Credit: Kamwo
The Practical Herbalist #03: Gui Zhi in the Clinic
INTRODUCTION: The Practical Herbalist is not a list of shortcuts nor a substitution for a classical understanding of prescribing herbs from the Flavor and Nature paradigm that defined our medicine. It expects the reader to have this as a foundation and assumes this knowledge going forward. If the reader is new to the concept of prescribing from the Flavor Nature perspective that was established in the Nei Jing, or would like refreshing on its core principals, they are directed to the four excellent articles by JulieAnn Nugent-Head on classical herbalism published by the Journal of Chinese Medicine. If they wish more information, they can also watch her 3 hour introductory video The Nei Jing as Our Guide to Herbs or her complete online training program, The Classical Herbalist: an In Depth Training Course. Both are available on the Association for Traditional Studies’ online teaching platform: https://association-for-traditional-studies.teachable.com. Simply search for them in the search box to find them among our many online courses.
By far the herb that I prescribe the most frequently and in greatest quantity in my practice is Gui Zhi. Classified as Warm and Acrid, I discussed in Practical Herbalist #02 that it is physically warm and thus moves Yang, as opposed to moving Yang and thus being classified as Warm. Being warm and acrid, it goes into the body and dispels cold with its warmth, and breaks apart tightness and blockages with its acrid Qi. This makes it one of the most versatile herbs to warm the flesh, reach the extremities, and dispel stasis that is keeping flow from happening due to poor circulation. While I of course consider and do use it for patients coming in with the common cold or flu, it is the work horse I rely on in my formulas for internal conditions, musculoskeletal issues, masses, as well as auto-immune compounded by cold weak constitution leading to pain.
Classically, Zhong Zhongjing shows us how to pair Gui Zhi to accomplish what we need. We see it with Mu Li and Long Gu when we need to warm the lower Jiao and Ming Men; we see it paired with Fu Ling when there are masses or a concern of Ben Tun; we see it paired with bai shao when the Ying (Nutritive Qi) and Wei (Defense Qi) have lost harmony; we see it with Fu Zi to rescue Yang; we see it paired with Ma Huang both in large and halved doses to resolve cold; with Ge Gen for tight muscles; balanced with Shi Gao to warm without creating sweat; with Gan Cao for an exhausted heart condition; with Yi Tang to nourish weakness and cold; with ginseng when a person is weakened from purging; with Bai Zhu, or with Da Huang to address stagnation in the middle... It appears in cold formulas, hot formulas, to directly attack the Pernicious Qi or to protect the Upright Qi of the person.
This is just in the Shanghan Lun, and not addressing its uses in the Jin Kui nor by the many other doctors through the ages who made use of this herb. I once found myself a part of a lunch conversation between two professors at a Chinese medicine university in China. Both professors, one saying that he never had a reason to prescribe Gui Zhi as in his specialty no one ever came in with a cold and the other trying not to spit out his food at a statement which indicated a clear lack of any study of the classics. Even western medicine is recognizing cinnamon for its use in heart patients, and naturopaths are excited about its antioxidant polyphenol properties, anti-inflammatory properties, sensitivity boosting for insulin, anti-diabetic effects, and neurogenerative diseases. It is now also in studies for cancer prevention. Clearly, if used correctly, Gui Zhi is a very versatile herb with wide reaching applications in eastern or western medicine.
For us as Chinese medicine practitioners, what is important with Gui Zhi is correct pairing. It is warm acrid, and if we are not careful with the companion herbs in our formulas, we can accidentally dry our patients out and aggravate a dormant or current HSV flare or any floating heat conditions. But rarely is the Gui Zhi to blame, as by itself it is not that drying but with other herbs can have a strong synergistic effect. With a flexible understanding of flavor and nature to guide what we want to happen and where we want it to happen, we can be sure we get the results we want without the side effects we don’t. By looking at pairings from the past for our sick patients, we can learn to use the acrid warm of Gui Zhi to travel without being too warm or moving up and out to the surface. Paired with cool sour Bai Shao, we can warm the muscles while holding the fluids in. Patient still cold but already more hot and drying out? Replace Bai Shao with Cold Sweet Zhi Mu in our Gui Zhi Tang to not just protect the Yin, but replenish the Yin. Patient afraid of wind but not showing any sweating or Tai Yang heat (please reread the first 12 lines of the Shang Han Lun if you are confused how Gui Zhi might be used when there is heat in the Tai Yang)–Replace the cool sour protector of fluids Bai Shao with a warm sweet acrid herb to help the Ying such as Dang Gui. If we look up traditional uses of Dang Gui, one is relieves the surface!
In terms of internal conditions, pairing it with heavy shells allows us to warm and anchor the Spirit at the same time, which can be otherwise tricky in minute pulse patients who seem hot and are manic but are, upon inspection, happily wearing lots of clothes and are easily cold. Has that mania moved to perhaps agitation and no fear of cold but the pulses remained minute? Paired with Da Huang, we can clear heat yet protect a collapse of Yang by the strong purge in a weak constitution undergoing what looks like an excess flare. Masses, fibroids, cysts due to cold in the lower jiao? Gui Zhi brings the warmth that allows the saltiness of the shells to shrink the masses as well as invigorates the blood when we are at a point of wanting to knock them out with bitter Da Huang. These same herbs along with Gui Zhi treat both these conditions if further paired weighted correctly, which means we can treat the Spirit or the body with Gui Zhi as our primary herb to do the job.
Arthritis? Paired with Jiang Huang, or Wei Ling Xian or other warm traveling herbs ensures the channels and flesh are warm enough that there is good flow to and away from the joints. The Chinese concept of 吐納 (expelling the turbid to bring in the new) is well known in Qigong practice but somehow seems to have not crossed over into modern herbal formula strategies. In Chinese, we must first ensure the old is moved out before we can bring in new vitality. We understand this in the theory of enlivening blood (breaking down old, stuck blood) before tonifying the blood, but we do not recognize this as a mechanism which is true across all aspects of our health and treatments. As Gui Zhi warms the channels and encourages flow with its warmth, we are able to dislodge much of the stuck debris in the joints so new flow can come in. 通則不通不通則痛 is another classic expression whose fundamental role in the clinic is underestimated when writing formulas. It means: When there is flow there is no pain, and where there is no flow there is pain. This is true for hot painful swollen joint arthritis as well as cold painful arthritis. The Gui Zhi provides the warmth to create the flow, the accompanying herbs, hot or cold, will then move out the old and allow the new to come in. I mentioned in the Practical Herbalist #02 how Ma Huang was paired with Shi Gao and Yi Yi Ren to treat arthritis—so can Gui Zhi be paired with cold herbs to be sure there is good exit and entry to the areas afflicted. If we need movement to and away from any part of the body, Gui Zhi is an ideal herb to do just that.
What if we need warmth but want that warmth to stay put? We pair our Gui Zhi with sweet herbs. Sweet slows, which allows the Gui Zhi to settle in and enliven without scattering due to its acrid nature. Here, we see classic combinations with Zhi Gan Cao or Yi Tang to nourish the heart or the spleen. I have never done a research study, but I think we would be hard pressed to find any other single herb (perhaps Gan Cao excepted) that is so widely paired with such different flavor and natures to address such a wide variety of internal and external conditions. It is even key in external liniments and soaks.
This does bring up a question I am often asked by observers in our teaching clinic. Why do I use Gui Zhi and not use Rou Gui? This is because 20+ years ago I had the good fortune and bad luck of discovering what true Rou Gui was. Traditionally, good Rou Gui was known as 紫油肉桂, or Purple Oil Rou Gui. Dragging down this Rou Gui with a finger nail showed a purple oil oozing out. This, according to my teachers, was critical for successful use of Rou Gui in internal formulas. The oil balanced the heat to bring warmth to the lower jiao without creating irritation or flaring heat signs like HSV. Without the oil, they preferred to use Gui Zhi well paired to avoid contemporary Rou Gui’s燥, or drying/aggravating nature. The loss of the oil meant that it had lost its Yin within Yang balance and was irritating. I do continue to use Rou Gui in external soaks and liniments, but find it much easier to avoid overly drying my patients with Gui Zhi for internal formulas. Interestingly, I was discussing this with a nutritionalist years ago who laughed and told me I was simply buying the wrong Cinnamon. It seems that there is Cassia cinnamon which we assume to be Rou Gui, but it is known for having negative properties in naturopathic/nutrition circles. But there is a better variety known as True Ceylon which has a different make up and is not irritating/toxic. I have never gone to the effort of sourcing freshly harvested True Ceylon to see if it would have the purple oil I experienced so many years ago, but the writings on the toxicity of Cassia cinnamon in large doses does match the old doctors’ concerns with currently sourced varieties being too irritating to use.
I have made Gui Zhi sound like a miracle herb, and we do use it in our clinic with miraculous responses from a wide variety of patients. But I do have to put in a caveat: we use traditional Shanghan Lun doses to get the great results we do. This means that a standard dose an observer might see in the clinic is 15 to 45 grams, with occasional need to follow the 桂枝加桂Gui Zhi Jia Gui formula in which there are 5 兩 Liang of Gui Zhi, or roughly 75 grams. The doses currently listed in the English language teaching texts of 3-9 grams can and will occasionally be successful, but for acute or severe conditions, we do need to consider using medicinal amounts. I am not encouraging anyone to be reckless, and I always suggest starting small and working up if needed. But, realistically, if the smaller doses could cure bigger illnesses, most people who put cinnamon in their oatmeal in the mornings would never get sick.
Andrew Nugent-Head
February 07, 2019
© Andrew Nugent-Head, reprinted with permission only