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WHAT'S IN A NAME?
Free and Easy Wanderer's Powder
Xiao Yao San, and one of its modifications, Jiawei Shao Yao San, are among the most commonly-used Chinese formulas today. Western practitioners often focus on the use of Xiao Yao San in treating premenstrual syndrome, the main indication given by Jake Fratkin in his book on patent medicines (12). However, this formula (common name: Bupleurum and Tang-kuei Formula) has broad applications. For example, Shiro Hosono gives the following indications based on the traditional Chinese texts and the work of Kampo physicians in Japan (13):
Blood weakness; exhaustion; irritating heat in the heart, palms, and soles; whole body pain; dizziness; heaviness of the heat; being easily startled, dryness of the mouth and throat; night sweats; poor appetite; excessive sleeping; blood and heat in conflict; irregular menses; umbilical swelling and pain; malaria-like fever and chills; uterine blood weakness; yin weakness; disharmony of wei and ying qi; cough with sputum; high fever; emaciation.
Ou Ming (14) mentions that Xiao Yao San: "has been widely applied for various diseases of internal medicine, surgery, and gynecology." According to Bensky and Barolet (9), the formula can be applied (with appropriate presentations) to treatment of:
Hepatitis, pleurisy, chronic gastritis, peptic ulcer, anemia, functional uterine bleeding, menopausal syndrome, pelvic inflammatory disease, fibrocystic breasts, neurasthenia, optic nerve atrophy, and central retinitis.
The diverse applications of the formula reflect, in part, the fact that Xiao Yao San is aimed at treating a commonly-occurring underlying syndrome that, according to traditional Chinese medical principles, contributes to numerous diseases. The action of the formula is one that is difficult to convey briefly, being based on an aspect of Taoism described in ancient Chinese texts that has been incorporated into Chinese thinking about health and longevity.
The name given to the herb formula-Xiao Yao San-is intriguing, making reference to the unfettered wandering of the Taoists who prided themselves in being in tune with the movements of nature. There is a modern expression, "going with the flow," which may have been derived from the introduction of Taoist philosophy to the West via the book Tao Te Ching (pinyin: Dao De Jing). This book, attributed to the legendary Lao-tzu (pinyin: Laozi) is one of the most widely translated books of all time.
In chapter 8 of the 81-chapter work (a chapter being only a few sentences long), the Tao is likened to water. The translations vary among the popular English language versions (1-4), but a rendering that captures the essence of all of them is this one provided by Robert Henricks (21):
The highest good is like water; water is good at benefiting the ten thousand things and yet it has tranquility [or, does not compete with them]. It dwells in places the masses of people detest, therefore it is close to the Way [Tao].
There are three key elements of this phrase about water as a depiction of the Tao: that water is positive (good, beneficial); that it can flow without striving or competing, remaining tranquil; and that it enters places that people would usually avoid. The way water flows around obstacles, as observed when watching a mountain stream, has been taken by many readers of this ancient book as an emblem of the proper way the mind should deal with the difficulties it encounters. Joining the flow of Tao, where ever it may go, leads one to unusual places, but places meant to be visited by those who have devoted themselves to the Tao.
The philosophy of Taoism was further elucidated by Chuang-tzu (pinyin: Zhuangzi), who is believed to have lived around 365-290 B.C. (Taoism is sometimes referred to as the Lao-Chuang philosophy). A record of Chuang-tzu's teachings, simply called the Chuang-tzu, was recorded around 310 A.D. by Guo Xiang in a form similar to that which exists now. By that time, Taoism had become a major force in Chinese society. It had influenced Chinese herbalists, many of whom were Taoist alchemists seeking immortality. They used a variety of means to attain their goal, including meditation, special exercises (that were later to become the familiar chi-kung (pinyin: qigong) and ingestion of various alchemical substances.
The first chapter of the book of Chuang-tzu's teachings (5) is titled Xiao Yao; this has been translated as "Wandering Boundless and Free." Xiao has the current meaning of free and unrestrained; yao has the current meaning of distant; thus, the term implies going a long distance without restraint. The chapter is comprised of short sayings or stories (in English translation, each is about 50-100 words) that encourage the reader to be free of rigid concepts. These sayings, steeped in Chinese mythology and culture, are often difficult for Westerners to interpret; one that is relatively easy to understand is:
Lieh-tzu [one of the three early Taoists associated with books of sayings; the other two being Lao-tzu and Chuang-tzu] rode the wind and set out, boundless and clear, returning after only 15 days. To be so blessed is rare-and, yet, however free that wind made him, he still depended on something. But, if you mount the source of heaven and earth and the ten thousand changes, if you ride the six seasons of qi in their endless dispute-then you travel the inexhaustible, depending on nothing at all. Hence the saying: 'The realized remain selfless; the sacred remain meritless; the enlightened remain nameless.'
The key is to depend on nothing at all, that is, to be free of all rigid concepts, all obstructions to movement through life, to have one's mind and body move according to the Tao, often translated as the "Way." The realized Taoist becomes selfless (helpful to others but not concerned about receiving rewards and praise, hence meritless and nameless). In this description, it is said that to set out boundless and clear (free) is a rare and blessed thing. This roaming is not referring to actually traveling about the countryside; it refers to what goes on within the mind, either during meditation or in daily life. This saying by Chuang-tzu reflects the words in Chapter 25 of the Tao Te Ching, where the Tao is depicted this way (3):
Something mysteriously formed, born before heaven and earth; in the silence and the void, standing alone and unchanging. Ever present and in motion, perhaps it is the mother of ten thousand things. I do not know its name, call it Tao. For lack of a better word, I call it great. Being great, it flows. It flows far away. Having gone far, it returns....Man follows the earth; earth follows heaven; heaven follows the Tao; the Tao follows what is natural.
As in the Chuang-tzu story, there is movement going away and coming back, and it is a long distance (in the story, 15 days in roundtrip being a short journey); the movement is entirely natural. Another telling passage in Chuang-tzu's chapter titled Xiao Yao is this small debate between Chuang-tzu and Hui-tzu. Hui-tzu was a contemporary of Chuang-tzu that held a contrary and competing philosophical view based on rationalism:
'I have a big tree,' said Hui-tzu to Chuang-tzu. 'Its huge trunk is so gnarled and knotted that no measuring string can gauge it, and its branches are so bent and twisted they defy compass and square. It stands right beside the road, and still carpenters never notice it. These words of yours [referring to the stories of Chuang-tzu recorded in this chapter], so vast and useless, everyone ignores them the same way.'
Chuang-tzu replied [after giving some esoteric examples of his point from the animal world]: 'Now, you've got this huge tree, and you agonize over how useless it is. Why not plant it in a village where there's nothing at all, in a land where emptiness stretches away forever? Then you could be no one drifting lazily beside it, roam boundless and free as you doze in its shade. It won't die young from the axe. Nothing will harm it. If you have no use, you have no grief.
The tree that is logically useful (its wood is desirable) will be cut down; the tree that is logically useless (its wood too gnarled to be of value) is spared. So, which is better? To be useful or useless? In Chapter 22 of the Tao Te Ching it says (3):
Wise men embrace the one, and set an example to all. Not putting on a display, they shine forth; not justifying themselves, they are distinguished. Not boasting, they receive recognition, not bragging, they never falter. They do not quarrel, so no one quarrels with them.
The tree, in the story above, may be huge, but carpenters never notice it. The Taoist is likewise unnoticed because he does not try to call attention to himself; not calling attention to himself, no one quarrels with him. But, this does not mean that he is without value. Like the Tao, he is "great," like the tree, he can provide welcome relief (shade) and a break from desolation (absence of wisdom and virtue). He is not so useless after all.
In a passage from the second chapter of Chuang-tzu's teachings, there is a short story:
Long ago, a certain Chuang-tzu dreamt he was a butterfly-a butterfly fluttering here and there on a whim, happy and carefree, knowing nothing of Chuang-tzu. Then, all of a sudden, he woke to find that he was, beyond all doubt, Chuang-tzu. Who knows if it was Chuang-tzu dreaming a butterfly, or a butterfly dreaming Chuang-tzu?
This puzzle of existence-which is the dream, which is reality?-strikes most people at some time, but Chuang-tzu has captured the essence of the conundrum. When one does not have rigid thoughts about oneself, there is no differentiation between thoughts, dreams, and reality. Zhi Dun (314-366 A.D.) introduced Buddhism, a philosophy based on the avoidance of rigid concepts, to Taoist China. In his commentary about the book of Chuang-tzu, one passage survives to the present; it is about Xiao Yao (15):
Free and easy wandering refers to the mind of the perfected. When Chuang-tzu talks about the Great Tao, he uses the analogy of the Peng bird and the quail. Because the Peng's life is without obstruction, the bird is free from all limitation in the realm beyond the body. The quail, on the other hand, because it lives in the near and scorns the far, it is limited and obstructed in its mind.
The perfected one rides the truth of heaven, soars aloft, and wanders boundlessly in unfettered freedom. He treats beings as beings without being treated as a mere being himself. He is not self-satisfied in his wandering. Mystically one with the universe, he does not act purposefully. He is not hurried, yet moves swiftly. He goes everywhere in his freedom. He is truly a free and easy wanderer.
The concept behind Xiao Yao is deemed of such importance that modern books on the subject of Chuang-tzu's teaching often emphasize it. For example, one text is called Wandering at Ease in the Zhuangzi (16) and another is called Wandering on the Way (17); both were published in 1998. A popular bumper sticker reads: "Not all who wander are lost." Perhaps this is a reference to the Taoist classic.
The free and unfettered wandering of the mind is manifest at times in actual movement of the Taoist from place to place. In the book Road To Heaven: Encounters with Chinese Hermits (6), Bill Porter relays this poem by Wang Wei (699-761 A.D.), a Taoist who lived in Chungnan:
|In my prime, I loved the Way;
a Chungnan cottage in old age.
When I want to roam alone,
wonders are wasted all on me.
Hiking to the river's source,
sitting, watching clouds arise.
Sometimes with an old recluse,
talking, laughing, free from time.
The "Way" or Tao is freedom from worries about time (meaning worries about accomplishments that will be recognized as notable), with a life that appears leisurely, like that of a butterfly fluttering here and there. However, to attain the state of true freedom, each individual must cultivate the proper attitude: to overcome the tendency to strive for reward and resist obstacles in the way of some non-essential accomplishment.
The herbal powder named for the Taoist freedom of mind, has specific medical indications, yet a means of understanding the formula is to grasp its relation to its curious name. Xiao Yao San (san merely means powder; the pill is called wan), has been variously translated as Leisure Powder (7), Free Wanderer Powder (8), Rambling Powder (9), and Merry Life Powder (22), to try and capture the basic meaning of the term.
The function of the formula is to help overcome the ingrained personal approach of clashing with-rather than flowing around-a difficulty that is encountered. This way of being influences the person's flow of qi and blood, causing it to flow erratically and bind up. In the Chinese model of health and disease, the free flow of qi and blood is the requirement for health and the obstructed flow of qi and blood is a cause of disease (there are other causes, such as deficiencies and excesses). The obstruction of circulation corresponds to both a physical stagnation (repression of natural movement) and the psychological condition we call depression, the sense of inability to move and change to overcome obstacles. Zhu Danxi said (10): "So long as the qi and blood enjoy harmonious flow, none of the hundreds of diseases can arise. Once they are depressed and suppressed, various diseases are produced."
The central herb of Xiao Yao San is bupleurum (chaihu), used to release the liver qi that is stagnated by emotion. As C.S. Cheung describes its function (7), "it dredges the liver and relieves congestion." The term "dredges" is particularly appropriate, because the Chinese concept is that the liver, especially when it has been disturbed by frustration (inexpressible anger) can tenaciously hold on to the qi that it is supposed to help circulate, and the qi needs to be released by some means. The primary herb for treating stagnation with emotional depression has long been cyperus (xiangfuzi), which is notable for its pleasant and penetrating fragrance. However, during the past century, bupleurum has gradually taken on this role. It is especially relied upon when there is a stagnation of circulation associated with both the liver and spleen. The spleen is said to distribute the qi and moisture from food, a function that is disturbed by anxiety and worry.
The liver is associated with the wood element, which corresponds with growing plants. It is said that young plants that are full of moisture and essence grow vigorously during the spring (the season associated with wood) and bend easily under the pressure of wind (the climatic condition associated with wood), bouncing back readily. On the other hand, when wood has become aged and dried, its growth is slowed and it is no longer able to bend in the wind; rather, it can easily break; it can also easily be burned by fire. To assure that the liver, as representative of the wood element, remains healthy and able to easily respond to stresses (like the variable wind and the fire of emotion or disease), it needs to be moistened. Hence, in the formula Xiao Yao San, bupleurum is joined by tang-kuei and peony, two herbs that nourish the liver blood. These herbs prevent and even reverse a condition of liver dryness.
In his description of uses for Xiao Yao San, Hosono mentions symptoms of blood deficiency, of dryness, and of heat. In particular, he mentions the condition of conflict between heat and the blood. This is a reference to the basic yin/yang concept, in which the well-nourished blood (the yin aspect) can restrain heat (the yang aspect); in return, the well-directed heat circulates the blood and prevents it from coagulating. In this case, the blood is insufficiently nourished and the heat is agitated and alternately constrained or rushing out without direction. Thus, the blood and heat (yin and yang) are in conflict rather than harmony. From the philosophical viewpoint, the heat represents the struggling with obstacles while the blood deficiency represents the failure to cultivate wise ways. The two are interconnected; wisdom releases one from struggling; relaxing the struggle gives one a chance to cultivate wisdom.
The spleen is associated with the earth element, corresponding to the soil in which plants grow. When the soil is well drained, it supports the health of plants. When the earth becomes too moist, it is no longer a healthy medium; instead, plants growing in such conditions yellow and wilt, and their roots may rot. The soil that is saturated with moisture can no longer drain additional moisture that falls as rain, so there are floods and damage. Therefore, by this analogy, to keep the spleen healthy, the excess moisture must be drained, and this is accomplished in the formula Xiao Yao San with the moisture resolving herbs hoelen and atractylodes. In addition, the function of the spleen is invigorated by baked licorice, a sweet, tonifying herb.
Some authors suggest that the formula is aimed at treating the case where the liver is overbearing and the spleen is weak, resulting in the impingement of the liver qi on the spleen, further weakening it. Qin Bowei argued against this way of interpreting the prescription (8). Xiao Yao San may be better viewed as a coordinated attempt to assure proper circulation: the spleen circulating moisture and the liver circulating blood (both organs aiding the circulation of qi). In other words, for the person who requires Xiao Yao San, both the spleen and the liver are in a weakened state, even if the liver has become heated. Both organs have their functions simultaneously improved by Xiao Yao San.
The formula is fundamentally comprised of this group of six herbs. Three of the herbs (bupleurum, tang-kuei, and peony) are aimed at improving liver function, three (hoelen, atractylodes, baked licorice) are aimed at improving spleen function. Looking at it another way, three of the herbs serve primarily as nourishing tonics (tang-kuei, peony, and baked licorice) and three serve primarily as herbs to disperse stagnation (bupleurum, hoelen, and atractylodes). This formulation approach is similar to that which is found in another famous prescription, Rehmannia Six Formula (Liuwei Dihuang Wan), which is also very widely used in modern times.
The complete Xiao Yao San formulation is filled out with two other herbs as adjuncts: mentha, to aid in the dredging of the liver; and fresh ginger, to aid the function of the spleen. These two herbs are also used to resolve congestion at the body surface, as does bupleurum. If surface relieving actions are not required, the ginger can be fried (its nature will then be more warming and drying), which will make it suitable as a directing herb to benefit the spleen.
The proportions of the herbs vary slightly according to the reference text. As an example of the instructions, one can use 9 grams each of bupleurum, tang-kuei, peony, hoelen, and atractylodes, with 6 grams of baked licorice ground to powder. This powder is to be taken with tea made with 3 grams of mentha leaf and with fresh ginger slices, about 6 grams (7). The herbs other than mentha and fresh ginger are ground in advance; when ready to be used, the powder is boiled for a short time, with 6-9 grams of the powder making a dose. The herbs can be made by the decoction method without first preparing a powder, but the mentha should be added later in the decoction process to avoid loss of the aromatic components. The formula with all 8 herbs combined together is available in the form of granular, dried hot-water extracts, to which hot water is added to make a tea; a dose is about 2-3 grams of the granules.
Due to the popularity of the formula, convenient pills have been produced by numerous factories in China. These are listed in the Pharmacopoeia of the PRC (11). The official procedure to make them is to use equal amounts of each of the six main ingredients (except just 80% as much baked licorice), plus 20% as much mentha, grind them to powder, and combine the powder with decoction of fresh ginger (for 600 grams of powder, 100 grams of ginger is extracted and added). The resulting moist material is then dried and made into pills. According to the Pharmacopoeia, its functions are to soothe the liver, invigorate the function of the spleen, and nourish the blood; the formula is indicated for depression of liver qi. Examples of symptoms to be treated are: distending pain in the chest and hypochondriac regions, dizziness, impaired appetite, and menstrual disorders. Practitioners today often prescribe this formula as a general therapy for stress, tension, depression, and irritability.
There are two primary modifications of Xiao Yao San described in the literature. The most widely used one is Jiawei Xiaoyao San (jiawei means added ingredients; literally, added flavors), commonly referred to as Bupleurum and Peony Formula, which has gardenia and moutan added to the basic prescription. Gardenia and moutan both clear heat; gardenia is said to purge fire from the liver and moutan is said to clear heat from the blood. The formula was first described in Naike Zhaiyao (Summary of Internal Medicine by Wensheng, in the mid-19th Century).
This modified version is one of the most frequently prescribed formulas in Japan, particularly used for emotional disorders and "erratic complaints" (numerous changing symptoms) experienced by women; it is commonly given for perimenopause and early stage of menopause. In addition, it is frequently prescribed in Japan for treatment of viral hepatitis. In books about Kampo medicine, such as Major Chinese Herbal Formulas (18), Healing with Chinese Herbs (19), and Kampo Treatment for Climacteric Disorders (20), Jiawei Xiaoyao San is mentioned but the original Xiao Yao San is not.
The primary difference in indications for Xiao Yao San and Jiawei Xiaoyao San is the finding of evident symptoms of heat and agitation that would call for the inclusion of moutan and gardenia in the latter formula. Such heat symptoms are mentioned in the traditional indications for Xiao Yao San, but the added herbs improve the treatment when those symptoms are more severe. Examples of indicator symptoms are fever, headache or heaviness of the head, conjunctival congestion, facial flushing, tongue ulceration, excessive menstrual bleeding, chronic cystitis, or mental distress (13, 14).
The other well-known modification is Hei Xiao Yao San (hei = black), which is made by adding the black-colored herb rehmannia to Xiao Yao San. This formula was first reported in Yifang Xinjie (New Explanations of Medical Formulas) by Ma Youdu, in 1980. It is mainly used in cases of more severe deficiency of the liver blood, particularly for associated menstrual disorders. The formula originally called for raw rehmannia, but cooked rehmannia is often substituted for its stronger blood nourishing qualities; the adjunctive herbs mentha and ginger are sometimes left out of the prescription (9).
The broad applications listed for Xiao Yao San can be understood in terms of its objective: treating a fundamental underlying disorder, which is the obstructed flow of qi that results from certain mental processes. The mind that has not learned how to face problems effectively, that struggles, strives, and competes, will cause the body's qi to stagnate, which, over time, yields various symptoms and diseases. The solution on the mental level is to study, understand, and apply the teachings of the Tao; on the physical level, the solution is to gently promote the smooth circulation of qi. The simple formula embodies the medical principles of tonifying and dispersing in a balanced manner. The herbs benefit spleen and the liver, the two organs that are commonly involved in disharmony of qi circulation.
The story of Xiao Yao San illustrates the potential advantage of looking beyond the simple act of prescribing herbal remedies for treating symptoms and diseases. If the practitioner limits the process to deriving a diagnosis of physical disorders and then, as a primary solution, administering some teas or pills, the bigger picture is lost. The herbal therapy is one part of a comprehensive approach to becoming healthy. Since patients cannot all be expected to take interest in and study Chinese cultural concepts such as Taoism, it is the role of the practitioner to gain a deep understanding of the medical system and its philosophical underpinnings. In that way, the patient can be inspired to head in the right direction by the practitioners words and actions.REFERENCES
Painting by Zhang Daiqian (1899-1983) ca. 1936, entitled A Thousand Meters Up. This is a copy of a painting by the Ch'an Buddhist monk Shiqi done in 1661. The characters at the top of the painting, which are also copied from the original, include this: "Suddenly I'm roaming off into the sky, my heart and mind open wide; Crouching on the peak, I lift my head and let loose a crazy shout: 'Who is it who's dotting the firmament with all these lots of ink?'"