by Chris Powell
Chái líng tāng (Bupleurum and Poria Decoction)

Chái líng tāng (Bupleurum and Poria Decoction) or Sairei-to in Japanese, is a formula that appears in a 1773 text by Shên Jïn-Ào (沈金鏊). His book, Master Shen’s Book on Revering Life, (Shên Shì Zün Shëng Shü 沈氏尊生書), was his work on “revering life” with the use of Chinese Medicine (Ao, 1775; Chen 2006). There is speculation that this formula was perhaps one of Zhang Zhong-Jing’s masterful creations, but that to date has at best been difficult to prove. Nevertheless, the creation of this formula has had an immense impact on human health for the past several hundred years. This formula is not widely taught in American acupuncture schools, and when mentioned is usually not given much attention. However, to those who have studied this formula it is obvious as to the power and the capability of this particular combination of Shang Han Lun formulas, especially when considering modern clinical applications.

Chái líng tāng (Bupleurum and Poria Decoction) is a brilliant combination of the formulas xiǎo chái hú tāng (Minor Bupleurum Decoction) and wû líng sân (Five-Ingredient Powder with Poria). Xiǎo chái hú tāng (Minor Bupleurum Decoction) is the archetypal Shang Han Lun formula used to harmonize the exterior and interior to relieve a shaoyang presentation. Additionally, it dispels water stagnation, phlegm accumulations, and nodules.

Many practitioners generally consider xiǎo chái hú tāng (Minor Bupleurum Decoction) when treating manifestations of disease within the shaoyang confirmation, but it is interesting to note that wû líng sân (Five-Ingredient Powder with Poria), also treats diseases considered half exterior and half interior through the unblocking of the water transport mechanism. In shaoyang disease for example, hypochondria pain, bitter taste in mouth, frequent retching, heart vexation, lack of desire to eat, or alternating sensations of heat and cold often lead practitioners to immediately think of using xiǎo chái hú tāng (Minor Bupleurum Decoction) as the treatment of choice. The shaoyang has the least yang of three yang channels. It is here that disease progresses from the exterior yang confirmations towards the interior yin confirmations, and the subsequent transformation of heat from fevers to cold from deficiency (Mitchel et. al., 1999).

As has been pointed out in previous works about shaoyang syndromes, it is essential to remember that a shaoyang disease is neither an exterior nor an interior pattern. It is one that arises in the space between the exterior and interior; thus a pivot wherein disease can transfer from the yang confirmations to the yin confirmations with the shaoyang being the pivot of change between the two. The Gallbladder and the Sanjiao are the organs associated with shaoyang and when impaired, the Gallbladder’s free coursing of qi and the Sanjiao’s regulation of water pathways in the body will produce “impairment of the pivot mechanism” (Mitchel et. al., 1999).

Disruption of the water regulation can also be commonly seen in the clinic in situations where an exterior evil was not eliminated, and allowed to enter from the channel level into the respective taiyang (Urinary Bladder) organ. This disruption of the regulation of the water pathways leads to inhibition of urination with mild heat and thirst. Water begins to build up in the lower burner inhibiting urination and producing more heat, therefore thirst begins to develop. The use of wǔ líng sǎn (Five-Ingredient Powder with Poria) is essential as it treats the accumulation of water in the interior, and at the same time treats exterior conditions, such as headaches and fever. Wǔ líng sǎn (Five-Ingredient Powder with Poria) affects both the taiyang channel and the taiyang organ levels.

Let us analyze the two original formulas separately and discuss their individual herbs and herb combinations, or dui yao, and the actions they perform.
Dui Yao

First, xiâo chái hú täng (Minor Bupleurum Decoction) is a formula with a long history in Chinese medicine. It is comprised of:
. SHL modern
chái hú (Bupleuri Radix) 24g [12g]
zhì bàn xià (Pinelliae Rhizoma preparatum) 9g [9g]
huáng qín (Scutellariae Radix) .5c [9g]
shëng jiäng (Zingiberis Rhizoma recens) 9g [9g]
rén shën (Ginseng Radix) 9g [9g]
zhi gän câo (Glycyrrhizae Radix pr) 9g [9g]
dà zao (Jujubae Fructus) 12 pc. [4 pc]

In looking at herbal prescriptions, it is through the actions of the combination of herb pairs that we understand the entire formulation, and the effects it has as a complete formula. First off with the combination of chái hú (Bupleuri Radix) and huáng qín (Scutellariae Radix), we can see that one dispels while one drains respectively. Chái hú (Bupleuri Radix) upbears yang while huáng qín (Scutellariae Radix) downbears turbidity. This particular combination dispels external evils while also draining internal evils. When chái hú (Bupleuri Radix) and huang qin (Scutellariae Radix) are cooked together they harmonize the shaoyang level, clear the Liver, and eliminate dampness and heat of the Liver and Gallbladder (Chen, 2006).

The dui yao pairing of zhì bàn xià (Pinelliae Rhizoma preparatum) and huáng qín (Scutellariae Radix) are interesting. First of all, zhì bàn xià (Pinelliae Rhizoma preparatum) is warm while huáng qín is cold. Zhì bàn xià (Pinelliae Rhizoma preparatum) is acrid and frees the flow of qi, while huáng qín (Scutellariae Radix) is bitter and drains heat. When these two are combined they harmonize and re-establish interaction between yin and yang, clear heat and drain fire, harmonize the Stomach, stop vomiting, and scatter nodules.

When dà zâo (Jujubae Fructus) and shëng jiäng (Zingiberis Rhizoma recens) are combined, they move wei qi, nourish ying qi, harmonize the defensive wei and constructive qi, fortify the Spleen and harmonize the middle Jiao.

In the combining of chái hú (Bupleuri Radix) with rén shën (Ginseng Radix) we see an interesting effect. Chái hú (Bupleuri Radix) prevents the tonic effects of rén shën (Ginseng Radix) from retaining the pathogen in the body while rén shën (Ginseng Radix) prevents the dispersing effect of chái hú (Bupleuri Radix) from damaging qi.

Turning now to a look at wû líng sân (Five-Ingredient Powder with Poria), the formula itself regulates water circulation and dispels dampness. It warms yang and disperses water accumulation. Wû líng sân (Five-Ingredient Powder with Poria) also regulates disorders at the level of both the taiyang channel and organ, thus the important exterior and interior treatment spoken of earlier. Wû líng sân (Five-Ingredient Powder with Poria) is composed of the following herbs:

bái zhú (Atractylodis macrocephalae Rhizoma) [9g]
zé xiè (Alismatis Rhizoma) [15g]
zhü líng (Polyporus) [9g]
fú líng (Poria) [9g]
guì zhï (Cinnamomi Ramulus) [6g]

There are two notable dui yao combinations in wû líng sân (Five-Ingredient Powder with Poria). In the combination of bái zhú (Atractylodis macrocephalae Rhizoma) and fú líng (Poria); bái zhú (Atractylodis macrocephalae Rhizoma) supplements while fú líng (Poria) percolates. Bái zhú (Atractylodis macrocephalae Rhizoma) dries while fú líng (Poria) disinhibits urination. When combined, they reinforce each other’s ability to supplement the Spleen and dry dampness. The other important combination within wû líng sân (Five-Ingredient Powder with Poria) is that of fú líng (Poria) and zhü líng (Polyporus). These act as the deputy herbs and strengthen the diuretic effect of zé xiè (Alismatis Rhizoma).

Modern Research

There is some controversy about modern chemical analysis of herbal prescriptions by some traditionally trained herbalists and the use of these formulas in modern clinical settings, usually in a hospital or medical research institution. However, since a primary method of pharmaceutical research and development is to synthesize drugs from the constituents of individual herb, this allopathic approach to the study of Traditional Chinese Medicine herbs and formulas is apparently here to stay. Because so much attention is paid to these single herbs and their chemical constructs, there are practitioners who run the risk of just combining herbs in prescriptions based only on modern research models, many of whom find these “formulas” will not necessarily perform well in the clinic. Chinese herbal medicine has centuries of experience and results with combinations based upon Chinese medical principles. When those principles are abandoned in favor of modern chemical analysis, the results may be tenuous at best. However, when studying classic Chinese formulas and applying classical diagnostic principles while taking into account modern research, the results are much more interesting.

Chái líng täng (Bupleurum and Poria Decoction) is one such formula that has been the subject of considerable research, much of it quite impressive. In treating renal disease, this formula has much to offer. Many studies of diabetic nephropathy suggest the nephroprotective effects of chái líng täng (Bupleurum and Poria Decoction) (Guo Wai, 1990; 1991; 1995). It also appears to affect the amount of protein dispensed in the urine (Li, P. 1995). There was a landmark study in 1997 that demonstrated the suppressive effects of chái líng täng (Bupleurum and Poria Decoction) on monoclonal antibody 1-22-3 induced glomerular nephritis (Pathology International, 1997). This particular study became the catalyst for the continued research of chái líng täng (Bupleurum and Poria Decoction) in Japan for the treatment of serious kidney disease. The diuretic effect of chái líng täng (Bupleurum and Poria Decoction) has been studied and measured in research studies with not only lab animals, but in human trials as well (Fujitsuka, et. al. 2004). There are new studies currently underway in Japan studying the efficacy of chái líng täng (Bupleurum and Poria Decoction) for the treatment of most forms of acute renal disease since few treatment strategies exist for renal disease outside of organ transplant.

Much has been written about the use of xiâo chai hu tang (Minor Bupleurum Decoction) and liver disease, but there are three very specific studies concerning the use of chái líng täng (Bupleurum and Poria Decoction). One of the studies of note is an ongoing research program studying the effects of chái líng täng (Bupleurum and Poria Decoction) and alcohol induced liver damage. In 1991, these researchers discovered that the liver repaired itself rapidly with the use of chái líng täng (Bupleurum and Poria Decoction). In fact, the research suggests chái líng täng (Bupleurum and Poria Decoction) is more successful at healing the liver than xiâo chái hú täng (Minor Bupleurum Decoction), silymarin from milk thistle, xiäo yao sän (Rambling Powder), and even pharmaceutical intervention with Interferon 2 alpha. These studies were then applied to human trials with equal results. At the same time, researchers noticed that many of those in the study also suffered from chronic hepatitis. These individuals also began to show improved hepatic function and, through the use of liver biopsies discovered increased cellular repair of the liver (Guo Wai, 1991). These studies inspired a series of research articles based upon treating liver cancer (Hagiwara, A. et. al, 2002) showing the use of chái líng täng (Bupleurum and Poria Decoction) to reduce cancer cell and lesion activity while promoting healthy rebuilding of liver tissue.

Hagiwara and his team also found that bladder cancer is treated much more effectively with chái líng täng (Bupleurum and Poria Decoction) than those treated with xiâo chai hu tang (Hagiwara, et. al., 2002). These were based on rat studies that examined how tetraogenesis, carcinogenesis, and mutagenesis were all affected quite impressively with chái líng täng (Bupleurum and Poria Decoction). The therapeutic mechanism appears to be due to the combination of herbs and not one specific medicinal. One such effect appears to be that the herbal formula reduces tumor growth via increased activation of peritoneal macrophages, thus increasing phagocytic and lysosomal enzyme activity (Egawa Y, et.al. 1991).

Since many cancers and auto-immune disorders are generally thought to be a shaoyang disorder and treated accordingly, the use of chái líng täng (Bupleurum and Poria Decoction) appears to be more successful treating patients with that condition, than those treated with xiâo chái hú täng (Minor Bupleurum Decoction). However, the use of, or the combination of, classic formulas appears to be more successful (Yakigara, 2008) than those using only “modern” research oriented formula constructions based solely upon chemical constructs found in those herbs.

Turning to a completely different issue, a team of Japanese researchers found that use of chái líng täng (Bupleurum and Poria Decoction) induced ovulation in those women suffering from polycystic ovary syndrome (PCOS) (Atsushi, S., et. al., 1999). When using chái líng täng (Bupleurum and Poria Decoction) these researchers found a 70.6% induction rate, enabling the ovaries to produce viable follicles. They found that this herbal formula decreases LH hormone while normalizing the LH/FSH hormone ratio. There currently is a research project at the National Institutes of Health on PCOS based on the above protocol. Another study examined the use of chái líng täng (Bupleurum and Poria Decoction) and the common problem of recurrent miscarriages. This particular study found that women with recurrent miscarriage due to positive antiphospholipid antibodies had a dramatically reduced incidence of spontaneous abortions with the use of chái líng täng (Bupleurum and Poria Decoction), outperforming many other herbal protocols and even allopathic intervention (Takakuwa, K et. al., 1996).

For the past 20 years, many monographs have been published in China regarding the use of chái líng täng (Bupleurum and Poria Decoction) and autoimmune disorders. As allopathic medicine begins to categorize more diseases as autoimmune related, the use of Chinese Medicine will likely become more prevalent. Chái líng täng (Bupleurum and Poria Decoction) prepared as a single formula has been shown to be more effective treating rheumatoid arthritis, systemic lupus erythematosus, and ulcerative colitis (Guo Wai, 1993, 1994, 1995) than treating these disorders with xiâo chái hú täng (Minor Bupleurum Decoction) or wû líng sân (Five-Ingredient Powder with Poria) administered as separate formulas.

One of the most impressive of all studies was in the use of chái líng täng (Bupleurum and Poria Decoction) with organ transplant patients. In this landmark study, physicians used chái líng täng (Bupleurum and Poria Decoction) as an adjuvant therapy when patients received an organ transplant. What they discovered was startling– these physicians found that when using chái líng täng (Bupleurum and Poria Decoction) the survival times increased from days to months. These researchers then intentionally mismatched cardiac allografts in rats and found that even with mismatched tissue, the rat subject survived only seven days without the administration of chái líng täng (Bupleurum and Poria decoction), but the survival rate increased to 100 days with the administration of the formula (Zhang, Q, et. al., 2009). What truly stood out in this particular study is that when just one herb was removed from the formula, the survival rate dropped significantly.

The modern study of chái líng täng (Bupleurum and Poria Decoction) certainly has brought this formula to light over the past 20 years. A classic formula, most often used without modification, that has found its place in the modern era is being studied rigorously both in the United States and Asia. This formula, composed of two prescriptions commonly used by Zhang Zhong-Jing, has treatment significance with many diseases that do not respond all that well to allopathic intervention. With so many studies of individual herbs and their prospective chemical ingredients being published every month, it is important to not lose sight of the fact that the strength of Chinese Medicine lies not in the individual chemical components of those herbs, but to realize entire formulas constructed even 2000 years ago still hold the key to improving the health and life of a modern people.

ACKNOWLEDGMENTS

I would like to thank Travis Spire-Sweet for his exhaustive help in gathering research and pushing me to write as well as David Toone for his help in editing and helpful suggestions. Most of all, I would like to thank Michael Max for his gently applied pressure to write several articles for publication.

REFERENCES CITED

Atsushi, S, et al. Induction of ovulation by Sairei-to for PCOS patients. Endocrine Journal 1999; 46(1) 217-220.

Chen, J. & Tina Chen. Chinese Herbal Formula and Applications. Art of Medical Press 2009.

Egawa. Y, et. al: Chai Ling Tang as an oral adjuvant. International Journal of Immunopharmacology, 1991; 13(7):1031-1036.

Fujitsuka, N, et al: The diuretic effect of Sairei-to is mediated by nitric oxide production in pentobarbital anesthetized rats. Journal of Pharmacology Science 2004 Feb;92(2):185-191.

Guo, W. Monograph of Nephropathy from Foreign Medicine, 1989;11(6):18.

Guo, W. Monograph of Diabetic Nephropathy from Foreign Medicine, 1990;(5): 297

Guo, W. Monograph of Chronic Hepatitis from Foreign Medicine, 1991; 3:168.

Guo, W. Monograph of Alcohol Induced Liver Damage from Foreign Medicine, 1991; 13:31.

Guo, W. Monograph of Ulcerative Colitis with prednisolone from Foreign Medicine, 1993; 15(4): 25.

Guo, W. Monograph of Systemic Lupus Erythematosus from Foreign Medicine, 1994; 16(4): 25.

Guo, W. Monograph of Rheumatoid Arthritis from Foreign Medicine, 1994; 16(5): 25

Hagiwara, A, et. al.: Lack of enhancing effect of two kampo medicines, sho-saiko-to and Sairei-to, on a rat urinary bladder carcinogenesis initiated with n-butyl- (4-hydroxybutyl) nitrosamine. Tetratogenesis, Carcinogenesis, and Mutagenesis 2002; 22:41-50.

Li, P. et. al: affects of chai ling tang on protein urea in rat models. Journal of Traditional Chinese Medicine 1995, March; 15(1): 48-51.

Mitchel, C. et al: Shang Han Lun. Paradigm Publications, 1999.

Pathology International; Suppressive effects of Sairei-to on monoclonal antibody 1-22-3 induced glomerukarnephritis: Analysis of effective components. Pathology International 1997; 47:430-435.

Takekuwa, K et. al: Treatment for patients with recurrent abortion with positive antiphospholipid antibodies using a traditional Chinese herbal medicine. Journal of Perinatal Medicine 1996; 24(5) 489-94.

Zhang, Q, et. al: Prolonged survival of fully mismatched cardiac allograft and generation of regulatory cells by Sairei-to, a Japanese herbal medicine. Journal of Transplantation 2009; 87(12): 1787-1791.