What to do when tonics don't work

On my own, but I’m a practitioner myself. I have pale tongue with white coat.

Can you include a picture of your tongue? What is your pulse? And what other symptoms besides “fatigue” do you have that you feel lead towards a true deficiency pattern? Finally, what do you mean when you say you have “yin fire flaring” when you do “too much exertion”? What are your exact symptoms from doing exactly what? Sweating from walking up stairs, panic attacks from jogging, what exactly?

Long story short, if bu zhong yi qi wan made you worse, you most likely have a far more layered condition than a true deficiency (what it is best at).

I had this myself and treated it quite successfully, however it takes diligence so I’m not going to sugar-coat the reality of what you have to do. I’m an intensive herbalist, have cured myself and friends of so very much, and I lived in China and Taiwan for many years with fluency in Mandarin.

The reason 補中益氣丸 makes you worse is because when taken continually it depletes the liver of its yang and further exacerbates the very clear damp stagnation you have–most likely originating in the spleen. Many ingredients (which vary among producers) exacerbate dampness and can actually create damp-heat (like Gan Cao and Huang Qi), so you have to mindful of these properties. You may feel better hours or days after the initial administration, but soon after you’ll feel much worse. Because of the systemic dampness you exhibit, your digestion is impaired. Because of poor digestion, your absorption of nutrients is poor and thus you have blood deficiency. When emptiness is coupled with stagnation over a chronic timeline this is the perfect scenario for yin fire to emerge (as it had in myself). The good news is this condition is very receptive to the proper formula and administration method, but still the majority of practitioners lack the understanding needed to effectively see this nasty pattern resolved.

Herbal treatment of Yin Fire demands gentleness, or “the Kingly Dao.” The trick is to tonify without exacerbating the damp retention in the organ channels that accumulate the most dampness–which in your case I would say is both the spleen and liver. The liver typically responds the quickest to herbal treatments since the active constituents of herbs have to traverse through the blood and channels initially where they target eventual organs and organ systems. For example, if one uses Dang Gui they must account for its damp nature (it’s contraindicated with abdominal distention and damp-heat patterns in the lower burner–which is where the liver and kidney resides). Dang Gui is used to quicken and nourish the blood but it is heavy and cloying in nature. I would substitute this for Hong Hua which is much lighter in action and therefore does NOT encumber dampness but instead works to help resolve it gradually. Also, substitute Chai Hu with Xiang Fu instead. The latter enters all channels to rectify the qi, and it is temperature-neutral and gentle-enough to be used long-term in formulas with constitutional weakness and deficiency. Xiang Fu and Hong Hua work synergistically to gently and powerfully resolve stagnation.

I would also recommend using Nu Zhen Zi, Bai Shao, and Du Zhong together to wholly and functionally support the liver and blood. This combination is extremely effective in my experience on myself and on countless clients. Bai Shao shouldn’t be consistently used longer than about 2-3 weeks. After this period, you can swap it with He Shou Wu once a bit of the dampness has cleared from the lower burner.

Keep in mind that although Chen Pi works to clear away dampness and regulate qi, it also easily damages spleen and/or stomach qi which exacerbate one-another. It’s too harsh to be used in particularly deficient patients in my opinion.

I would keep the spleen tonics in 補中益氣丸 and use my suggestions for a decoction (amounts are for one day or three doses):

Tonics

• Bai Zhu 9 grams
• Cang Zhu 9 grams
• Dang Shen 15 grams
• Huang Qi or Zhi Huang Qi 15 grams
• Nu Zhen Zi (crushed) 15 grams
• Du Zhong 15 grams
• Bai Shao* 10 grams

Qi Rectifiers and Blood Harmonizers

• Xiang Fu 6-9 grams (if liver and/or kidney fire is quite strong then instead/alongside use Mu Dan Pi for a while–it can’t be used long-term)
• Hou Po 6 grams
• Hong Hua 9 grams

Notes on decoction of ingredients

Always soak all herbs for at least 10 minutes prior to introduction into the cooking pot. Try to use earthenware when possible, or glazed pots (I use a ceramic-coated cast iron dutch oven). Make sure the cooking temperature is at most on medium heat (it should only gently bubble here and there). I first cook the tonics with 6 cups of water for either an hour or until the liquid is down to 3 cups or half the volume–whichever comes first. Just before this is up, soak the Xiang Fu and Hong Hua together for at least 10 minutes and then put them in there with another 3 cups of water (so you’re back to 6 cups total). Then cook that until it’s just about back down to 3 cups again, and then add the Hou Po (soaked) for no longer than 15 minutes. This is because it contains several volatile oils that can evaporate if cooked too long and/or hot. I cook mine for 10 minutes–right on the mark. These processes yields maximum results. Back in the day, I would cook two days’ worth and put in mason jars for easy administration (dose is 1 cup x3 daily). Whenever you heat a dose up, always use the stovetop and NEVER use the microwave. This will rupture the medical constituents of the decoction and render it useless.

Also, on a last note: don’t use pills. These have added strain on the spleen and stomach. It’s my professional opinion that you’re too weak for these yet. You need to decoct your formula for around 2-3 months–and it will definitely change as your body gradually heals. In my clinical practice, I would veer from using tinctures during Yin Fire episodes as well. Also, if and when you receive acupuncture, request that they also supplement the liver (and possibly also the kidney) in addition to the treatment protocol, which will most likely focus on dredging the liver channel (which may feel nice for a while but make you hurt much worse afterwards). Your liver needs supplementing AND coursing simultaneously so that the stagnant, old blood can be dredged while new, healthy, and active blood replaces it. This is the precursor to the healing of your spleen channel–which takes a bit longer to resolve. Your kidney will be the last organ system to resolve if the source of your rebellious fire is the lifegate （命門）.

I hope this helps you in some way. I wish you the best in healing. Much love.

Thank you, I will try that.

I would personally be weary of dredging the liver. Make sure you do not have true deficiency of the liver channel underneath all that stagnation, because if you do and you take Chai Hu Shu Gan Wan you will create more problems for sure. Build first, rectify once that is attained (or simultaneously–and very carefully). You should be checking out information on Li Dong-Yuan and Gu conditions.

I would also like to add that Goji is cloying so be very mindful when including it in a treatment regimen wherein a weak spleen is concerned. Personally I would omit it entirely until your spleen function is a bit stronger.

If you have constipation regularly, you could use Dang Gui, or a combination of Dang Gui alongside Hong Hua. Only thing is it’s hard on the spleen when taken long-term and has to be balanced in a formula so that the spleen tonics can do their thing with drying the middle. The trick with Yin Fire/Gu patterns is that you have to do a lot of things at once: tonify the spleen (dry the middle), mobilize the blood, and nourish/rear the new blood in its place.

Spleen dampness can manifest as a lot of things. Dysbiosis (candida falls under this category) is one such manifestation of damp-heat in the spleen channels but it can start in other channels as well. I just think that the spleen is the crux of your issues. Secondarily, a deficient liver exacerbates everything into all of the ailments you experience.

Build your formula up like the food pyramid (regarding dosages and number of each used in the category); at the base put your spleen tonics, in the middle aid the liver and nourish the blood, and at the top you can add like one or two qi rectifiers. In the most severe cases, qi rectifiers are omitted since they consume qi. You don’t ever want to be consuming qi when there is deficiency in those channels affected.

Two points:

(1) Traditional Chinese Medicine (TCM) works synergistically; this is to say that one needle on one acupoint or one herb taken on a regimen is not part of TCM philosophy nor practice. The energies of your body need to work in harmony, and due to the complexity of biological processes then treatments must simultaneously address everything going on.

Basically, TCM is the original (read: oldest form of) functional medicine.

(2) I’m going to share with you some of my findings–in as brief a manner as I can because there’s a lot on this topic: the correlation of dampness leading to heat and the presence of a diet rich in oxalate compounds with a high degree of intestinal permeability and/or dysbiosis. Dybsiosis is an imbalance and/or absence of essential bacteria and microorganisms in the intestinal tract. This leads to the condition of “leaky gut,” or when the immunological response is heightened and inflammation is concentrated in the submucosa (and sometimes even the muscular layers as well) because nutrients can’t be absorbed properly or at all. This causes the villi to erode over time and exacerbate gut disease. Ever hear of naturopaths or functional medicine practitioners talk about how all illness begins in the gut? Now, do you think there’s a coincidence that most patterns in TCM among chronic patients exhibit spleen deficiency as the crux of all other patterns? Eureka.

The reason this all relates to cardamom is because many herbs (including cardamom) originating from nuts, fruits, and or seeds contain the highest concentrations of oxalates in nature. Oxalates are normally broken down via the shikamate pathway (a biochemical metabolic process) which is mediated by a variety of bacteria species. If someone doesn’t have enough of the species or the proper variety of them, then this pathway gets compromised. Oxalates are very sharp compounds–when viewed under a microscope these (mostly) calcium crystals are shaped like knives with a texture similar to fiberglass. Would you eat fiberglass? That’s essentially what’s happening to a person with leaky gut if they eat spinach, wheat, beets, bone broth, and nuts–to name just a few. Watching my dietary intake of oxalates alongside supplementation of adequate forms of B6 and lysine was crucial to my own success.

How does oxalate intake and TCM relate? Let’s go back to what I was saying about dampness encumbering heat: Through meticulous study, I’ve found that herbs which have a contraindication of exacerbating dampness (especially in the lower burner) and/or cloying yin tonics have the highest concentration of oxalates. ANYONE with intestinal disease will not heal from a typical herbal regimen unless this concern is addressed properly. Intestinal disease is likely far more complex and commonplace nowadays than it was during the Tang dynasty.

Goji berry is one of the herbs with the highest concentration of oxalates, next to Da Huang (rhubarb). Asparagus is loaded with these as well (Mai Men Dong and Tian Men Dong). Di Huang has a lot. Turmeric has a lot. Ginger has some. The list goes on and on.

When you examine the functions of these herbs, you begin to notice a pattern: herbs that have more oxalates than others typically have contraindications surrounding dampness leading to heat or heat exacerbating dampness. It’s important to understand that although some of these herbs are cold in nature and may even expel heat (Da Huang for example), if there is an underlying qi deficiency then using these will provide temporary relief with a recurrence of symptoms that are then worsened, because emptiness creates heat as well, and dampness likes to fuse with heat. It then becomes a self-exacerbating cycle–and this is why Gu patterns and Yin Fire scenarios have always been noted as particularly stubborn and complex issues that demand a thorough understanding of all disease patterns and their relationship with other patterns, as well as an appropriate treatment regimen.

Also, certain mineral compounds will bind to dietary oxalates, becoming complexes. These complexes are then expelled as waste, thus preventing a great deal of oxalates from becoming absorbed by the villi of the small intestine and therefore rooting inflammation. I personally take calcium citrate powder or juice a few citrus fruits in stir fry now and then–especially if I eat a high-oxalate meal. Interestingly, in TCM many mineral powders like Long Gu or Gui Ban contain compounds like these, and have properties which anchor the yang to the yin–in Gu, the main cause of gut sagging or bloating is because yin fluids downbear and the yang upbears, causing a whole myraid of nasty symptoms including chronic fatigue. It’s interesting that a yang-anchoring medicinal also functions to complex oxalates in the body. It’s a fascinating and enlightening relationship.

It depends on what your levels are now, but more than likely you’re deficient with both nutrients. There are several herbs that contain either one, the other, or both nutrients (ironically, Goji berry comes to mind) but I would have to go back and reference my materials. I’ll get back to you on this.

Fleeceflower (He Shou Wu) is superb at eliminating pathogenic yeasts–and that’s only a single herb. I’m sure that many other ingredients mentioned have antifungal properties–especially wherein they are combined.

You may be sleepy from the peony because it is a mild sedative (why it shouldn’t be taken for longer than 3 consecutive weeks)–I put a * next to this on my message above with the formula suggestion. It could also be the resolution of a lot of stagnation, and providing a better connection between the heart and kidney channel. A lot of patients with insomnia and restlessness more pronounced before bedtime exhibit a disconnect between the heart and kidneys. Once it’s more reestablished they can feel drowsy when they need to feel drowsy naturally.

You have real ginseng in your formula? That’s expensive stuff! The wonderful thing about Cang Zhu is that it works so well to boost the spleen and free up the lower burner from dampness accumulation that exacerbates a lot of liver stagnation issues and pathogenic fire. You can eliminate the “food” source of yin fire (dampness) and “starve” out the pathogen. Your stamina is low because you need time to regenerate the kidney channel. Once your liver channel gets supplemented with new, healthier blood to replace the old, stagnant blood you will feel much better. Du Zhong is amazing at this–it nourishes the liver and improves the yang function of it simultaneously. When you add the perfect dose of Hong Hua in the mix, over the period of about a week you’ll see amazing improvement in the liver channel. The liver is often always the most receptive channel to herbal treatment that specifically targets it.

Why are you exercising with blood deficiency? I wouldn’t exercise if I were you until this is remedied. There’s another thing I want to point out about herbal pills: I would say 9 times out of 10 that the doses of the herbs used in such products is only a tiny fraction of the effective amounts needed in order to be considered medicinal. Certainly there are always benefits to the consumption of certain herbs at any amount, but this is not to be confused with such doses as having any medicinal properties. Ginseng is about $100/pound the last time I checked, and I would definitely not be surprised if it’s much more expensive now. This leads me to question the effective dose of the ginseng contained in the capsules you purchased. For example, the minimum effective dose of ginseng is 3 grams per day (1 gram each dose). I highly doubt your capsules contain anything near to this amount. Before I studied TCM I also took ginseng as a supplement–if you look on the back of the label, it will probably state that several pills are the serving size. Therefore, if you aren’t getting near the effective dose, it’s pretty much just wasting money. You would be much better off focusing on your diet while taking no herbs whatsoever. That being said however, your best-case scenario is still a dietary assessment alongside herbal administration.

" Chronic fatigue", isn’t a TCM diagnosis is it? Can you be more specific about the signs and symptoms? Some of what you’ve said suggests kidney yang deficiency, some spleen deficiency, some lung yin deficiency, some blood stagnation and some disharmony between heart and kidney (at least these are the possible patterns that come to mindt), but really this is whistling in the dark. Tell us more!

Oh, right, no other symptoms. So you’d naturally think of Qi and Blood
deficiency and if it were me I’d probably just use Ba Zhen Wan for a while
and see how I respond.

But maybe it’s a bit more complex. Can you say what sort of pain occurs in
the chest? Is it sharp and stabbing, like a stitch because you are short of
breath, or something different?

And what about the signs? You said the tongue was pale with a white coat
right? Is the coat thin or thick, dry, wet, greasy etc? Any cracks or
depressions in the tongue? Is the tip or are the edges swollen or red? Any
blue under the tongue? What is the colour of your skin (pale face maybe)?
Are your lips or nails pale? What about digestion, elimination and sleep
signs, are they all normal? I think you said somewhere that your feet are
usually cold Any other cold (or hot) signs when not exercising)? Any
spontaneous perspiration? Depression?

And what about the pulse? You said you are not an expert (neither am I) but
you can perhaps say if it feels week or strong, superficial or deep, fast or
slow.

Chronic fatigue and spontaneous sweating indicate Lung / Wei Qi deficiency
and burning feet on exertion suggests also some Lung (or Kidney) Yin
deficiency so, if that were all, I would consider either Yi Ping Feng San
for the Lung Qi deficiency or Sheng Mai San for Lung Qi and Yin deficiency.

Pale skin and nails indicated Qi and blood deficiency (and check your lips
outer and inner, if they are also pale it confirms blood deficiency). A
mottled pale pink (not white) tongue body indicates Blood (rather than Yang)
deficiency and the swelling of the tongue body and edges usually occurs with
blood (as well as Yang) deficiency I believe so, again, if that were all, I
should conside Ba Zhen Wan or similar to tone the blood.

I think the aching in the chest (if, as I suppose, it goes away quickly when
you rest) is just an acute Qi deficiency sign from over exertion.

BUT the tongue also shows thick, moist looking, yellow coat over the
spleen and stomach area with areas of apparent erosion where the heat is
most intense; the pulse being strong and superficial also suggests heat as
does constipation. It may well be that that is the heat that is consuming
your Qi and blood and, probably, was the cause that toning the tonics you
took have not worked. In any case it is a pathogen that should be cleared
first before toning.

If that’s the case the next question is, is the heat an excess heat or are
we looking at Stomach Yin deficiency? I’d identify the digestive and
constipation signs more carefully e.g. is there heat on defaecation or any
pus or blood in the stool, is there strong odour or is the stool pale and
soft etc. Is there any regurgitation of food, nausea, vomiting acid
reflux, pain, etc is the appetite poor, not able to eat much, any obvious
heat, swelling after eating etc.

I hope these observations are helpful and I am very happy to continue this
if you find it helpful but I also hope someone else will comment on my
observation because I’m definitely still learning.

So it seems we have Qi deficiency with spontaneous perspiration, which,
naturally, is worse on exertion including eating, mild blood and maybe some
yin deficiency, heat in the centre with Stomach Qi counter-flow on occasion
and dryness in the intestines (presumably caused by heat in the Stomach)
with a pale (pink) swollen tongue, a thick yellow/white coat and a strong
and fast pulse.

I think I would diagnose Qi and Blood deficiency with dryness of intestines
and, initially, would treat with Run Chang Wan for habitual constipation
with Yin and Blood Deficiency and Qi stagnation, which formula will also,
inter alia, clear heat, drain damp and direct the Stomach Qi downward,
together with Ba Zhen Wan for the constitutional treatment, to tonify Qi and
blood and prevent loss of fluids through spontaneous perspiration Ma Zi
Ren Wan would be stronger for heat clearing but I think, because of the Qi
deficiency, it might be too strong).

What do you think?

Run Chang Wan has only a little Da Huang, it also contains moisturising,
blood nourishing and Qi regulating herbs and the idea is to take it together
with a Qi or a Qi and Blood tonic so I really think it would be safe.

However, you must of course make your own decision about that.

Qi Gong is a great healer.

Best of luck with your recovery.

It’s clear as day that you have Yin Fire （陰虛火旺）. Look into Li Dong-yuan and his treatment protocol. It’s very complex and difficult to treat. But you have to treat it now before it worsens. You can be ill with this sort of thing indefinitely until it takes your life eventually. Here’s a few points:

1. The reason for you having blood deficiency after the pills can be many-fold, but generally if you try to boost the spleen with warm, drying herbs it will worsen everything in the long run if you have Yin Fire–since it feeds the pathogenic fire.

2. Weak and tired after food is absolutely spleen deficiency. The heat from overexertion on very edges of the appendages is a sign that the collaterals are overwhelmed with pathogenic fire, since the finger tips and toe tips mark the end/beginning of the meridians.

3. You’re right about herbs that are too drying. In fact, with Yin Fire it’s important to nourish the blood and yin fluids since the pathogenic fire feasts ravenously on these. The trick is to not overwhelm the spleen by having a treatment course with thick, cloying yin tonics (which most use). You have to replenish yin and blood very carefully while simultaneously clearing heat where it originates and also continue with drying the spleen.

4. Ba Zhen Wan will make you much worse–in time. This is because it leaves out a crucial factor of resolving Yin Fire: clearing heat in the lower burner (typically originating from the kidney and almost always spreading to the liver and into the blood, which is why total systemic inflammation can occur in many).

5. Notes on the tongue: the area of heat is not in the spleen/stomach area but rather in the kidneys and creeping up into the middle burner. The fatness everywhere is due to the damp stagnation in all channels due to concomitant qi deficiency, blood deficiency leading to stagnation, and pathogenic fire consuming the yin fluids where they coagulate into phlegm “pockets.”

6. Can you be much, much more detailed on the pulses? (i.e. all twelve organs and viscera)

7. If the quality of superficial is at most or all positions of the pulses this means that what little yang you have has separated from the yin and instead upbears while the yin downbears–when it should be vice-versa in a healthy individual. As soon as the yang separates from the yin chronic illness takes root.

8. Why on earth would Yu Ping Feng San be used with such a prominent heat case? Bad bad idea. The honey-cooked Huang Qi is extremely cloying in nature–even for someone without much dampness and especially over an extended period of administration. The same goes for Sheng Mai San; Mai Men Dong is super cloying and is pathogenic fire’s wet dream while Wu Wei Zi traps lung qi and adds even more fire to the lifegate! Stay far, far away from these formulas.

9. There is no “onion;” although it’s widely accepted in our practice to first clear pathogens prior to tonification, this does not hold true with Yin Fire scenarios. The fire is spawned from deficiency, so it must be addressed simultaneously. There is no exception.

10. If you take Run Chang Wan, I bet you $100 that you go from constipation to diarrhea with a pale color and undigested bits of food.

11. Any formula that directs the stomach qi downward without addressing the separation of yin and yang will cause abdominal distention and a worsening of fatigue (especially after eating) in the case of Yin Fire.

12. DO NOT EVER TAKE DA HUANG (RHUBARB). It’s incredibly damp, hot, and a horrendous idea for someone with qi deficiency to your degree and especially contraindicated with Yin Fire.

13. Your weakness “schedule” tells us some things: these hours from noon to mid afternoon are dominated by the fire element (Wu Xing reference). Fire can rebell against Earth; read: pathogenic heat will overcome the spleen and stomach. 7-11 PM precisely aligns with Water. Water can quell the blazing inferno going on inside you to allow for some momentary relief.

Yin Fire takes comprehensive diagnosis and wholistic treatment–anything short of this will do absolutely nothing for the patient, and never can. It’s very tricky business, but fortunately it’s absolutely curable and typically requires a LOT more arsenal than Qi Gong alone (unless you’re a Shaolin master ).

Dear Xiaomei,

According to the Chinese Clock 11-00-01.00 p.m. is Gall Bladder Time, when
GB receives most and heart receives least Qi: 07.00 - 09.00 p.m. is CX
(Pericardium) time when CX receives most and stomach receives least.
09.00-11.00 p.m. is TW time when TW receives most and Spleen receives least.

So it seems you feel most fatigue just as heart Qi is at its lowest point
in the daily energy cycle and you feel most energetic when spleen and
stomach are at their lowest point in the daily energy cycle.

That makes sense to me because the tongue seems to be saying that there is
heat in the centre (spleen and stomach) and it seems probable that you
would indeed feel better when centre Qi is least.

It would be instructive to know how you feel between 07.00 am and 09.00 am
and 9.00 and 11.00 a.m. when the Stomach and Spleen are at their respective
high points.

Regards,

Sandra

So between 7 a.m. and 11 a.m. when Spleen/Stomach are naturally most
energized you are, nevertheless, still very fatigued. I suppose that could
be because the centre is too weak to respond as it should to the influx of
Qi, but I greatly doubt that. It might however, as already suggested, be
due to heat in the Spleen/Stomach being exacerbated by the influx of, and
burning, Qi. It might also be due to the fact that CX / TW, which are
naturally least energized at this time, are deficient or obstructed, so that
the Qi does not, “arrive”, in the Spleen/Stomach when it should.

The fact that you feel most energized when CX / TW are most energized, even
though at that time Spleen and Stomach are least so, also suggests that we
should look to the circulation.

The fact that you feel least energized between 11 p.m. and 01 a.m. is
perhaps just due to the fact that heart is naturally least energized then.
However, GB is most energized at that time so it might be worth considering
LV blood deficiency leading to stagnation and heat in the centre. I know
you don’t have s/s of these condition but it would be consistent with the
blood deficient appearance of the tongue and the sign in the nails.

Kind regards,

Sandra