warming methods with strong qi such as Xiao Chaihu Tang, Shen Su Yin, and Jie Fang Baidu Yin; these methods enabled the heat, lifting and scattering qi too powerfully. Others had tried mixed combinations of Jinyinhua, Lianqiao, Huangqin, Huanglian with herbs like Zhishi, Xingren, and Banxia in large doses that produced a strong flavor; these methods were all too heavy in dosage as well as in the qi and wei of the formula. Instead, I chose a strategy of neutral and soft tonification of the middle burner with light, agile and mobile herbs. This combination of Dan Zhuye, Zhuru, Chao Baizhu, Fuling, Yiyiren, Sharen, Cheqiancao and Taizishen brought the fever down in one dosage. After three dosages, the heat was completely gone. I then used Si Junzi Tang with Lianzi, Wumei, Yiyiren, and Muxiang to regulate the middle burner and in two weeks, the baby had made a complete recovery.
The strategy of using “that which is light to overcome excess” in this case is different from the drying and warming actions of herbs like Ganjiang, Fuzi, Jingjie, Fangfeng, Chaihu, Qianghuo and Duhuo that raise yang and stimulate fire; it also avoids the use of Huanglian, Huangbai, Huangqin and Dahuang, which with a bitter cold nature can inhibit the qi mechanism and damage the middle burner. This strategy is not limited to external conditions of warmth or heat. It can also be used effectively for a wide range of internal medical conditions including liver disease, heart disease, ankylosing spondylitis, hypercholesterolemia, hyperuricemia, diabetes, essentially, all conditions resulting from congestion due to constitutional excess with internal trapped heat, where the qi mechanism is constrained, the surface is not flowing smoothly, and the channels and vessels are obstructed.
When vital qi and pathogenic factors are battling in the upper burner, Rendongteng, Pipaye, Sangbaipi, Digupi, Pugongying, Suye, Sugeng, Heye, Zhuye, Cheqiancao, Cheqianzi, Bohe, Sangye, Peilan, Lianqiao, and Lugen can be used to lightly open the upper burner and smoothly expand the qi mechanism in order to draw the heat outward. When constrained within the qi level of the middle burner, Foshou, Xiangyuan, Sharen, Chenpi, Baidoukou, Yiyiren, Houpo, and Zhuru can gently restore balance to the middle burner, reactivate its rising and descending action, and draw qi downward. In clinical situations where strategies to tonify and circulate the middle burner using Muxiang, Sharen, Ganjiang, Wuzhuyu, Buzhong Yiqi Tang, Ping Wei San or Huoxiang Zhengqi Tang are unsuccessful or result in counter-flow qi and rising fire, vexation and dry heat, this method of using “that which is light to overcome excess” should be considered. Stasis in the lower burner can be treated with Zelan, Wangbuliuxing, Shuihonghuazi, Shuizhi, Sanqi, Binglang, Honghua, Taoren, Bianxu, Qumai, Chixiaodou, Baimaogen, Dayuji, Xiaoyuji, Qiancao, Puhuang, Danshen, Zicao, Cebaiye.
In 2008, I began to treat a patient with liver cancer who had undergone aggressive radiation. He was a member of the Communist Party and a government official, a career characterized by metal excess. His family life was also in disarray. He was suffering emotional estrangement from his wife, with whom he had not had a meaningful conversation for many years. On top of this, he had not exercised for years. Exercise is a key method to circulate qi and blood, open the channels and collaterals and to expand and smooth the flow of wood energy. These factors contributed to long-term constraint of the qi mechanism. He presented with a wiry, rushed pulse that had strength. His cheeks were flushed, his mouth felt hot with chronic bad breath and his bowel movements were difficult. His affect and movements were tense and angular. He suffered a constricted and often painful feeling in the right hypochondrium and epigastric region, poor appetite, and chronic acid reflux. His tongue was an inflamed red color with a thin, dirty coating lacking in moisture; the sublingual vessels were black and enlarged. He had a short temper that caused him headaches with poor sleep and an unsettled shen. This is a pattern of severe yang qi constraint.
I treated him using Dr. Song’s methods to soften the Liver, circulate yang qi, open the collaterals and transform dampness. This included Sangye, Sangzhi, Zhuye, Rendongteng, Pugongying, Juhua, and Lugen to open and circulate the yang qi of the upper burner; Yiyiren, Baidoukou, Sharen, Houpo, Chenpi, Zhiqiao, Zhishi, Tianhuafen, Sheng Guya, Wumei, Jineijin, and Foshou to regulate the Spleen and Stomach and circulate the yang qi of the middle burner; Sheng Muli, Zhenzhumu, Zishiying, Shuihonghuazi, Biejia, Honghua, Dilong, Zelan, Sheng Puhuang, Sanqi, Danshen, Xianhecao, Zicao, Hanliancao, Qiancao and Chixiaodou to open and dispel the stasis within the lower burner blood level. I followed the patient’s shifting energetic posture, using appropriate combinations of these herbs for over two years to a successful outcome; the patient is still alive and well today. This method of using “that which is light to overcome excess” with an emphasis on circulating and penetrating is not limited to externally contracted conditions; it can be applied to all manner of internal diseases.
People today suffer from diseases of modern lifestyle, characterized by deficiency of the jing and qi of the five zang organs with accumulation of damp heat, undigested food and phlegm in the intestines. Qi circulation in the exterior is obstructed; smooth flow of the qi mechanism in the interior is congested by blood level stasis. Jing and qi are deficient and weak. There is severe obstruction by pathogenic factors with an ungrounded Spirit. These conditions are not amenable to acrid, fragrant, warm, dry herbs that move the qi and blood or bitter, cold herbs that weaken the middle and suppress the qi mechanism. They are even less suitable to the long-term use of large dosages of extremely acrid and extremely hot or extremely bitter and extremely cold herbs with both thick qi and wei.
Effective employment of these methods using that which is light to overcome excess through light, agile circulation and penetration is contingent upon appropriate treatment strategy and herb selection based on the real-time condition of the patient. There is a common misperception held by many doctors that these light, soft herbs and formulas associated with the Wenbing movement are merely superficial in their actions; that while they may be appropriate for dispelling external heat, they lack the power required to treat internal disease. This is an incomplete understanding of these methods. I know because before I met Dr. Song, I used to feel the same way.
3. Circulating the yang is not dependent on heat
Dr. Song used to say, “Circulation is movement. This is yang; this is qi. This is the nature of the triple burner, the fu organ of circulation of yuan qi.” Dr. Song taught that the strategy of circulating yang is fundamentally different from reviving yang and warming yang. Reviving yang is used in cases of yang collapse; that’s why this strategy is said to ‘revive yang and save [one from] counter-flow. Warming yang is used in cases of the failure of yang qi to warm due to deficiency. In contrast, the method of circulating yang utilizes herbs that are acrid and neutral, sweet and neutral, acrid and cool, slightly bitter or slightly acrid. It is used in cases where yang qi is constrained due to vital qi deficiency and the resulting obstructing influence of pathogenic factors. This is not the same as yang deficiency, yang collapse, excessive cold, and other life-threatening conditions. It can be used to smooth and connect the flow of yin and yang and alleviate all obstacles to the proper circulation of the qi mechanism, without relying on warm and hot herbs alone.
Jinyinhua and Rendongteng (honeysuckle flower and stem).
Herbs like Lugen, Shengjiangpi, Rendongteng, Peilan, Fangfeng, Jingjie, and Shichangpu circulate the upper burner and connect the Heart and Lung; Zhiqiao, Foshou, Chenpi, Huoxiang, Baidoukou, Sharen, Houpo, Yiyiren, and Fulingpi assist transformation of the middle and extend outward to the four extremities; with a bland and leeching nature, Baimaogen, Chixiaodou, Lulutong, Tongcao, Huashi, and Zhuye descend to assist the Kidney circulate the yang qi of the lower burner by gently dispelling excess via urination. All is dependent upon circulating and encouraging the qi transformation of the triple burner. When qi moves, yang circulates; when yang circulates, pathogens are expelled.
Herbs like Mahuang, Fuzi, Xixin, Qianghuo, Wuzhuyu, and Shengjiang that circulate yang and move qi powerfully on a systemic level possess an acrid, fragrant, drying and warm nature. For constitutions and pathological mechanisms that are of a cold, constricted nature, they can be widely used. However, most people today are of a deficient constitution with internal constraint. The pathological mechanism usually involves additional heat and dampness resulting in concurrent excess and deficiency together with a complicated mixture of damp heat. The abovementioned herbs will often enable the heat, damage the yin and move too strongly, leading to excessive dispersion of qi. I have treated dozens of cases of pediatric conditions like allergies, eczema, and dermatitis. These are examples of yang qi intermixed with damp, heat and cold pathogenic factors causing constraint within the muscles and skin. They are often the result of static damp heat and food accumulation in the middle burner. Using Qianghuo, Fangfeng, Jingjie or Guizhi to open the surface qi would most likely make these conditions worse. Lightly opening the upper burner with herbs like Rendongteng, Sangye, Sangbaipi, Qiancao, Juhua, and Lugen together with Maiya, Yiyiren, Tianhuafen, Wumei and Fuling to softly circulate the middle burner has proven highly effective.
These three methods involving “soft herbs”, “that which is light to overcome excess”, and “circulating yang” represent the deepest and most valuable insights that I have gained through study with Dr. Song. While these three methods may appear somewhat different, they are fundamentally the same. They are all based on the principle of using slightly bitter, slightly acrid, sweet, bland, neutral, slightly warm or slightly cool strategies to circulate and connect the qi mechanism. Once the qi mechanism begins to circulate, the turbid constrained pathogenic factors are naturally expelled through sweat and stool. This method is centered and balanced; it does not over stimulate qi and blood or cause damage to the vital qi and yin fluids. The herbs are light and the flavor is bland, but results are conclusive.
For those readers who wish to further reflect on these clinical strategies, the key lies in the four flavors and five natures; rising, descending floating and sinking; opening, gathering, moving and stabilizing; hard and soft; light and heavy; slow and rapid.
Links to Dr. Song’s books available on Amazon: