Full title: “Discussions on Gui Zhi Jia Long Gu Mu Li Tang: Applications for Treatment of Trauma and Substance Abuse”
In this article, I introduce a formula that I have found very useful over the years in my herbal practice: Cinnamon Twig with Oyster Shell and Fossilized Bone, or Gui Zhi Jia Long Gu Mu Li Tang, which I refer to from here on out as Modified Cinnamon Twig Formula. I also give an introduction to a tradition of Chinese herbal practice that is at the heart of contemporary and classical East-Asian herbal practice. I will present the modern indications for the formula and, through case examples, illuminate some possible applications, some of which apply directly to the references in the text and others that rely on my interpretation of clinical findings.
Modified Cinnamon Twig originally appears in the Prescriptions from the Golden Coffer, or Jing Gui Yao Lue, written by Zhang Zhong Jing CE 220. Zhang Zhong Jing’s methods of treatment, outlined in Treatise on Cold Damage (Shang Han Lun) and in Prescriptions from the Golden Coffer, emphasize warming and supplementing therapies. Zhang Zhong Jing lived in an era of intense famine and his development and chronicling of this system was in part a reaction to what he perceived to be deleterious treatment of disease with purgation therapies.
To introduce and explore the use of Modified Cinnamon Twig Formula as a method for treating various expressions and origins of post-traumatic stress disorder (PTSD) and substance abuse, both together and separately.
While I have studied and used this formula for years, my interest in it was invigorated around eight years ago when I began studying the works of Zhang Zhong Jing with Dr. Arnaud Versluys through the Institute of Classics in East Asian Medicine and received a thorough explanation of its origins and inclusion in Jin Gui Yao Lue. Over the following years, I began to observe a few common patterns in individuals for whom this formula appeared to be strongly indicated. These observations were based on traditional methods of inquiry in East-Asian medicine, including pulse and abdominal palpation, constitutional assessment via observation of habitus, and a standard inquiry of body functions.
I began to see common denominators of different expressions of post-traumatic stress disorder, often as sequelae of sexual abuse, substance abuse withdrawal, a history or concurrent use with psycho-pharmaceuticals or illegal narcotics seeking harm reduction, and states of either sexual hypo- or hyper-arousal, usually consciously linked to abuse, substance abuse patterns, or both. The continuity of relief that Modified Cinnamon Twig Formula brought about from both acute and chronic suffering has led me to believe that this is a very valuable tool when used appropriately for providing support to individuals experiencing these forms of imbalance.
One of my main objectives, as well as my hope and intention, is that readers will find these methods useful in relation to their existing practice and that they might be motivated to study East-Asian herbal medicine to learn the context in which this formula is traditionally applied.
My secondary aim in presenting these cases and this formula is to introduce the concept of harmonization to audiences of Western-trained herbalists and healthcare providers who may be aspiring to offer herbs to patients and are exploring a variety of paradigms within which to do so.
HARMONIZATION IN TCM
‘To harmonize’ is defined in A
Practical Dictionary of Chinese Medicine as ‘To coordinate one element of the body with the rest of the body or to coordinate two elements of the body.’1 This can refer to harmonizing organs in disharmony with the rest of the body, organs in disharmony with each other, or the reharmonization of physiologic phenomenon unique to Chinese medicine, such as harmonizing constructive and nutritive aspects of the body or harmonizing lesser yang.
Each of the cases below exhibits unique ways in which the formula in question embodies principles of harmonization. In particular, this is an example where the body is being supplemented and strengthened while the mind and nervous system are being sedated and calmed. A simplified description that Western herbalists may consider analogous would be the concurrent use of adaptogenic or various ‘tonic’ herbs for building strength and nervines or sedatives to relax and calm the mind and/or the nervous system as it integrates with specific organs.
As this article may reach a diverse audience of herbal practitioners, it is my intention to offer tools and insight into methods that I have found useful in bringing relief of suffering. These methods utilize a diagnostic framework that is over 2000 years old and tools to bring about relief or resolution of disharmonies in multiple body systems, which may not be treated concurrently in other medical or healing frameworks. I recognize that it can be problematic to break from tradition, as I am doing, and I hope that readers with strong convictions about such matters will be patient and recognize my interpretations for a broader audience, which may bring about more alleviation of suffering. In particular, it is important to acknowledge that taking bits and pieces from traditional systems without a broader context for application may lead to injury of the patient or no recourse for evaluation of the therapeutic methods when they do not work.
Zhang Zhong Jing first discusses Modified Cinnamon Twig Formula in the Blood Impediment and Vacuity Taxation section of the Jin Gui Yao Lue, or Essential Prescriptions from the Golden Cabinet. The original signs emphasized are seminal loss with string-like tension in the lesser abdomen, yin head-cold, hair loss, seminal loss for men, and dreaming of intercourse in women. The pulse described is “scallion stalk,” stirring, and slightly tight.
Modified Cinnamon Twig is categorized in modern formularies under ‘Formulas that Secure and Astringe’ and is primarily indicated for restraining incontinence of urine and semen. The formula is also used for mental/emotional imbalances, particularly when there is an intersection with urological or gynecological complaints. Modern lists of indications include: tension in the lesser abdomen, excessive sexual dreams, seminal leakage, cold in the head of the penis, impotence, insomnia with excessive dreams, bed-wetting in children, dizziness, palpitations, forgetfulness, neurosis, hair loss, occasional watery diarrhea, generalized weakness in physical strength and condition, cold body, night sweats, a floating pulse, and muscle aches. The presence of any of the above symptoms or signs should point the practitioner to consider Modified Cinnamon Twig Formula as part of the treatment plan.
There are several signs and symptoms that occur in the source text and other commentaries on the formula that I have found to can be useful in interpreting whether this is an appropriate for a given patient. Several of these will be explored throughout the case histories presented below.
INGREDIENTS AND ACTIONS
Cinnamon twig (gui zhi) 9g
White Peony root (bai shao) 9g
Fresh Ginger root (sheng jiang) 9g
Licorice root (gan cao) 9g
Jujube date (da za) 12 pieces
Fossilized bone (long gu) 9g
Oyster shell (mu li) 9g
The formula is traditionally prescribed as a decoction, and the above dosages are those used for a daily dosage, three times per day. The formula is currently available in the Western market in powdered extract and pill form as well.
Modified Cinnamon Twig uses the base formula, Cinnamon Twig Decoction, to gently warm and nourish the body when it is necessary to harmonize the interior and exterior of the body. This occurs in the incidence of colds and flus where the body has insufficient resources to expel an externally contracted pathogen, thus facilitating a warm diaphoresis. The addition of fossilized bone and oyster shell astringes fluids, calms and settles the mind, and assists the formula in harmonizing the ascending and descending of qi and fluids in the body. In this case, the yang qi of the kidneys fails to restrain the fluids of lower orifices, resulting in leakage of water through the bowel, urine, and semen. At the same time, the fluids unchecked cannot restrain the yang qi, which ascends and creates a scenario in which empty heat affects the mind, causing agitation and excessive dreaming. Cinnamon twig warms the yang or vital energy of the body while peony restrains and nourishes the yin, or substantial fluid aspect of the body. The functions of these herbs both support and attenuate each other’s effects. Ginger and jujube date support the nourishing aspect of the chief ingredients, while licorice harmonizes the actions of the other herbs in the formula. In addition to calming agitation and settling the mind, fossilized bone and oyster shell astringe leakage of sweat, urine, and semen. As evident in the cases, the formula is often further modified to emphasize treatment of various aspects of the presentation.
Neil is a patient I have treated almost every week for the past six years, primarily with acupuncture. He came to me a couple of years ago with an acute head-cold accompanied by copious sinus drainage and confided to me that he was coming down from a 48-hour methamphetamine binge after seven years of sobriety (following 20-plus years of chronic methamphetamine and crack abuse). He was very anxious and described his drug abuse history as “related to patterns of sexual compulsion that stem from sexual abuse as a child” and that in this binge he had indulged such behaviors and “wasn’t dissatisfied with the results.” Upon inquiry, Neil reported feeling very cold with tight neck and shoulders, night sweats, and his stools were quite loose. He hadn’t slept in 48 hours and was experiencing palpitations. His pulse was floating and weak and upon abdominal palpation exhibited pulsations in the midline and below the navel. Neil is also HIV-positive and lives in a neighborhood that he describes as “taking 5 years to grow accustomed to the amount of violence.”
Neil’s presentation has indications of both the Modified Cinnamon Twig decoction and the base formula, Cinnamon Twig decoction. I gave Neil five packets of the formula modified with 9g of kudzu (ge gen) to address the loose stools, tight neck and shoulders, and congestion then instructed him to make one bag every day. Upon completion of the initial course of herbs he appeared much more calm and rested. He reported his bowel stabilizing and his head cold abating, with reduced cravings for sex and drugs. He also reported feeling more energized and warm, and his night sweats and palpitations had ceased. The pulse was still weak but no longer floating, and the abdominal pulsations had reduced considerably. He and I agreed that this formula suits his constitution well and he continued to take the formula, with the kudzu removed, multiple days a week for several weeks. Later, he reported that it helps support a more restful sleep, reduces mental agitation, and that it reduces his cravings and ideation about drug use.
Neil’s acute exacerbation of this presentation – a particularly exaggerated example of excessive sexual activity – is a primary etiology of the disease according to the source text. In combination with the use of very depleting substances helped to put both his constitution and some of the aspects of his imbalance under the microscope. His insomnia and mental agitation, night sweating, and palpitations are the main expressions of the deficient yin leading to yang ascending. His sensation of bodily cold, frequent urination, and loose stools were the main expressions of weak yang losing control of yin.
Vivian was three-months postpartum following a difficult pregnancy and fragile neonatal experience for both mother and child. In early January she began to have panic attacks during which she experienced amplified ideation of the death of her new baby. During the attacks she would become immobile and cry inconsolably, including while standing, remaining uncommunicative with her spouse for hours. She described her body as very cold and “frozen” during the attacks, and that this further escalated her sense of helplessness and fear. She experienced frequent urination and nighttime urination, but suffered no hair loss. When I first received a call about this I recommended that they use a preparation of Western Pasqueflower (Anemone occidentalis)7, California Poppy (Eschscholzia californica), California Skullcap (Scutellaria californica), and Kava Kava (Piper methysticum). This seemed to abate the symptoms and possibly bring the initial round of attacks to a halt rather quickly.
I have seen this grouping of herbs work effectively in numerous severe psycho-emotional crises and find it plausible that it was indeed responsible for stabilizing the patient. I do not believe that this grouping of herbs has the potential to address the underlying constitutional imbalance of this or other cases mentioned. I believe they have the potential to be used in formula with additional herbs to address the root imbalance, although that discussion is beyond the scope of this article.
I then prescribed a variation of Modified Cinnamon Twig with the addition of sprouted wheat (fu xiao mai). Sprouted wheat, along with licorice and jujube date, adds the indications of Licorice, Wheat, and Jujube Combination (Gan mai da zao tang) to the formulas. These indications include frequent crying spells. A month elapsed between the initial prescription and her confiding that she had not taken the formula and was continuing to have a difficult time. She let me know that she had begun to process her own sexual abuse history, that it was at the root of her breakdowns, and that she was actively in therapy for it. I had already begun writing this article and forming impressions of the value of Modified Cinnamon Twig in the treatment of PTSD and sexual trauma and chose to tell her about it, which prompted her to take the herbal prescription more seriously. At of the time of this article, she has been on the formula for seven days, taking a bag of tea per day consistently, and she reported that she immediately felt substantially more tranquil, warm, and supported since commencing to take the decoction and is enthusiastic about continuing with it. Vivian is a somatic integration therapist and expressed that the formula has allowed her body to be a more “comfortable container for some of the complex emotions and experiences I have been visiting.”
I think it is important to consider the associated sign, “women dreaming of intercourse” from the source text as an important guide for application of this formula for sexual trauma that remains a source of discomfort for the individual of any gender. I also believe it is useful to cite the “birth as being analogous to the blood loss” etiology listed in the source text for the formula. Anxiety, panic attacks, and intense fearfulness account for the ascending deficiency yang in the symptom picture, and the contracting coldness along with frequent urination is indicative of yang deficiency cold.
Ricki is a 24-year old female whose chief complaints are anxiety, frequent urination, nighttime urination, and occasional incontinence. She has a history of sexual trauma and reports having frequent ideation of this trauma that is disruptive to her daily life. She claims to have loose stools when she doesn’t eat a celiac diet, which she tends to not adhere to very well. The patient had a very difficult time making eye contact in the initial session and seemed very startled every time she spoke. I saw her in an integrated clinic, so I had access to the background of her case in chart notes from other physicians, including abuse history, counseling status, and recommendations she received for natural therapies that were out of her price range. This information enabled me to do a fairly efficient intake with someone who was admittedly uncomfortable speaking. It also enabled me to have a clear picture of the abuse history without having to probe for a story. She also reported coldness, low energy, and scant menstrual periods. Pulsations in the midline of the abdomen and pulsations below the navel were very strong and forceful, and her pulse was weak and floating.
Ricki was dispensed seven bulk packets of Modified Cinnamon Twig Decoction and consumed these over two weeks. Upon seeing her for the first return appointment she was very excited and eager to share her progress. She was much more lucid and articulate than during our first meeting and described feeling much more energy, warmth, and confidence in communicating with others. She reported spending a lot less time in ideation about her trauma. She shared that she had not had any episodes of incontinence and that her urinary frequency had greatly diminished. Her pulse was still weak and hollow, and her abdominal pulsations were reduced in strength. I have since continued her on the formula for several months, which she takes with a similar consistency. She states that it continues to support her in the ways described above.
I believe that the etiology of this case is related to the symptom in the source text of excessive dreams of sexual intercourse, which manifests as continual ideation of sexual trauma. This case illustrates clearly the primary contemporary application of the formula of ‘securing and astringing the urine’. Many herbalists and physicians will note that this can be an extremely difficult problem to treat and that the formulaic method for resolving the urinary problem is very different that those commonly employed, usually involving the use of sour, astringent herbs. The complication of loose stools can also be interpreted as a descent of substances due to unsecured yang. Her confusion, lack of focus, and frequent ideation of her trauma are all clear signs of ascending yang due to lack of yin.
Two common denominators found throughout these three cases indicate that Modified Cinnamon Twig is an appropriate formula for strong pulsations from the base of the sternum to the umbilicus and pulsations just below and to the side of the navel. These are not modern indications for this formula but rather are indications from the Japanese herbal tradition called Kampo. Pulsations above the navel in the midline are an indication for the use of cinnamon and oyster shell, while pulsations below the navel are an indication to use fossilized bone, according to the 17th century Japanese scholar Yakucho. Early Kampo scholars are famous for having united the practice of Fukushin, or abdominal palpation, with the works of Zhang Zhong Jing, where it continues to be utilized in Japan’s national health care system.
For the Western herbalist who is disinclined to use Chinese herbal medicine, I feel it is valuable to extract the therapeutic principle of harmonization from these cases and formulas. It is not difficult to recreate formulas that are warming, invigorating, and ascending that simultaneously cool, relax, and descend agitated mental states utilizing herbs domestically produced or wild-harvested. Most of the herbs in the base formula Cinnamon Twig Decoction have already been commonly adopted into Western herbal practice for decades or even centuries. Cinnamomum, Glycyrrhiza, and Zingiberis are all plants that are commonly available here in the West. Paeonia is widely available, though may not be as familiar to some.
WESTERN PLANTS USEFUL AS POTENTIAL MODIFICATIONS:
Palpitations: Motherwort (Leonurus cardiaca) + Western Pasqueflower (Anemone spp)
Wind- damp pain and stiffness: Kava (Piper methysticum) + Black Cohosh (Actaea racemosa)
Withdrawal, stiffness, and pain: Kava (Piper methysticum) + Pedicularis (Pedicularis sp.)
Urogenital discomfort and coldness: Western Pasqueflower (Anemone spp)
Substance use withdrawal (in conjunction with constitutional support):
Rx medication: Vervain (Verbena officinalis) + Skullcap (Scutellaria lateriflora)
Amphetamines and psychedelics: Western Pasqueflower (Anemone spp), Skullcap (Scutellaria lateriflora), California Poppy (Eschscholzia californica), Hawthorn (Crataegus sp.)
Alcohol: Kudzu (Pueria lobata)
By virtue of these three examples, I think that with an appropriate presentation, Modified Cinnamon Twig Formula is an important formula to look at in cases of PTSD. I have prescribed this formula for several other patients who present with a similar picture and report a history of sexual or other trauma, including those who have found the limits of Western psychiatric pharmaceuticals and various forms of counseling. As patients may not always conform exactly to the patterns that are studied, it is the responsibility of the practitioner to interpret findings and corroborate with the perspective of other physicians. By no means should the reader interpret this to mean that this is a ‘go-to’ formula for PTSD, but rather, it is meant to be an example of how studying the language of classical text from various conditions and eliciting the correct interpretation, we can often find solutions to common biomedically-defined complaints that have only relatively recently been used to define various phenomenon of the human experience.
Regardless of your herbal prescribing proclivities, it can be of great utility to study styles with archaic roots that continue to find expression in modern medical systems. In the case of this formula, the precedent exists in a text that is 1800 years old and it is a currently prescribed in the medical systems of several East-Asian nations. It is my intention that this article serves as a bridge to readers taking interest in the formula itself and the therapeutic principles it embodies, as well as the formulaic style of Zhang Zhong Jing.
1) Wiseman N, Feng Y. A Practical Dictionary of Chinese Medicine. Taos, NM: Paradim Publication; 2014.